فهرست مطالب کاویان قندهاری

Despite advances in medical treatments, readmission of stroke patients remains high and has been reported between 31% and 56.1% during the first year after discharge. The difference between the risk factors of readmission and the risk factors of stroke is not clear. The purpose of this study is: 1) to determine the preventable risk factors associated with stroke readmission and 2) to provide a conceptual model for preventable factors that effective in the readmission of stroke patients.

This integrated review was performed according to Whittemore and Knafl (2005) method in five stages including problem identification, literature search, data evaluation, data analysis, and presentation. In order to find relevant articles, PubMed, Web of Science, CINAHL, Scopus databases and Google Scholar search engine were searched. The search was conducted using the keywords "stroke," "readmission," "recurrence," "re-hospitalization," "review," and "systematic review," for the period between January 2023 and September 2023, following the PRISMA guidelines. In addition to providing a qualitative synthesis of readmission factors categorized into categories, a conceptual model of these factors was also presented.

Out of a total of 3785 article titles, 38 articles were included in the study for the final analysis after screening and removing duplicates. The most important risk factors for readmission in four categories: (1) knowledge deficit about the comorbidities (such as hypertension, atrial fibrillation, diabetes), (2) unhealthy diet and medicine, (3) high-risk behaviors (smoking, alcohol consumption, and tobacco use disorder), and (4) psychological distress (depression and worry about the future). In addition, the conceptual model showed that the most important preventable factor in readmission of stroke patients is of knowledge deficit about comorbidities (especially hypertension). 

The most important preventable risk factors that are effective in the readmission of stroke patients are knowledge deficit regarding clinical risk factors, especially high blood pressure, high-risk behaviors and unhealthy diet and medicine. Therefore, more detailed care and follow-up programs should be designed for stroke patients after discharge.

Background and purpose: Lack of clear boundaries and standard reference about the diagnosis of stroke, necessary evaluations and interventions, effective treatments, and referral of stroke patients resulted in various inconsistent services. Therefore, this study aimed at developing practical national strategies for stroke in Iran. Clinical guidelines about diagnosis and management of stroke were extracted from different guidelines. Three guidelines were selected according to AGREE scoring system after quality assessment and evaluation of clinical guidelines. In order to adapt the guidelines, recommendations of the three clinical guidelines were recorded in the form of clinical questions. Evidence supporting each recommendation was identified based on references and compared in terms of initial outcomes. Cost of interventions, the side effects, and clinical benefits were also studied. Finally, the national guideline for management of stroke was developed. The results of this investigation were presented as clinical recommendations for diagnosis and management of stroke (2016). For example, strict control of blood glucose level and fever in patients with aneurysmal subarachnoid hemorrhage was recommended in the guideline. The current indigenous stroke guide for the Iranian population is believed to be of great benefit in screening, referral, diagnosis, treatment, and follow-up of stroke.

Carotid Endarterectomy (CE) can be mentioned as a valuable theraputic method for primary and secondary prevention of stroke, provided it can be performed in vascular surgery centers with a low surgical risk. Thus, the present study aimed to assess prognosis of CE in high risk patients of an Iranian vascular surgery center.
This prospective observational study consisted of 50 high risk CE patients during 2011-14 in Mashhad University of Medical Sciences. All the high risk CE were performed by a vascular surgeon and a surgical carotid shunt was placed in each CE. Neurologic evaluation was performed before CE and serial neurologic axamination was done after CE by a neurologist. Surgical complications including stroke, death and lower cranial nerve palsy were recorded for 30 days after operation.
The study results revealed that 80% of high risk CE patients had symptomatic carotid stenosis on the operation side and 80% had carotid stenosis contralateral to the operation side. Thirteen high risk CE were performed simultaneously with coronary artery by pass graft and 24 patients were demonstrated to have diabetes. Post surgical death and stroke in the high risk CE patients were reported 2% and 4%, respectively. Lower cranial nerve palsy appeared in 2% of patients.
The 6% post operative stroke and death rate in the high risk CE patients are comparable to best vascular surgery centers in Europe and North America.

Determining the effect of stress on strock in benficial. If there is a relationship between them, using public education can lead to decrease the risk of stroke. This study investigate the effect of stress on cerebrovascular accident. This study was a prospective case-control, which was performed on the patients with stroke referred to nerve clinical Ghaem Hospital, and the control group were selected among the staff of the university with no history of stroke during winter 2015. The persian translation of questionnaire of Holmes and Rahe stress scale related to the last month was completed among all of the participants in both groups. Diagnosis of stroke and determination of its etiology was made by neurologist. By considering the frequency of serve stress, 361 patients with stroke were investigated and from these 190 patients were in the control group. The relative frequency of stress and stroke and intracerebral homorrhage and subarachnoid hemorrhage were meaningful(p<0.001, p<0.001, p=0.006). There was no significant relationship between the relative frequency of serve stress among the patients with ischemic stroke, cryptogenic infraction, and cardioembolic with atherosclerotic and the control group (p=0.637, p=0.311, p=0.439, p=0.109,). There were a significant relationship between serve stress and atherosclerotic stroke(p=0.026). While, high stress score was significantly more frequent in atherothrombotic subtype of brain infarction than controls, p=0.046. There was a meaningful relationship between stress as an important risk factor in the patients with hemorrhagic stroke and atherothrombotic brain infarction. Based on this research stress could be considered as a risk factor of stroke.

Stroke is one of major causes of disability. Therefore, it is important to introduce and develop new treatment approaches in order to improve and enhance post-stroke recovery process for medical, social, and economical purposes. The present study aimed at determining the effect of mirror therapy on walking ability of patients with stroke regarding the muscular power of the affected leg.

This semi-experimental study was done on 50 stroke patients that were hospitalized in Mashhad Imam Reza and Quaem hospitals. They were randomly classified into two equal groups of control. and mirror therapy(experimental group).For the experimental group, twenty 30 –minute sessions were daily held, so that every. patient did the range of motion of lower extremitiy of the healthy side in front of a mirror and observed just its mirror image. In addition to mirror therapy, the routine program physiotherapy was performed for both groups. Power of muscle in the affected leg was assessed on the basis of a 5-score scale and every patient`s walking ability was assessed before, during, and after intervention using function ambulation classification. Finally, the obtained data was analyzed by means of SPSS software(V:11.5), using independent T, paired T,Mann-Whitney and Wilcoxon statistical tests.

The two groups showed no significant difference in terms of walking ability regarding the muscular power of the affected leg and confounding variables before intervention (P=0.210). Walking ability of the affected leg in mirror therapy group did not significantly improve.in comparison with the control group after intervention (P=0.756). But the walking ability regarding the muscular power of the affected leg in mirror therapy group was significantly improved in comparison with the control group in the 10th session (P=0.038).

Mirror therapy can improve walking ability of patients with stroke as a simple, inexpensive and a patient-oriented treatment.

Cardioembolic stroke account for one-fifth of ischemic stroke and atrial fibrillation is the most common underlying cause. Taking an oral anticoagulation (Warfarin) is an effective way of preventing ischemic stroke but bleeding complication is common. This study was carried out to evaluate the validation of HASBLED score in prediction of hemorrhagic complications in patients with brain ischemia and atrial fibrillation under warfarin therapy. In this cohort study 112 patients with non-valvular atrial fibrillation in term of major and minor bleeding complications were followed to the predictive value of HASBLED criteria for one year. Major bleeding complications defined as intracranial bleeding, bleeding leading to hospitalization, drop of hemoglubin of more than 2gr/dl or requiring transfusion. HASBLED criteria were defined as hypertension, abnormality in liver and renal function tests, history of stroke, history of bleeding, large fluctuations in coagulation tests results, age more than 65 years and an Anti-platelet and non steroidal anti-inflammatory drugs and alcohol use one point is awarded to each of the aboves. During one year follow up, 10 (9.1%) of patients had major bleeding and 28 (25%) patients had minor bleeding. The risk of major bleeding was significantly related with a history of minor bleeding and HASBLED scores (P<0.05). The risk of minor bleeding was significantly related with warfarin toxicity and high INR (P<0.05). HASBLED score>3 was associated with the likelihood of major bleeding in future. Patients with HASBLED score>3 should be causious in initial stage of taking oral anticoagulant.

Stroke is a major cause of disability. Developing new treatment approaches in order to improve and enhance post stroke recovery process is critical. The aim of this study was to determine the effect of mirror therapy on motion range of extremities of patients with stroke. Methods & Materials: This semi-experimental study was conducted among 50 patients with stroke hospitalized in Emam Reza and Qaem hospitals in Mashhad during 2012 to 2013. Patients were randomly allocated into two control (25 patients) and mirror therapy (25 patients) groups. In the mirror therapy group, twenty 30–minute daily sessions were implemented in where patients practiced motion range of upper and lower extremities of healthy side in front of mirror and observed the mirror image. Motion range of upper and lower extremities was assessed at baseline, during the sessions and in the last session of the intervention using the goniometer. Data were analyzed using the t-test and repeated measure ANOVA. There were no significant differences in terms of ability of motion range at baseline. The total motion range did not improved significantly in the intervention group in comparison with the control group after the intervention (P>0.05); however, in some joints, the motion was improved (P<0.05). Mirror therapy, as a simple and inexpensive process can improve self-care of patients with stroke.

The Detection of neurologic signs for topographical disorders in central nerves system can prevent unnecessary neuroimaging techniques such as MRI. This study was performed to determine the diagnostic value of physical examination for topographic detection of infratentorial lesions in patients with cerebrovascular syndromes. This descriptive study was done on 200 patients with cerebrovascular syndrome in Qaem Hospital in Mashhad, north-east Iran during 2011. Regarding to topographic physical examination, sensitivity, specificity, positive and negative predictive value and accuracy of signs of syndromes were compared to MRI as gold standard method. The accuracy of tetraparesis and crossed syndromes for localization of brain lesion in brainstem was 79% and 83%, respectively. The accuracy of hemiataxia for localization of brain lesion in ipsilateral cerebellar hemisphere was 98%. The accuracy of Wallenberg syndrome for localization of brain lesion in posterolateral medulla was 98%. Using clinical neuro-examination skills and accurate topographic physical examination can prevent unwanted MRI technique for the diagnoses of cerebrovascular syndromes.

Determination of diagnostic value of neurologic syndromes for neurotopographic diagnosis of lesions of central nervous system may decrease unnecessary neuroimaging and its costs.
In this study, 200 patients who had undergone brain MRI and had a single new well defined cerebrovascular lesion in the brain underwent neuroexamination and were categorized based on syndrome diagnosis. This clinical evaluation was performed by a neurologist who was blind to the result of brain MRI. Also, the topography of vascular and parenchymal lesions was reported by a neuroradiologist who was blind to the clinical data. Then, true, false positive and false negative cases were identified compared to the standard method for determination of lesions topography; i.e., brain MRI. Afterwards, sensitivity, specificity, positive and negative predictive values, and accuracy of these syndromes were assessed.
The diagnostic accuracy of broca and wernicke aphasia for localization of brain lesion in lateral left frontal and left temporoparietal was 94%. Besides, the accuracy of hemiparesis for localization of brain lesion in the contralateral hemisphere was 95%. Additionally, the accuracy of aphasia and hemihypoesthesia for localization of brain lesion in the left hemisphere and contralateral hemisphere was 100%.
Topography of symptomatic cerebrovascular lesions could be more accurately determined using clinical neuroexamination skills for detection of neurological syndromes.

Stroke is one of the major causes of disability. Therefore، it is important to introduce and develop new treatment approaches in order to improve and enhance post stroke recovery process for medical، social and economical purposes. To determine the effect of mirror therapy on motor ability of patients with stroke. This Randomized Controlled Trial was conducted on 38 patients with stroke، hospitalized in Imam Reza and Quaem hospital in Mashhad. They were randomly allocated into two groups of control (18 patients) and mirror therapy group (20 patients). In an experimental group، twenty 30minute sessions were performed daily or every other day. In this procedure، patients performed a range of motion of upper and lower extremities of healthy side in front of the mirror and observed only the mirror image. In additional to mirror therapy in both groups، the routine program (physiotherapy and neuromuscular stimulation) was performed. Upper and lower extremity motor abilities were assessed before، during and after the intervention using motor recovery scale، function index measure and function ambulation classification. Finally، data were analyzed by SPSS version 14. Two groups showed no significant difference in terms of motor ability indexes and confounding variables before the intervention. Motor ability indexes، movement recovery and walking ability in mirror therapy group were significantly improved in comparison with control group after the intervention. (P>0. 05) Mirror therapy can improve motor ability of patients with stroke as a simple، inexpensive and patient-oriented treatment.

Background and

Stroke is one of major causes of disability and self care. Therefore, it is important to introduce and develop new treatment approaches in order to improve and enhance post stroke recovery process for medical, social and economical purposes. The aim of this study was determine the effect of mirror therapy on self care of patients with stroke.

This Randomized Controlled Trial was conducted on 50 patients with stroke hospitalized randomly allocated in two groups of control (25 patients) and mirror therapy (25 patients). In experimental group, twenty 30 –minute sessions were done daily or every other day patients did range of motion of upper and lower extremities of healthy side in front of mirror and observed just its mirror image. In additional to mirror therapy in both groups, the routine program (physiotherapy and neuromuscular stimulation) was performed. Ability of self care was assessed before, 5th, 10th, 15th and last sessions of intervention using barthel index scale. Finally data analyzed in different phase by t-test and repeated measure.

Two groups showed no significant difference in terms of ability of self care and confounding variables before intervention. In 5th, 10th and 15th were significantly different (p<0.05) but in last sessions of intervention in mirror therapy group were not significantly improved in comparison with control group after intervention (P>0.05). Repeated messure showed significant independently effect of group and step on self care of patients with stroke (P<0.05), however this effect was not interactional (P>0.05).

Mirror therapy can improve self care of patients with stroke as a simple, inexpensive and patient-oriented treatment.

Stroke is the third common cause of disability and death. Diagnosis of stroke is based on its clinical manifestations and/or observation of infarct in the neuroimaging. Standard battery of diagnostic investigations and classification criteria is required for detection of stroke etiology. This review article deals with the diagnosis and management of brain infarction particularly in our country and is provided for non-neurologists. Using online scientific search engines and in some parts referring to laboratory archives constituted base of this review article. Acute stroke management is almost similar in its various etiologies. Neuroprotective drugs have little value in acute stroke management. At present time, a few Iranian medical centers have infrastructure of thrombolysis therapy. Prevention of stroke is based on the detection and control of its risk factors. Aspirin, 80 mg per day is the most common drug for stroke prevention. Co-administration of aspirin 80 mg/d and Dipyridamole 200-400 mg/d increases the preventive effects of aspirin. Clopidogrel 75 mg/d is the stroke preventive drug of choice in patients with peptic ulcer and coronary artery disease. Co-administration of aspirin and clopidogrel is more effective in stroke prevention but has more hemorrhagic complications. Using warfarin for stroke prevention is suggested only in patients who have facilities for repetitive coagulation tests. Carotid endarterectomy is indicated in symptomatic patients with more than 70% stenosis of extracranial internal carotid artery, if performed only by vascular surgeons experienced in carotid surgery. Many stroke patients are managed by general practitioners and non-neurologists, e.g. internists, cardiologists and neurosurgeons. This review article provides continuous medical education according to Iranian medical curriculum

Clinical findings affecting disability in stroke patients are important as presence of these factors determines the prognosis and future course of these patients. Consecutive stroke patients admitted at Ghaem hospital, Mashhad were enrolled in this prospective study in 2008. Hemihyposthesia, hemianesthesia, hemineglect and homonymous hemianopsia was evaluated in these patients. Disability score was based on the Modified Ranking Disability Score (MRDS), 72 hours post stroke. Mean of MRDS was analyzed by T test and Fisher tests and p<0.05 was considered as significant. A total of 329 stroke patients were investigated. Hemihyposthesia, hemianesthesia, hemineglect and homonymous hemianopsia was found in 37.4%, 13.8%, 7.9% and 7.3% of the patients, respectively. MRDS was significantly higher in patients with hemianesthesia as compared to other stroke patients, (p<0.001). MRDS of patients with hemihypoestheisa, hemineglect and homonyous hemianopsia was not significantly different than patients without these abnormalities (p=0.44, p=023 and p=0.83). Patients with triad of hemianesthesia, hemineglect and homonymous hemianopsia had significantly higher MRDS than others (p<0.001). Hemianesthesia is a clinical factor affecting sensory disability in cerebral stroke patients. Presence of the above triad could increase MRDS in these patients.

HTLVI infection is an endemic disease of Khorasan state in Iran. Distribution of Multiple Sclerosis (MS) is different around the world. Methods and Materials: Data of MS patients were taken of MS registries for interferon prescription in Razavi, Northern and Southern Khorasan provinces. MS was diagnosed by neurologists based on McDonald criteria. Records from clinics and hospital based researches consitituted data of distribution of patients infected with HTLV1 with or without spastic paraparesis in Razavi and Southern Khorasan provinces. Serologic tests of blood and/or CSF for HTLV1 and neuroexam by neurologists formed the methodology of HTLV1 investigation. Statistical centers of health deputy of medical universities in the Khorasan provinces provided the population data. Total Prevalence of MS in Razavi, Northern and Southern Provinces of Khorasan is 12.9, 8.7 and 5.3 cases per 100000 population respectively. Prevalence of MS in female population of Razavi, Northern and Southern provinces of Khorasan is 19.9, 11.2 and 8.3 cases per 100000 women respectively. Prevalence of MS in male population of Razavi, Northern and Southern Provinces of Khorasan is 5.9, 6.2 and 2.5 cases per 100000 men respectively. Total prevalence of HTLV1 infection in Razavi and Southern provinces of Khorasan is 2.4 and 0.5 cases per 100000 population respectively. Prevalence of HTLV1 infection in female population of Razavi and Southern provinces of Khorasan is 2.9 and 0.3 cases per 100000 women respectively. Prevalence of HTLV1 infection in male population of Razavi and Southern provinces of Khorasan is 1.9 and 0.6 cases per 100000 men respectively. Spastic paraparesis was found in 46 % and 50% of cases infected with HTLV1 in Razavi and Southern provinces of Khorasan respectively. Frequency rate of MS is less than half in Southern province compared to Razavi province of Khorasan. HTLVI infection is 10 times more frequent in female population of Razavi compared to Southern province. There is considerable difference in geographical distribution of MS and HTLV1 cases in Khorasan territory.

Progressing stroke (PS) and Crescendo Transient Ischemic Attacks (CTIA) are generally accepted, though unproven, indications for urgent anticoagulation and there remains evidence-free practice of intravenous heparin therapy in these patients. Methods and Materials: Consecutive PS and CTIA patients admitted in Mashhad Ghaem hospital during 2007- 2008, enrolled in a prospective observational study. PS and CTIA patients underwent intravenous heparin therapy 1000 units per hour for 3 days without bolus dose. PS and CTIA patients who had a contraindication of intravenous heparin therapy received 80 mg Aspirin per day. Early clinical courses including improvement, stabilization, deterioration and development of residual stroke were evaluated in two therapeutic groups of PS and CTIA patients.. 170 PS patients (103 males, 67 females) with mean age 60.4±12.3 years and 88 CTIA patients (50 males, 38 females) with mean age 60.1± 6.8 years were investigated. 141 PS and 64 CTIA patients received a short period of intravenous heparinization. The distribution of subtypes of early clinical course into two therapeutic groups of PS and CTIA patients was significantly different X2=10.487, df=2, p=0.005 and X2=6.72, df=2, p=0.035 respectively. Distribution of residual stroke in two therapeutic groups of PS and CTIA patients was not significantly different X2=1.443, df=1, p=0.23, OR=0.557 (0.212-1.462) and X2=1.01, df=1, p=0.315, OR=0.617 (0.24-1.587) respectively. PS and CTIA patients who received a short period of intravenous heparin therapy have significantly more probability of improvement and less probability of deterioration in their early clinical course.

Surgical intervention is a routine treatment in patients with Subarachnoid Hemorrhage (SAH). However influence of aneurysm surgery in the developing counties may be different than developed countries. Decision for surgical intervention in patients with Intracerebral Hemorrhage (ICH) is a subject of controversy. Methods and materials: Consecutive patients with SAH or ICH admitted in Ghaem hospital, Mashhad during 2005-2009 enrolled in a prospective clinical study. Diagnosis and work up of SAH and ICH was performed by neurologists. Decision for performing aneurysm surgery and evacuation of hematoma was made by neurosurgeons. All of the SAH or ICH patients received a standard conservative medical management. Frequency of complications and mortality was compared in medical and surgical groups of SAH patients. 120 SAH patients (52% females) with mean age of 50.6±7 years were evaluated and 46.6% of them underwent aneurysm surgery. The effect of therapeutic type on mortality of SAH patients was not significant X2=1.8, df=1, p=0.17. Difference in frequency of rebleeding in two therapeutic groups of our patients was not significant X2=0.37, df=1, p=0.54. The influence of rebleeding in mortality of our patients was significant X2=4.50, df=1, p=0.048. 193 ICH patients (52% females) with mean age of 61±3 years enrolled the study and 62.7% of them underwent surgery. Frequency of mortality was not significantly different in two therapeutic groups of ICH patients X2=2.34, df=1, p=0.126. The influence of surgery on mortality of the ICH patients was not significant in lobar, putaminal, cerebellar and thalamic subtypes of our patients (X2=0.16, df=1, p=0.77), (X2=2.34, df=1, p=0.126), (X2=0.01, df=1, p=1) and (X2=3.09, df=1, p=0.08) respectively. Influence of aneurysm surgery in frequency of death is not significant in Iranian patients with SAH which could be due to delay in performance of surgery in Iranian neurovascular centers. Influence of surgery in frequency of death is not significant in our patients with ICH. Surgical intervention is not usefull in patients with lobar, putaminal and cerebellar hemorrhage and may be harmful in patients with thalamic hemorrhage.

Carotid Endarterectomy (CEA) is recommended in patients with symptomatic and some times asymptomatic carotid stenosis in vascular surgery centers with low perioperative complication rate. A retrospecticve study was carried out in patients who underwent CEA in 3 vascular surgery centers in Tehran and 2 centers in Mashhad. Patients selection criteria, methods of detection of carotid stenosis, method of anesthesia, surgical techniques and perioperative complications were evaluated. 388 CEA in 345 patients (65% males) with mean age of 66.8 years ranged 46-84 years were evaluated. Detection of carotid stenosis was made by one carotid duplex ultrasound in 90% of CEA candidates. The whole perioperative stroke and death rate in reported Iranian vascular surgery centers is 6.4%. Perioperative stroke and death rate in Emam Reza, Razavi, Shohada Tajrish, Taleghani and Iranmehr hospitals was 2.4%, 0%, 4.8%, 10.2% and 10.2% respectively. In Iran, CEA is recommended only in patients with symptomatic ≥70% ICA stenosis and preferably in patients with symptomatic ≥90% ICA stenosis. Method of detection of carotid stenosis in Iranian vascular surgery centers should be corrected.

Evaluation of clinical competencies continuously، is an effective experience to improve medical educations quality that was applied by developed countries. 50 general practitioners of health care centers and 50 general practitioners in hospital of Khorasan Razavi province participated. In this cross sectional descriptive study، they were selected randomly by systematic sampling. Significant of practical application of each title in neurology and their clinical competencies was determined as high، moderate. Low and compared between two groups. 100 general practitioners (64 males and 36 females) with 4. 5 ± 2. 2 years of services participated in this study. The procedures such as: history taking، physical exam of N. S، headache، comma and epilepsy were the most applicable subjects. Subjects of comma and cerebrovascular accidents in hospitals practitioners were important than in health care practitiners. There was a significant different in professional competencies between two groups. based on results، medical doctor''s clinical competencies in 85% of neorologic educational titles were moderate or low، but weaknesses of clinical competencies in emergency part was more evident.

ardioembolism is among the most important causes of ischemic stroke around the world. A pilot double-center study evaluated subtypes of cardioembolic mechanisms in stroke patients in two different racial subtypes. This prospective clinical study was conducted on 100 consecutive stroke patients in Mackenzie hospital, Canada and 100 consecutive stroke patients whom were age and sex matched in Ghaem hospital, Iran in 2007. All of the Canadian patients consisted of white North American race and all of the Iranian patients were white Persian race. Diagnosis of ischemic stroke was made by stroke neurologists. Assessment of the cardioembolic mechanisms was maded based on the standard method. The frequency rate of ischemic heart disease, congestive heart failer and atrial fibrillation, was detected in the two studied groups. Chi-Square and Fisher tests served for statistical analysis and p<0.05 was declared as significant. 92 males and 108 females with ischemic stroke were investigated. The influence of race on the frequency rate of ischemic heart disease, congestive heart failer and atrial fibrillation was insignificant, p>0.05. However rheumatic mitral valve disease was significantly more frequewnt in the Iranian group, df=1, p=0.037. The effects of race on frequency rate of other cardioembolic mechanisms was not significant in each gender separately, p>0.05. However ischemic heart disease was significantly more frequent in Canadian females, df=1, p=0.03. There is no significant difference in frequency rate of cardioembolic mechanisms between North American and Persian stroke patients except of rheumatic mitral valve disease

Atherosclerotic stenosis of carotid territory is the most common cause of ischemic stroke. A higher frequency rate of intracranial arterial stenosis in African and Far East races has been reported. This double center and prospective study was carried out in 304 geriatric ischemic stroke patients admitted in Mackenzie Hospital, Canada and the same number of geriatric ischemic stroke patients with similar sex ratio admitted in Valie-Asr Hospital, Birjand during 2003-2005. The cause of brain infarction in carotid territory was made by neurologists was vasular origin. All of the patients underwent transcranial and carotid doppler studies based on the standard method by a neurosonologist. Topography of arteriosclerotic stenosis in bilateral Internal Carotid Artery (ICA) territories was determined. Fisher exact test served for statistical analysis and p<0.05 declared as significant. In Iranian group; 71 patients (23.3%) and in North American group 83 patients (27.3) had extracranial ICA stenosis without a significant difference; p=0.3, df=1, OR=0.81, 95%CI(0.56- 1.17). Sever ³70% extracranial ICA stenosis was found in 14 Iranian patients (4.6%) and 23 North American patients (7.5%) without a significant difference. p=0.17, df=1, OR=0.59, 95%CI(0.3-1.77). In Iranian group, 14 cases (4.6%) and in North American group 5 cases (1.6%) had intracranial ICA territory stenosis which had a significant difference p=0.038, df=1, OR=2.9, 95%CI(1-8.1). Mixed intracranial and extracranial ICA territory stenosis was found in 2 Iranian and 1 North American patients. Atherosclerotic stenosis of intracranial ICA territory is more common in Iranian than in North American populations.

Clinical findings effective on disability of stroke patients have importance due to their effects on prognosis and future recovery following rehabilitation. Consecutive stroke patients admitted in Valie-Asr hospital, Khorasan enrolled in a prospective study in 2005. Hemihyposthesia, hemianesthesia, hemineglect and homonymous hemianopsia were evaluated in the patients. Disability score was determined based on the Rankin scale at 72 hours post stroke. Mean of Rankin Disability Score (MRDS) was analysed by T and Fisher tests and p<0.05 declared as significant. 329 stroke patients were investigated. Hemihyposthesia, hemianesthesia, hemineglect and homonymous hemianopsia were found in 37.4%, 13.8%, 7.9% and 7.3% respectively. MRDS was significantly higher in patients with hemianesthesia than other stroke patients, p<0.05. MRDS of patients with each of hemihypoestheisa, hemineglect and homonyous hemianopsia was not signigicantly different than patients without these abnormalities respectively. Patients with triad of hemianesthesia, hemineglect and homonymous hemianopsia had significantly higher MRDS than others, p<0.05. Hemianesthesia is the most important clinical effector on MRDS of the stroke patients. Presence of above triad predicts the highest MRDS in these patients.

There is no difference in clinical characteristics of headache between old individuals and younger’s. However, differential diagnosis of migrainous aura and transient ischemic attacks may be difficult in old people who frequently have vascular risk factors. Old people have less headache than the young’s. Chronic tension headache is the most common primary type of headache in the elderly. Chronic paroxismal hemicrania and headache due to giant cell arterities are specified to the elderly, Secondary headaches; e.g headache due to cervical spondylosis and brain tumors is more common in the old people than young. Old people poorly tolerate headache drugs, i.e. Ergotamine, Triptans and Tricyclics. Trigeminal neuralgia is often seen in the elderly and is resistant to medical therapy in the old people. Headache could be the main manifestation of depression in old people. Headaches secondary to disorders of internal medicine; i.e. hypertension and chronic obstructive pulmonary disease have importance in the elderly. Subarachnoid hemorrhage is considered in every old person with sudden onset explosive headache especially in cases with decreased consciousness and neck stiffness. Old individuals use a collection of different drugs due to suffering various diseases and commonly have drug induced headaches. Neuroimaging should be performed in a geriatric patient with new onset sever headache without medical disorder or consumption of drug induced headache. Some of the old people suffer of multiple types of headache.

Atherosclerotic stenosis of carotid territory is the most common cause of ischemic stroke. A higher frequency of intracranial arterial stenosis has been reported in Africa and the Far East. 304 geriatric ischemic stroke patients admitted in Mackenzie hospital, Canada and the same number of geriatric ischemic stroke patients with similar sex ratio admitted in Valie-Asr hospital, Iran during 2003-2005 were enrolled in a double center and prospective study. Diagnosis of brain infarction in the carotid territory was made by stroke neurologists. All of the patients underwent transcranial and carotid doppler studies. Doppler studies performed were based on the standard method by a neurosonologist. Fisher exact test served for statistical analysis and p<0.05 was declared significant. In Iranian group 71 patients (23.3%) and in North American group 83 patients (27.3%) had extracranial ICA stenosis without a significant difference df=1, p=0.305. Sever ³70% Extracranial ICA stenosis was found in 14 Iranian patients (4.6%) and 23 North American patients (7.5%) without a significant difference. df=1, p=0.17. In Iranian group, 14 cases (4.6%) and in North American group 5 cases (1.6%) had intracranial stenosis in carotid territory which was significantly different df=1, p=0.038. Mixed intracranial and extracranial carotid territory stenosis was present in 2 Iranian and 1 North American patient. Atherosclerotic stenosis of intracranial branches of carotid territory is more common in Iranian than North American populations.