Effect of Extracorporeal Shockwave Therapy on Pain Management of Patients with Post-Stroke Hemiplegic Shoulder Pain: A Prospective Randomized Controlled Trial.

Background: Post-stroke hemiplegic shoulder pain (HSP) is a common complication leading to significant activity limitation. Some approaches have been recommended for the management of HSP, and most of them have various adverse effects, while none were established to be effective. This study aimed to evaluate the effect of minimally invasive extracorporeal shockwave therapy (ESWT) on patients with HSP pain management. Materials and Methods: Using a single-blind, randomized clinical trial, 43 patients with HSP were randomly assigned to complete three focus ESWT sessions once a week and additional five radial ESWT sessions twice a week. Patients in the control arm received zero energy ESWT. Visual analog scale, passive range of motion (ROM), Fugl-Meyer upper extremity assessment (FMA-UE), and shoulder pain and disability scale (SPADI) were measured at baseline, at the end of the interventions, and within four and eight weeks' intervals to evaluate the pain, function, and ROM in the affected shoulder. Result: Both groups showed an improvement in pain scores on the fourth and eighth weeks visits (P-value <0.001). Intervention with ESWT could effectively lead to a less severe pain score compared to the control group (P-value <0.001). In the intervention group, the ROM improved in both passive abduction and forward flexion (P-value <0.05), but no significant change was observed in the control group (P-value >0.05). FMA-UE and SPADI did not differ significantly between groups. Conclusion: Based on the findings of this study, the combination of rESWT and focused ESWT can efficiently improve stroke-induced HSP.

Watershed infarction in COVID-19: The necessity of neuroimaging in patients with subtle neurological symptoms.

Background: Cerebrovascular diseases comprise a significant portion of neurological disorders related to coronavirus disease 2019 (COVID-19). We evaluated the clinical and imaging characteristics of a cohort of COVID-19 patients with stroke and also identified patients with watershed infarcts. Methods: In this cross-sectional study, seventy-three COVID-19 patients with ischemic stroke were included between October 2020 and January 2021. Patients were evaluated based on the following clinical and imaging features: severity of COVID-19 (critical/ non-critical), stroke type, presence/absence of clinical suspicion of stroke, medical risk factors, Fazekas scale, atherothrombosis, small vessel disease, cardiac pathology, other causes, and dissection (ASCOD) criteria classification, and presence or absence of watershed infarction. Clinical outcomes were assessed based on Modified Rankin Scale (MRS) and mortality. Results: Most cases of ischemic stroke were due to undetermined etiology (52.1%) and cardioembolism (32.9%). In terms of imaging pattern, 17 (23.0%) patients had watershed infarction. Watershed infarction was associated with the clinically non-suspicious category [odds ratio (OR) = 4.67, P = 0.007] and death after discharge (OR = 7.1, P = 0.003). Patients with watershed infarction had a higher odds of having high Fazekas score (OR = 5.17, P = 0.007) which was also shown by the logistic regression model (adjusted OR = 6.87, P = 0.030). Thirty-one (42%) patients were clinically non-suspected for ischemic stroke. Critical COVID-19 was more common among patients with watershed infarct and clinically non-suspicious patients (P = 0.020 and P = 0.005, respectively). Patients with chronic kidney disease (CKD) were more prone to having stroke with watershed pattern (P = 0.020). Conclusion: Watershed infarct is one of the most common patterns of ischemic stroke in patients with COVID-19, for which clinicians should maintain a high index of suspicion in patients with critical COVID-19 without obvious clinical symptoms of stroke.

Iran Quality of Care in Medicine Program (IQCAMP): Design and Outcomes.

BACKGROUND: Assessment of quality and cost of medical care has become a core health policy concern. We conducted a nationwide survey to assess these measures in Iran as a developing country. To present the protocol for the Iran Quality of Care in Medicine Program (IQCAMP) study, which estimates the quality, cost, and utilization of health services for seven diseases in Iran. METHODS: We selected eight provinces for this nationally representative short longitudinal survey. Interviewers from each province were trained comprehensively. The standard definition of seven high-burden conditions (acute myocardial infarction [MI], heart failure [HF], diabetes mellitus [DM], stroke, chronic obstructive pulmonary (COPD) disease, major depression, and end-stage renal disease [ESRD]) helped customize a protocol for disease identification. With a 3-month follow-up window, the participants answered pre-specified questions four times. The expert panels developed a questionnaire in four modules (demographics, health status, utilization, cost, and quality). The expert panel chose an inclusive set of quality indicators from the current literature for each condition. The design team specified the necessary elements in the survey to calculate the cost of care for each condition. The utilization assessment included various services, including hospital admissions, outpatient visits, and medication. RESULTS: Totally, 156 specialists and 78 trained nurses assisted with patient identification, recruitment, and interviewing. A total of 1666 patients participated in the study, and 1291 patients completed all four visits. CONCLUSION: The IQCAMP study was the first healthcare utilization, cost, and quality survey in Iran with a longitudinal data collection to represent the pattern, quantity, and quality of medical care provided for high-burden conditions.

Application of the Intracranial Arterial Pulsatility Index for Determination of Prognosis after Lacunar Infarct.

Background: We aimed to investigate the usefulness of intracranial arterial pulsatility index to assess the prognosis of lacunar infarcts. Materials and Methods: Forty-nine patients with confirmed acute lacunar infarct were enrolled in the study. A transcranial color-coded sonography was performed to assess the pulsatility index of bilateral middle cerebral, posterior cerebral, vertebral, and proximal internal carotid arteries. Patients' clinical status was assessed using a modified Rankin scale. Spearman correlation was used for reporting the relation between quantitative data. Statistical significance was defined as a two-tail p-value of less than 0.05. Results: The mean age ± standard deviation was 64.1 ± 9.07 years old, and 57.1% of the patients were male. Upon discharge, only 8.2% of the patients were ranked as 0 on the modified Rankin scale; however, after a 6-month follow-up period, this number increased to 49%. There were no significant differences between the left and right pulsatility index measurements in any of the assessed arteries. Patients with vertebral artery pulsatility indexes >1 on their primary assessment had significantly worse outcomes during the first, third, and sixth months follow-up (all r > 0.3, p-values < 0.01). Pulsatility indexes from other arteries did not predict the prognosis. Conclusion: Sonography-assisted assessment of the vertebral artery blood flow during the early stage of lacunar infarct provides a reliable reference for prognosis estimation.

Re-Evaluating Risk Factors, Incidence, and Outcome of Aneurysmal and Non-Aneurysmal Subarachnoid Hemorrhage.

OBJECTIVE: Subarachnoid hemorrhage (SAH) is one of the world's most life-threatening types of stroke. SAH can be classified into two main categories, aneurysmal (aSAH) and non-aneurysmal SAH (naSAH). In the present study, we aimed to prospectively evaluate SAH and its subcategories incidences, risk factors, complications, and outcomes in central Iran. METHODS: All SAH patients diagnosed between 2016 and 2020 were included in Isfahan SAH Registry. Demographic, clinical characteristics, incidence rates (based on age categories), and laboratory/imaging findings were collected and compared between aSAH and naSAH subgroups. Complications during hospital stay and outcomes were also analyzed. Binary logistic regression analysis was performed to investigate the predictors of aSAH versus naSAH. Kaplan-Meier curves and Cox regression were used to evaluate the survival probability. RESULTS: A total of 461 SAH patients were included through Isfahan SAH Registry. The SAH annual incidence rate was 3.11 per 100,000 person-years. aSAH had higher incidence rate than naSAH (2.08/100,000 vs. 0.9/100,000 person-years, respectively). In-hospital mortality was 18.2%. Hypertension (P = 0.003) and smoking (P = 0.03) were significantly associated with aSAH, whereas diabetes mellitus (P < 0.001) was more associated with naSAH. After Cox regression analysis, there were higher hazard ratios for reduced in-hospital survival in conditions including altered mental status, Glasgow Coma Scale ≤13, rebleeding, and seizures. CONCLUSIONS: This study provided an updated estimation of SAH and its subgroups incidences in central Iran. Risk factors for aSAH are comparable to the ones reported in the literature. It is noteworthy that diabetes mellitus was associated with a higher incidence of naSAH in our cohort.

Cardioembolic stroke, the most common subtype of stroke in COVID 19: A single center experience from Isfahan, Iran.

Background: Some studies showed the cerebrovascular manifestation in patients with recently pandemic coronavirus 2 named the coronavirus disease 2019 (COVID-19). However, there are rare reports about stroke subtypes in these patients. Here, we reported the stroke subtype in patients with laboratory-confirmed diagnosis of COVID-19 and treated at our hospitals, which are located in Isfahan, Iran. Materials and Methods: This is a retrospective, observational case series. Data were collected from March 01, 2020, to May 20, 2020, at three designated special care centers for COVID-19 of Isfahan University of Medical Sciences. The study included 1188 consecutive hospitalized patients with laboratory-confirmed diagnosis of COVID-19. Results: Of 1188 COVID-19 patients, 7 (0.5%) patients developed stroke. Five (0.4%) had ischemic arterial stroke, 1 (0.08%) hemorrhagic stroke and 1(0.08 %) cerebral venous and sinus thrombosis. Sixty percent of ischemic stroke were cardioembolic stroke (CE) and the rest 2 (40%) were embolic stroke of undetermined source. Three male patients (40%) had stroke as a presenting and admitted symptom of COVID-19. Four patients (57%) had severe COVID-19. Conclusion: Stroke was an uncommon manifestation in COVID-19 patients. CE was a common subtype of stroke in COVID-19 patients in our centers.

The effects of royal jelly supplementation on oxidative stress, inflammatory mediators, mental health, cognitive function, quality of life, and clinical outcomes of patients with ischemic stroke: study protocol for a randomized controlled trial.

BACKGROUND: Stroke is a debilitating disease that affects over 15 million people worldwide each year, resulting in the death of one-third of those people and severe disability in two-thirds of survivors. Previous studies reported various health benefits of Royal jelly in the context of its anti-inflammatory properties. We will aim to investigate the effects of royal jelly supplementation on oxidative stress, inflammatory mediators, mental health, cognitive function, quality of life, and clinical outcomes of patients with ischemic stroke. METHODS: The present study will be a triple-blind randomized placebo trial. Patients who meet our eligibility criteria will be assigned to the intervention or the control groups to receive allocated intervention for 12 weeks. Individuals of the intervention group will consume 1000 mg of Royal jelly dragee daily after breakfast. Subjects of the control group will receive a placebo dragee identical to the Royal jelly dragee. The severity of the stroke, cognitive function, mental health, quality of life, clinical outcomes, and biochemical measures will be assessed at baseline and post-intervention. DISCUSSION: The current study is designed to investigate the effectiveness and safety of royal jelly supplementation in a randomized, parallel, two-arms, single-center, triple-blind, placebo-controlled manner. This study will provide evidence as a phase III clinical trial. TRIAL REGISTRATION: IRCT20180818040827N4, registered on 16 October 2021. https://www.irct.ir/trial/59275.

Clinical and Neuroimaging Characteristics of Ischemic Stroke in Rhino-Orbito-Cerebral Mucormycosis Associated with COVID-19.

PURPOSE: The aim of this study was to compare clinical, neuroimaging, and laboratory features of rhino-orbito-cerebral mucormycosis (ROCM) in COVID-19 patients with and without ischemic stroke complications. METHODS: This observational study was conducted between August and December 2021 and 48 patients who had confirmed ROCM due to COVID-19, according to neuroimaging and histopathology/mycology evidence were included. Brain, orbit and paranasal sinus imaging was performed in all included patients. Data pertaining to clinical, neuroimaging, and laboratory characteristics and risk factors were collected and compared between patients with and without ischemic stroke complications. RESULTS: Of the patients 17 were diagnosed with ischemic stroke. Watershed infarction was the most common pattern (N = 13, 76.4%). Prevalence of conventional risk factors of stroke showed no significant differences between groups (patients with stroke vs. without stroke). Cavernous sinus (p = 0.001, odds ratio, OR = 12.8, 95% confidence interval, CI: 2.3-72) and ICA (p < 0.001, OR = 16.31, 95%CI: 2.91-91.14) involvement was more common in patients with stroke. Internal carotid artery (ICA) size (on the affected side) in patients with ischemic stroke was significantly smaller than in patients without stroke (median = 2.4 mm, interquartile range, IQR: 1.3-4 vs. 3.8 mm, IQR: 3.2-4.3, p = 0.004). Superior ophthalmic vein (SOV) size (on the affected side) in patients with stroke was significantly larger than patients without stroke (2.2 mm, IQR: 1.5-2.5 vs. 1.45 mm IQR: 1.1-1.8, p = 0.019). Involvement of the ethmoid and frontal sinuses were higher in patients with stroke (p = 0.007, OR = 1.85, 95% CI: 1.37-2.49 and p = 0.011, OR = 5, 95% CI: 1.4-18.2, respectively). Patients with stroke had higher D­dimer levels, WBC counts, neutrophil/lymphocyte ratios, and BUN/Cr ratio (all p < 0.05). CONCLUSION: Stroke-related ROCM was not associated with conventional ischemic stroke risk factors. Neuroimaging investigations including qualitative and quantitative parameters of cavernous sinus, ICA and SOV are useful to better understand the mechanism of stroke-related ROCM in COVID-19 patients.

Effects of the royal jelly consumption on post-stroke complications in patients with ischemic stroke: results of a randomized controlled trial.

Aims: There is a paucity of evidence regarding the benefit of royal jelly (RJ) on post-stroke complications in patients with ischemic stroke. To address this knowledge gap, this randomized, triple-blind, placebo-controlled clinical trial was carried out to determine the effects of RJ consumption on post-stroke clinical outcomes. Methods: Of 64 eligible ischemic stroke patients (45-80 years), 32 were randomized to the RJ and 32 to the placebo groups and completed a 12-week intervention. The intervention group was advised to receive 1,000 mg of RJ dragee daily after breakfast. Post-stroke complications including cognition, fatigue, mental health, and appetite, along with serum levels of brain-derived neurotrophic factor (BDNF), and mid-upper arm circumference (MUAC) were assessed in groups pre-and post-intervention. Results: After 12 weeks of RJ consumption, cognitive function [adjusted mean difference, 4.71; 95% confidence interval (CI), 1.75 to 7.67], serum levels of BDNF (adjusted mean difference, 0.36; 95% CI, 0.05 to 0.67), stress (adjusted mean difference, -3.33; 95% CI, -6.50 to -0.17), and appetite (adjusted mean difference, 1.38; 95% CI, 0.19 to 2.56) were significantly improved. However, the findings for fatigue (adjusted mean difference, -4.32; 95% CI, -10.28 to 1.63), depression (adjusted mean difference, -1.71; 95% CI, -5.58 to 2.16), anxiety (adjusted mean difference, -2.50; 95% CI, -5.50 to 0.49), and MUAC (adjusted mean difference, 0.36; 95% CI, -0.11 to 0.84) were less favorable. Conclusion: Findings support the benefits of RJ consumption in improving post-stroke complications and clinical outcomes.Clinical trial registration: https://www.irct.ir/trial/59275, Identifier IRCT20180818040827N4.

A Hospital-Based Case-Control Study on Whole- and Refined-Grain Intake and Risk of Stroke.

INTRODUCTION: The aim of the present study was to ascertain the correlation between the intake of whole and refined grains and the risk of stroke in the Iranian adult population. METHOD: This hospital-based case-control study was conducted at Alzahra University Hospital, Isfahan, Iran, in 2008. The cases (n=195) were stroke patients admitted to the neurology ward, and the controls (n=195) were patients admitted to other wards in this center, with no prior history of cerebrovascular accident or any neurological disorders. The usual dietary intakes of the study participants during the previous year were assessed using a validated semi-quantitative food frequency questionnaire. Whole and refined grains were defined according to the definition of the American Association of Cereal Chemists International; foods that contained at least 8 g per 30 g of their weight were considered as whole grains. RESULTS: The mean age of the case and control groups was 68.0 (±13.5) and 61.5 (±10.5) years, respectively; 40% of the cases and 53.3% of the controls were female. The total intake of whole grains (27.8±4.3 vs. 29.4±3.6 g/d, P=0.77) and refined grains (264±11 vs. 296±13 g/d, P=0.07) was not significantly different between the cases and controls. After adjusting for potential confounders, individuals in the second tertile of refined grain intake had a two-fold higher odds of stroke (OR: 2.02; 95% CI: 1.08-3.71), compared to those in the first tertile. Furthermore, no significant relationships were observed between the consumption of whole grains and the risk of stroke, before or after adjustment for confounding variables. No significant trend was found between the tertiles of refined or whole grain intake and the risk of stroke. CONCLUSION: The authors did not find a statistically significant association between the intake of whole and refined grains and the risk of stroke. Further prospective studies on the relationship between both whole and refined grains and stroke are warranted.

The Incidence of Cardiovascular Events in Small Versus Large Ischemic Stroke; A Three-Year Cohort Study.

INTRODUCTION: Cerebral ischemia and coronary artery disease (CAD), the major leading causes of mortality and morbidity worldwide, are pathophysiologically interrelated. Cerebral ischemic events are categorized as large or small vessels disease. The current study compares the factors related to CAD events incidence following ischemic large versus small disease CVA. METHOD: The current cohort study was conducted on 225 patients with ischemic stroke in two groups of large (n=75) and small (n=150) vessel disease during 2018-19. The patients' demographic, medical, and clinical characteristics were recruited. They were followed for three years regarding the incidence of CAD events, including ST-elevation myocardial infarction (STEMI), non-ST elevation myocardial infarction (NSTEMI), unstable angina (UA), and sudden cardiac death (SCD). Data about the coronary angiography, computed tomography angiography (CTA), Single Photon Emission Computed Tomography (SPECT), and the therapeutic approach were gathered. RESULTS: There were insignificant differences between the patients with small versus large vessels CVA in terms of ACS incidence (P-value=0.105), type of the events (P-value=0.836), angiographic (P-value=0.671), SPECT (P-value=0.99) and CTA findings (P-value>0.99) and approached CAD (P-value=0.728). Cox regression assessments revealed an increased risk of CAD events due to large versus small vessels disease after adjustments for hypertension, diabetes mellitus, dyslipidemia, re-stroke, and the previous history of IHD (HR=2.005, 95%CI: 1.093-2.988, P-value=0.021). CONCLUSION: According to the findings of this study, large-vessel involvement in an ischemic stroke was associated with more than a two-fold increase in the three-year probability of ischemic heart disease incidencet.

Can Early Neuromuscular Rehabilitation Protocol Improve Disability after a Hemiparetic Stroke? A Pilot Study.

BACKGROUND: The impairment of limb function and disability are among the most im portant consequences of stroke. To date, however, little research has been done on the early reha bilitation trial (ERT) after stroke in these patients. The purpose of this study was to evaluate the impact of ERT neuromuscular protocol on motor function soon after hemiparetic stroke. The sample included twelve hemiparetic patients (54.3 ± 15.4 years old) with ischemic stroke (n = 7 control, n = 5 intervention patients). ERTwas started as early as possible after stroke and included passive range of motion exercises, resistance training, assisted standing up, and active exercises of the healthy side of the body, in addition to encouraging voluntary contraction of affected limbs as much as possible. The rehabilitation was progressive and took 3 months, 6 days per week, 2-3 h per session. Fu gle-Meyer Assessment (FMA), Box and Blocks test (BBT) and Timed up and go (TUG) assessments were conducted. There was a significantly greater improvement in the intervention group com pared to control: FMA lower limbs (p = 0.001), total motor function (p = 0.002), but no significant difference in FMA upper limb between groups (p = 0.51). The analysis of data related to BBT showed no significant differences between the experimental and control groups (p = 0.3). However, TUG test showed significant differences between the experimental and control groups (p = 0.004). The most important finding of this study was to spend enough time in training sessions and provide adequate rest time for each person. Our results showed that ERT was associated with improved motor function but not with the upper limbs. This provides a basis for a definitive trial.

"Incidence, characteristics and prognosis of cervical artery dissection-induced ischemic stroke in central Iran".

OBJECTIVES: Ischemic stroke is the most common presentation of cervical artery dissection (CAD). Information regarding CAD-induced stroke is scarce, especially in the Middle East. Here we investigated the incidence of CAD-induced stroke, its characteristics, and the clinical course in central Iran. METHODS: This is an observational study conducted in the city of Isfahan, Iran. We recruited patients with ischemic stroke during 2017-2019. We analyzed characteristics of the CAD-induced stroke patients with regards to the involved vessel (internal carotid artery dissection (ICAD) or vertebral artery dissection (VAD)). We assessed functional outcome (modified Rankin Scale [mRS]) and recanalization status after 1 year of follow-up. RESULTS: Among 3630 ischemic stroke patients, 51(1.4%) had CAD-induced stroke (mean age: 41.8 ± 12.6; 40.4% female; 28 and 19 ICAD and VAD cases, respectively). The crude incidence rate of CAD-induced stroke was 1.20/100,000/year (0.66/100,000/year and 0.45/100,000/year for strokes due to ICAD and VAD, respectively). mRS ≤ 2 was present in 63.8% of the patients after 1 year of follow-up. History of exercise during the last days before stroke occurrence was associated with a better follow-up mRS (ß = -3.1, p-value: 0.037). Administration of anticoagulant or double-antiplatelets was related neither to mRS nor recanalization results. Trauma (27.7%), smoking (21.3%), and headache disorders/migraine (21.3%) were the most common reported factors. CONCLUSION: We found a crude incidence rate of 1.20/100,000/year for CAD-induced stroke. Trauma, smoking, and headache disorders were the most common reported factors among our patients. CAD-induced stroke had a favorable long-term prognosis regardless of the type of the involved vessel or the used medication.

New-onset acute ischemic stroke following COVID-19: A case-control study.

Background: Neurological manifestations of coronavirus disease 2019 (COVID-19) have been highlighted. COVID-19 potentially increases the risk of thromboembolism. We aimed to compare patients with COVID-19 with and without new-onset acute ischemic stroke (AIS). Materials and Methods: In this single-center retrospective case-control study, demographics, clinical characteristics, laboratory findings, and clinical outcomes were compared between 51 patients with both COVID-19 and AIS (group A) and 160 patients with COVID-19 and without AIS (group B). Results: Patients in group A were significantly older, more likely to present with critical COVID-19 (P = 0.004), had higher rates of admission in the intensive care unit (P < 0.001), more duration of hospitalization (P < 0.001), and higher in-hospital mortality (P < 0.001). At the time of hospitalization, O2 saturation (P = 0.011), PH (P = 0.04), and HCO3 (P = 0.005) were lower in group A. White blood cell count (P = 0.002), neutrophil count (P < 0.001), neutrophil-lymphocyte ratio (P = 0.001), D-Dimer (P < 0.001), blood urea nitrogen (BUN) (P < 0.001), and BUN/Cr ratio (P < 0.001) were significantly higher in patients with AIS. Conclusion: Stroke in COVID-19 is multifactorial. In addition to conventional risk factors of ischemic stroke (age and cardiovascular risk factors), we found that patients with more severe COVID-19 are more prone to ischemic stroke. Furthermore, leukocyte count, neutrophil count, neutrophil-lymphocyte ratio, D-Dimer, BUN, and BUN/Cr ratio were higher in patients with AIS following COVID-19 infection.

Safety of Intraparenchymal Injection of Allogenic Placenta Mesenchymal Stem Cells Derived Exosome in Patients Undergoing Decompressive Craniectomy Following Malignant Middle Cerebral Artery Infarct, A Pilot Randomized Clinical Trial.

Background: Malignant middle cerebral artery infarct (mMCAI) largely contributes to high mortality and physical disability among adults. Surviving individuals may not have proper outcomes and suffer from severe lasting disabilities. Utilization of stem cells and paracrine factor for regenerative purposes is considered as a potential strategy for patients with neurological deficits. While preclinical stroke studies have shown that mesenchymal stem cells (MSCs) reduce post-treatment neurological deficits and prevent disability and also promote recovery, few randomized clinical trials (RCT) have assessed exosome therapy in humans. Methods: In this RCT, we assessed the safety of intraparenchymal injection placenta MSC-derived Exosome in mMCAI patients with average age of 62 years between January, 2019, till September, 2020. The study was done in a single-center as an open-label RCT, with a 3-months follow-up. Primary outcomes assessed the safety and also disability indexes were followed. Results: Five mMCAI patients were included with mean NIHSS: 17.6 ± 5.02. The mean MRS was 3.25 ± 0.95 in three patients. No serious adverse events were observed. Hematoma or local reaction as excessive edema were not seen at the site of injection. Conclusions: Intraparenchymal implantation of MSC-EXO showed no post-interventional adverse effects in five ischemic stroke patients. It is proposed Local injection Exosome treatment following mMCAI can be safe and in future, it would be applied as a supportive, restorative and preventive treatment in patients who suffer from acute ischemic stroke and post ischemic disability.

Reversible Cerebral Vasoconstriction Syndrome and Multisystem Inflammatory Syndrome in Children With COVID-19.

BACKGROUND: Multisystem inflammatory syndrome in children (MIS-C) involves multiple organs and shows increased inflammatory markers. Since the onset of the coronavirus disease 2019 (COVID-19) pandemic, several studies have reported the association between severe COVID-19 and MIS-C. Reversible cerebral vasoconstriction syndrome (RCVS) presents with thunderclap headaches and multifocal reversible vasoconstriction on imaging. RCVS is very rare in children. This article reports two cases of pediatric COVID-19 with severe MIS-C and clinical and imaging features indicative of RCVS. METHODS: Clinical, laboratory, and imaging data of the patients were reviewed. The diagnosis of RCVS was confirmed based on clinical symptomatology and brain magnetic resonance imaging findings. RESULTS: Two pediatric patients with clinical findings compatible with severe MIS-C and hemodynamic compromise presented to the hospital. During their hospitalization course, they developed thunderclap headaches and neurological deficits. Both were receiving vasoactive agents, intravenous immunoglobulin, and immunosuppressants. Imaging studies showed marked multifocal cerebral vasoconstriction in both cases and infarcts in one. The course and management of the patients will be presented. After controlling inflammation and elimination of triggers, both patients were ultimately symptom free upon discharge. Cerebral vasoconstriction had completely resolved on follow-up imaging. CONCLUSIONS: Although a variety of symptoms including headaches may be seen in pediatric COVID-19 patients with MIS-C, RCVS should be considered as a differential diagnosis in cases of thunderclap headache accompanied by neurological signs in these patients. Imaging findings and follow-up are also key in establishing the diagnosis.

Investigating the effect of implementing a program based on transitional care model on the quality of life and the ability of doing activities of daily living among patients with stroke.

BACKGROUND: Stroke is one of the major causes of disability among individuals. Transitional care of a stroke patient can contribute to sustaining and enhancing the quality of care. The aim of this study is to determine the effect of implementing a program based on the transitional care model on the quality of life and ability of doing daily activities among patients suffering from stroke. MATERIALS AND METHODS: This research was an interventional study performed on 80 patients with stroke referring to the hospitals affiliated with Isfahan University of medical sciences. For data collection, demographic, quality of life measurement following stroke, and Bartell index of daily activity measurement questionnaires were used at the beginning of the study and 10 weeks following discharge. The transitional care model was undertaken for the intervention group from the second day of hospitalization until 10 weeks postdischarge. The data were analyzed using SPSS software and statistical methods. RESULTS: The results indicated that the mean quality of life and ability of performing the activities changed significantly after the intervention between the two groups, with the mean changes of these scores becoming significant compared to the preintervention between the two groups (P < 0.05). In both groups, the mean value of these scores increased after the study compared to the baseline, though this increase was greater in the intervention group. CONCLUSION: Implementing the transitional care model could contribute to improving the quality of life and performing the daily activities among stroke patients.

Effects of greater occipital nerve block with local anesthetic and triamcinolone for treatment of medication overuse headache: an open-label, parallel, randomized, controlled clinical trial.

AIM: There is a paucity of evidence and consensus on exactly how to carry out the detoxification process. To examine the effect of a greater occipital nerve block (GONB) in the detoxification process, we conducted an open-label, parallel, randomized, controlled clinical trial. MATERIALS AND METHODS: In order to conduct this study, 54 medication-overuse headache (MOH) patients were recruited and allocated randomly to group A (n = 27) or B (n = 27). In both groups, patients underwent detoxification processes without any acute migraine medication or analgesics. During the run-in period, all patients in both groups received the same education, managed by a neurologist and nutritionist. All patients were offered maximally 300 mL of promethazine syrup (5 mg/5 mL) to be taken 10 mg every 8 h during the first 10 days of the study. A 2-mL syringe containing 1 mL of lidocaine 2% and 1 mL of triamcinolone 40 mg/mL was prepared for each patient of group A for conducting GONB. Characteristics of headache attacks, including headache severity, frequency, and duration, were assessed at baseline and after 3 months of intervention. RESULTS: Twenty-six patients in group A (96.3%) and twenty-three in group B (85.2%) completed detoxification, and were thus cured of MOH (P = 0.351). The present study revealed that GONB with local anesthetic and triamcinolone significantly improved the characteristics of headache, including frequency (- 13.66 in group A and - 7.55 in group B), duration (- 7.92 in group A and - 5.88 in group B), and severity (- 3.44 in group A vs. - 1.33 in group B) in group A compared to control (all P value < 0.05). CONCLUSIONS: Although both detoxification programs were effective, detoxification with GONB resulted in better outcomes. TRIAL REGISTRATION: Iranian Registry of Clinical Trials (registration number; IRCT20150906023922N2).

The association between adherence to the MIND diet and stroke: a case-control study.

OBJECTIVES: Although some components of MIND diet were associated with stroke, no information is available on the association between adherence to the MIND diet and odds of stroke. This study was conducted to investigate the association between adherence to the MIND diet and odds of stroke among Iranian adults. METHODS: This case-control study was done on 193 hospitalized stroke cases and 195 hospital-based controls in Al-Zahra hospital, Isfahan, Iran. Dietary intakes of study participants were assessed using a validated 168-item food frequency questionnaire (FFQ). The MIND diet score was computed based on participants' dietary intakes obtained from FFQ. Stroke was confirmed by a trained neurologist using standard imaging methods. RESULTS: After controlling for age, sex, energy intake, physical activity, smoking, hypertension, diabetes, dyslipidemia, and heart disease, there was no significant association between adherence to the MIND diet and stroke (OR: 0.54; 95% CI: 0.26, 1.12). However, after further adjustment for BMI, we found that those with the greatest adherence to the MIND diet were less likely to have stroke compared with those with the lowest adherence; such that greater adherence to the MIND diet was associated with a 59% reduced odds of stroke (OR: 0.41; 95% CI: 0.18-0.94). CONCLUSION: In conclusion, we found that adherence to the MIND diet was inversely associated with odds of stroke in a case-control study. Further studies are required to confirm these findings.

Dietary phytochemical index in relation to risk of stroke: a case-control study.

BACKGROUND & AIM: No study explores the association of dietary phytochemical index (DPI) with stroke. This study was undertaken to obtain the required insight in this regard in Iranian adults. METHODS: This hospital-based case-control study was carried out on 195 stroke patients (diagnosed based on clinical and brained CT findings) and 195 control subjects with no history of cerebrovascular diseases or neurologic disorders). Data collection on dietary intakes was done using a 168-item validated FFQ. DPI was calculated using the McCarty equation. Logistic regression model in different models was used to evaluate the association between DPI and stroke. RESULTS: Mean age of study participants was 64.8 years, and 53.4% of them were male. Individuals in the highest tertile of DPI were younger (63 ± 11 vs. 67.4 ± 13 y, P = 0.01) and less likely to be physically active (2804 ± 5714 vs. 4772 ± 11912 M, P = 0.03). After adjustment for potential confounders, no significant relationship was observed between DPI and stroke risk (OR: 0.76; 95% CI: 0.39-1.49). However, when we considered the effect of dietary intakes, subjects in the top tertile of DPI were 61% less likely to have a stroke than those in the bottom tertile (OR: 0.39; 95% CI: 0.16-0.95). When BMI was controlled, the association between DPI and stroke became strengthened (OR: 0.32; 95% CI: 0.12-0.86). CONCLUSION: We found evidence indicating a significant inverse association between DPI and odds of stroke in adults. Further prospective studies are warranted to confirm this association.