Borderzone Infarction and Small Vessel Disease in a Sample of Egyptian Stroke Patients: Differences and Similarities.

BACKGROUND: The anatomical location of white matter hyperintense lesions in small vessel disease are apparently similar to those of borderzone infarction. The objective of this study is to find clinical and radiological points of differentiation between the two vascular disorders in a sample of Egyptian patients which might have an impact on primary and secondary prevention. METHODS: Ischemic stroke patients with white matter lesions were categorized into two groups: small vessel disease and borderzone infarctions. NIHSS was done on admission. Risk factor profile was reported, and investigations done including: HbA1C, lipid profile, CRP, ECG, echocardiography, carotid duplex, brain MRI, MRA and MR perfusion study. RESULTS: 46 patients completed the study, 29 with SVD and 17 with BZI. Smoking, hypertension and recurrent stroke were more common in borderzone infarctions, but only diabetes was significantly higher (p = 0.047). Limb shaking was more observed in borderzone infarctions (p = 0.049). Radiologically: lacunar pattern was observed more in small vessel disease, while rosary pattern was more in borderzone infarctions (p = 0.04). FLAIR symmetrical lesions and microbleeds were more significant in small vessel disease (p = <0.001; 0.048, respectively). Perfusion study time to peak denoted evidence of significant hypoperfusion in all regions of interest in borderzone infarctions. CONCLUSION: Limb shaking, retinal claudication or syncope, with MRI showing rosary pattern of white matter hyperintensity, few microbleeds and markedly impaired perfusion favor the diagnosis of borderzone infarctions. On the other hand, presence of lacunae, FLAIR showing symmetrical WMH and microbleeds with minimal or no perfusion deficit suggests the diagnosis of small vessel disease.

Arabic adaptation and validation of the revised amyotrophic lateral sclerosis functional rating scale (ALSFRS-R): Egyptian study.

INTRODUCTION: ALSFRS-R is 12-item scale used to assess disability and to measure disease progression in ALS patients. The objective is to validate the Arabic version of ALSFRS-R based on the original English version. Methods and patients: This is a cross sectional study. ALSFRS-R was administered to 162 Egyptian patients with ALS after being translated in Arabic, and reapplied after 1 week. Patients were recruited from 2 centers: Neuromuscular unit, Ain Shams University hospitals and the specialized ALS clinic which is located at the international medical center (IMC). Results: No significant differences were found between the application and reapplication of the scale (p = 0.5). The linear regression and internal consistency that were measured by Pearson correlation and alpha Conbrach respectively were significant. Discussion: The Arabic version of the ALSFRS-R proposed by the current was proven to be reproducible and valid among Egyptian ALS patients. Thus, it will provide a useful tool for professionals to evaluate Arabic speaking patients in clinical practice and research.

Diagnostic delay among ALS patients: Egyptian study.

Introduction: In the current study, we are going to look at different factors responsible for the diagnostic delay of ALS patients among the sample of Egyptian patients. Method/patients: This is a cohort study. ALS patients were recruited from December 2018 to January 2020 from the ALS clinic at the international medical center (IMC) (Cairo, Egypt). We analyzed the site of onset, the time from symptom onset to diagnosis, age and sex differences among these ALS patients. Results: Thirty patients were included in the study. Seventy percent of the patients had limb onset ALS with a mean age of onset of 50 ± 12.1 vs 58.6 ± 2.1 years for the patients with bulbar onset (p = 0.02). Bulbar-onset patients were diagnosed earlier than limb onset patients (mean lag of 8.2 ± 2.57 months vs 22.95 ± 17.6 months respectively, p < 0.05). The average diagnosis time for women was slightly longer than that of men with a mean lag of 20.7 ± 21.1 vs. 17.6 ± 13.6 months, respectively, p > 0.05. Diagnostic delay and age at onset of symptoms were negatively correlated, however, this was not statistically significant. Discussion: To our knowledge, this the first population-based study from Egypt about predicting factors of diagnostic delay among Egyptian patients. Limb onset, female gender and young age are correlated with increased mean time to diagnosis. Statistically insignificant results could be attributed to a small sample. Larger population-based studies are needed from Egypt.

Clinical Characteristics of Borderzone Infarction in Egyptian Population.

OBJECTIVES: In this research we wanted to highlight the importance of defining Borderzone infarctions (BZI) as a separate subtype in stroke classifications. We thus studied cases of isolated BZI, small vessel disease (SVD), and large vessel disease (LVD), to identify their points of similarities and difference in a sample of Egyptian patients. METHODS: This is a cross-sectional (observational) study. Consecutive 637 acute ischemic stroke patients were recruited over a 2 year period, from 2 stroke units of Ain Shams University hospitals in Egypt. Medical history and laboratory investigations were done to identify risk factors. National Institute of Health Stroke Scale (NIHSS) was performed on admission, and modified Rankin scale (mRS) on admission, and after 3 months. MRI brain was done to identify stroke subtype; MRA and carotid duplex were used to define vascular status. RESULTS: Among the studied group of patients, 72 (11.3%) had BZI, 145 (22.8%) had SVD, 165 (26%) had LVD, and 255 were excluded as they had either undetermined, or mixed etiology. BZI showed significantly older age, early confluent lesions, more disease severity by NIHSS, and worst outcome by mRS (P < 0.05). SVD had more microbleeds than BZI and LVD. LVD showed lower prevalence of hypertension and lower high-density lipoprotein levels. CONCLUSIONS: Isolated BZI, SVD, and LVD infarctions have characteristic risk factors and clinical patterns. Further studies are needed to identify if they are different from cases with mixed pathology. This could have an impact on the selection of primary and secondary preventive measures appropriate to each type.

Egyptian experience in increasing utilization of reperfusion therapies in acute ischemic stroke.

Background The rate of alteplase (tPA) thrombolysis utilization in acute stroke in Egypt is <1%. We report on the causes of this low rate of reperfusion therapies and take corrective action to improve it. Methods Two prospective observational studies were conducted at Ain Shams University hospitals. The first included 269 acute stroke patients admitted to the hospital over a six-month period. Obstacles to reperfusion therapy were identified, and based on the results, a corrective action plan was implemented including making alteplase(tPA) available, training, and establishing a standardized local protocol for reperfusion therapy. A second study was then conducted that included 284 acute ischemic stroke patients over another six-month period. Results In the first study, 53/269 patients (19.7%) arrived at hospital within 4.5 h and were eligible for reperfusion therapy. Of those, seven (13.2%) received alteplase(tPA), representing 2.6% of the total ischemic stroke patients admitted. The main causes for not giving thrombolytic therapy was unavailability of alteplase(tPA) (56.5%), wrong treatment decision (17.4%), missed window while performing brain imaging (15%), and unavailability of intermediate care bed (10.9%). The second study showed that out of 284 cases admitted with acute ischemic stroke, 37 were eligible for thrombolysis and 35 received alteplase(tPA) (94.3%), representing 12.3% of the total ischemic stroke admissions. Conclusion A comprehensive action plan that centers around making the drug available and training resulted in a significant improvement of reperfusion therapy utilization in Egypt.