فهرست مطالب reza rikhtegar

Rates of intracranial hemorrhage (ICH) after intravenous thrombolysis (IVT) differ depending on ethnicity, one reason that few Eastern countries have approved a lower dose of alteplase. Data in this regard are scarce in the Middle Eastern region.

The present retrospective study was performed on data extracted from the Safe Implementation of Treatments in Stroke (SITS) registry. Computed tomography (CT) image analysis was based on the SITS-Monitoring Study (SITS-MOST) definition for symptomatic ICH (SICH). Functional outcome at 3 months was assessed using the modified Rankin Scale (mRS). Multivariate logistic regression including adjusted analysis was used for comparison between groups.

Of 6615 patients, 1055 were enrolled. A total of 86% (n = 906) received a standard dose and 14% (n = 149) received a low dose of alteplase. Favorable 3-month outcome was achieved in 481 (53%) patients in the standard group and 71 (48%) patients in the low-dose group [adjusted odds ratio (AOR) = 1.24, 95% confidence interval (CI): 0.87-1.75, P = 0.218]. SICH occurred in 14 (1.5%) patients in the standard group and 3 (2%) patients in the low-dose group [odds ratio (OR) = 2.77, 95% CI: 0.36-21.04, P = 0.120]. At 3 months, mortality occurred in 145 (16.0%) patients in the standard group and 29 (19.4%) patients in the low-dose group (OR = 1.22, 95% CI: 0.78-1.91, P = 0.346).

Low-dose compared to standard-dose alteplase for patients with acute ischemic stroke (AIS) was not associated with fewer hemorrhagic events and there was no significant difference in the favorable 3-month outcome (mRS: 0-2) or mortality rate.

Cerebral venous sinus thrombosis (CVST) causes significant problems for patients in the working age and may therefore negatively affect their quality of life (QOL). In the present study, we sought to evaluate the QOL and its predictors in subjects with CVST.

This observational, prospective study investigated several outcomes of 56 CVST patients after thrombosis onset. Demographic characteristics, medical history, neurological signs and symptoms during hospitalization, and the employment status of the patients were retrospectively collected. Stroke-related functional scales, including the modified Rankin Scale (mRS) and Barthel Index (BI) were employed. For physical and mental aspects of the QOL, we used the validated Persian version of the Stroke Specific Quality of Life (SS-QOL) scale.

The physical and functional outcomes in the long-term were promising according to mRS and BI tools, as well as the improved rate of return to work. Mental domains of the SS-QOL, such as energy and personality represented the lowest scores. According to the multiple linear regression analysis, lower mRS score, and longer time interval between CVST onset and interview were associated with higher physical function of the patients while their better mental function was correlated with lower mRS score and thrombosis in merely one cerebral venous.

CVST patients experience an acceptable alleviation of the primary physical disabilities, while residual symptoms, mostly in psychologic/mental domains, impair their QOL

Carotid artery stenosis is one of the main causes of ischemic stroke in Iranian population. Carotid artery stenting (CAS) is a method with for treating carotid artery disease, in order to prevent stroke. Dispersion of the embolus is a significant risk for carotid angioplasty which can be prevented by using protective devices. But studies have shown that the use of these protective devices is not safe and can have side effects such as vascular spasm and dissection.

36 patients who underwent unprotected carotid artery angioplasty from April 2018 to August 2019 in Shahid Madani hospital retrospectively entered this study. Hospital records were studied for data collection. Patients were followed by phone interviews. Major adverse cardiovascular and cerebral events (MACCE) was defined as a composite of the occurrence of stroke, MI, bleeding, and all-cause mortality in the long term. Mean duration of our follow-up was 6 months.

During in-hospital course, an 82 years old woman with a history of CVA, hypertension, diabetes and a significant stenosis in her contralateral ICA, had an episode of stroke which was fatal. Also, there was a 46 years old woman without any risk factors, who had developed intracranial hemorrhage (ICH). 22 patients were followed. No MI, stroke, or death occurred in any of the patients. There were only 2 cases of bleeding.

Carotid artery stenting without protection may be is a safe method of carotid revascularization. Further prospective studies and clinical trials are needed.

Different criteria have been proposed to determine the mortality rate of primary intracerebral hemorrhage (ICH). This study aimed to evaluate ICH and Modified New ICH scores in predicting 30-day mortality in patients with primary ICH.

In this prospective cohort study, 107 patients diagnosed with primary ICH were enrolled at an interval of six months (October 2015-March 2016). They were evaluated using Modified New ICH and ICH scores. The Modified New ICH score was different from the New ICH score since the National Institute of Health Stroke Scale (NIHSS) variables were replaced by Modified Rankin Scale (MRS) in the modified score.

A total of 61 patients (57%) died, and 46 (43%) survived during the 30-day hospitalization. ICH ≥ 2 and Modified New ICH ≥ 3 scores predicted 30-day mortality rate in patients with the sensitivity and specificity rates of 87 and 63 percent, and 88 and 53 percent, respectively.

The current study showed that both ICH and Modified New ICH scores were almost equally effective in determining the mortality rate in patients with primary ICH, and both criteria had acceptable value in determining the mortality rate of patients. Therefore, routine assessment of ICH and Modified New ICH scores in patients with ICH in emergency wards is recommended.

Tissue plasminogen activator (tPA) has been long approved as an efficacious treatment in patients with acute ischemic stroke (AIS); however, due to some serious complications, particularly intracranial hemorrhage (ICH), many physicians are still reluctant to use it liberally. This study sought to find potential prognostic factors in patients with AIS treated with tPA.

A retrospective, hospital-bases observational study was conducted. Consecutively, a total of 132 patients with AIS treated with intravenous tPA, form June 2011 to July 2015 were enrolled. Inclusion and exclusion criteria were based on updated guidelines. Probable prognostic variables were examined separately in three distinct groups; the occurrence of ICH within 24 hours after treatment, poor 3-month outcome on the basis of modified Rankin Scale (mRS) and 3-month mortality.

Patients were 83 men (62.9%) and 49 women (37.1%) with a median age of 66 years [interquartile range (IQR)of 55-72]. Any type of hemorrhage, symptomatic hemorrhage [based on the European Cooperative Acute Stroke Study III (ECASS III) definition] within 24 hours posttreatment, poor 3-month outcome (mRS 3-6), and 3-month mortality were documented in 10.6%, 4.5%, 53.2%, and 23.6% of patients, respectively. Increased baseline blood glucose was a significant but dependent predictor of hemorrhage within the first 24 hours posttreatment. Dependent predictors of a 3-month poor outcome were high age, the National Institutes of Health Stroke Scale (NIHSS) at baseline, decreased admitting glomerular filtration rate (GFR), and the presence of atrial fibrillation (AF) rhythm, and ICH within 24 hours posttreatment. Only age [Odds ratio (OR) adjusted 1.05] and initial NIHSS (OR adjusted 1.23), however, were recognized as the independent variables in this regard. The only independent predictor of 3-month mortality was the initial NIHSS (OR adjusted 1.18).

According to the findings of the present study, advanced age and high baseline NIHSS are two independent prognostic factors in patients with AIS treated with tPA.

Stroke is the second most common cause of death and first cause of disability in adults in the world. About 80% of all stroke deaths occur in developing countries. So far, the data on stroke epidemiology have been limited in Iran. Therefore, this study was focused on stroke demographic data, risk factors, types and mortality.
A retrospective study was done in two university tertiary referral hospitals in Tabriz, northwest of Iran, from March 2008 to April 2013. Patients diagnosed with stroke were enrolled in the study. Demographic data, stroke subtypes, duration of hospitalization, stroke risk factors and hospital mortality rate were recorded for all the patients.
A total number of 5355 patients were evaluated in the present study. Mean age of the patients was 67.5 ± 13.8 years, and 50.6% were men. Final diagnosis of ischemic stroke was made in 76.5% of the patients, intra-cerebral hemorrhage (ICH) with or without intra-ventricular hemorrhage (IVH) in 14.3% and subarachnoid hemorrhage (SAH) in 9.2%. Stroke risk factors among the patients were hypertension in 68.8% of the patients, diabetes mellitus (DM) in 23.9%, smoking in 12.6% and ischemic heart diseases (IHD) in 17.1%. Mean hospital stay was 17.3 days. Overall, the in-hospital mortality was 20.5%.
Compared to other studies, duration of hospital stay was longer and mortality rate was higher in this study. Hypertension was the most common risk factor and cardiac risk factors and DM had relatively lower rate in comparison to other studies. Because of insufficient data on the epidemiology, patterns, and risk factors of stroke in Iran, there is a necessity to develop and implement a national registry system.

Stroke is among the leading causes of mortality and permanent disability in the world. Iran is located in the stroke belt and has a high age-adjusted stroke incidence rate. In this multistep prospective qualitative study, we aimed at investigating the status and challenges of stroke management in Iran and explore possible solutions.
In the first and second phase, we attempted to define the status of stroke management in Iran by searching the relevant literature and conducting semi-structured interviews with health-care providers in thirteen hospitals located in seven large cities in Iran. In the third phase, we tried to recommend possible solutions based on international standards and experience, as well as interviews with stroke experts in Iran and the United States.
Little public awareness of stroke symptoms and its urgency, low prioritization for stroke management, and an inadequate number of stroke-ready hospitals are some of the major obstacles toward timely treatment of stroke in Iran. Every hospital in our pool except two hospitals had guideline-based algorithms for the administration of intravenous thrombolysis. However, there was no single call activation system for stroke alert. Data from some of the centers showed that hospital arrival of stroke patients to final decision-making took 116-160 minutes. Although there were four endovascular programs in our target areas, there was no center with 24-hour coverage.
There are many challenges as well as potentials for improvement of stroke care in Iran. Improving public knowledge of stroke and establishing an organized and comprehensive stroke program in the hospitals will improve acute stroke management in Iran. The Iranian ministry of health should define and advocate the establishment of stroke centers, track the rate of death and disability from stroke, introduce pathways to improve the quality of stroke care through national data monitoring systems, and eliminate disparities in stroke care.

There are various methods of training for medical students in different colleges. Fast knowledge transfer and maximum learning are the main goals of education. Due to the limited time and also high volume of content knowledge during residency, using the best methods of training can play an important role in enhancing the skills of residents. In the current study, small group discussion as a teaching method was compared with the traditional method.
In this cohort study, two groups of residents that had finished a 4-year course of orthopedic residency training programs in Tabriz and Urmia universities of medical sciences was being examined. They were divided in two groups. In order to compare the impact of the training on residents, it was compared with the result of the State Board standardized exam. The number of residents passing the written test and the Objective Structural Clinical Examination (OSCE) per year have been identified and compared with the groups under investigation.
Fifty-one residents, including 4 women (7.8%) and 47 men (92.2%), were studied for this purpose. Success rate for the small group discussion in the written exam was 59.2% and in the OSCE was 24% (95% CI). On the other hand, the success rates for the group who were trained in the traditional way were 37% and 16.6% in the written exam and OSCE, respectively. In both cases the differences were significant.
The small group discussion method is an effective method in residency training in surgical fields that increases medical students’ learning abilities compared to traditional methods of education.

Vascularity of kidneys is very high, so these organs are potentially susceptible to be affected with toxins including snake venom. Hypersensitivity to snake venous could cause some neurological problem. Case Report: We present a 14-year-old boy with acute kidney injury (AKI) due to snake bite. After a few days, kidney failure with hematuria was developed. His serum creatinine level rose to 3 mg/dl and following 2 weeks gradually and decreased to normal level without any special treatment except for anti-venom, which was not prescribed inappropriate time (this type of AKI is not reported previously). He had seizure attacks, which were according to magnetic resonance imaging due to posterior reversible encephalopathy syndrome (PRES) (This neurologic complication has been seen in other kidney injuries but up to now it was not reported in snake bite victims). Sanke venom could cause PRES due to AKI and seizure could be one of the most important complications in snake bite.

Aphallia or penile agenesis is an extremely rare congenital anomaly with an estimated incidence rate of 1 in 10 to 30 million births. We report a rare case of aphallia with right kidney hypoplasia and left kidney dysplasia in a 10-day old Iranian-Azeri male. The patient had creatinine rise and renal failure due to dysplastic left kidney and hypoplastic right kidney and expired on fifth day of admission. There were only six cases of renal malformation associated with aphallia in the literature review. Three of the cases were complicated by Potter sequence and one of them was accompanied by chronic renal failure. Our case had a unique presentation because of bilateral renal malformation and subsequent renal failure without the Potter sequence.

Stroke is one of the important and common diseases, which can lead to permanent disability or even death to people. Intracranial hemorrhage (ICH) is a type of stroke that is associated with high mortality despite improved diagnostic and treatment methods, as well as the mortality rate remains high.
In the present review article, reputable internet databases since 2000 were analyzed. Studies that discussed the predicting mortality of ICH were included in this review.
For predicting the mortality rates in patients with primary ICH, physicians use several methods such as level of consciousness, bleeding volume and multiple rating systems. In this review, we introduce three scoring system of ICH in patients with ICH.
Perhaps its cut-off point of these three score systems were different in different societies according to conditions and facilities therefore it is needed to review these scores and record their results in different societies.

Due to underlying autoimmune background of Guillain-Barré syndrome (GBS), the possible role of infectious agents cytomegalovirus (CMV) and Epstein-Barr virus (EBV) and also due to association of anti-ganglioside antibodies with GBS, the present study aimed to investigate the associations between serum anti-ganglioside antibodies (AGA) level, type of infection and electrodiagnostic (ED) findings with the severity and three-month functional outcome of patients with GBS. In a prospective study, 30 patients with GBS were selected and before starting the treatment, baseline serum samples of patients were obtained for measuring the serum AGA including the antibodies against GQ1b, GT1b, GD1a, GD1b, GM1, GM2, GM3 and strains of CMV and EBV. All the patients were precisely examined for ED findings. Functional status of patients on admission and three months after admission were recorded according to the modified Rankin scale (mRS). The results of patient's serum assessment revealed that CMV IgM was positive in one patient (3.3%), CMV IgG in 29 patients (96.7%) and EBV IgG in 27 patients (90%). Anti-GM1 was found in 3 patients (10%) and anti-GM3 was found only in one patient (3.3%). However, no statistical significant association was found between the AGA and strain of the disease and ED findings. Despite the coexistence of AGA and serum antibodies against CMV and EBV in some GBS patients, there was not clear association in this regard. However, the AGA was positive in patients who suffered from severe phase of the disease.

This study evaluated the efficacy of focal intramuscular injection of botulinum (BoNT) toxin type A in comparison with oral tizanidine (TZD) in treatment of post-stroke upper limb spasticity. This was a double-blinded randomized clinical trial that recruited 68 patients with post-stroke upper limb spasticity. Thirty-four patients received BoNT (Dysport®) injections in affected muscles of upper limb at the baseline and week 12. Thirty-four patients were treated with tizanidine (Sirdalude) by gradual increase in dosage of 2mg/week to reach maximum 24mg at week 12. Modified Ashworth Scale (MAS) and Action Research Arm Test (ARAT) were evaluated at the baseline, week 12 and week 24 for all the participants. The mean score of MAS reduced from 3.32 and 3.13 at baseline to 1.79 and 1.56 at week 24 on elbow and wrist joints, respectively (P < 0.01). However, there were only reductions from 2.79 and 2.77 to 2.32 and 2.31(P < 0.001) in TZD group. ARAT increased from 1.79 to 10.97 (P < 0.001) in BoNT group. ARAT increased from 11.08 to 11.35 in TZD group (P = 0.026). BoNT injection was safe and effective in reducing post-stroke upper extremity spasticity in comparison with TZD.

In patients with acute stroke and middle cerebral artery (MCA) stenosis, microembolic signals (MES) can predict further cerebral ischemia. Therefore, this study was designed to evaluate the prevalence of MES by transcranial Doppler (TCD) in patients with MCA stenosis under treatment of aspirin or clopidogrel. A randomized clinical trial was performed on 40 patients with acute ischemic stroke in MCA territory. They were randomly allocated in two groups that treated with aspirin (80 mg daily) or clopidogrel (75 mg daily). Clinical and diagnostic work up was included evaluation of cerebrovascular risk factors, echocardiography, carotid color Doppler and brain imaging. TCD was performed between day 3 and 7 after symptoms onset to detect MES. All high intensity transient signals (HITS) were saved and analyzed offline. Carotid stenosis was found in 13 (65%) patients of aspirin group and 12 (60%) of clopidogrel group. Four (30.8%) of aspirin group and 5 (41.7) of clopidogrel group had stenosis between 10%-50%. One patient in each group had more than 50% stenosis and the remainder had less than 10%. There was no significant difference between two groups. MES was detected in 6 (30%) of patients treated with aspirin and 4 (20%) of those treated with clopidogrel. It showed no statistically significant differences (P-value= 0.46). Our results indicate a similar effect of aspirin and clopidogrel on frequency of MES in patients with MCA territory ischemic stroke.