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  Citation statistics : Table of Contents
   2020| January-March  | Volume 6 | Issue 1  
    Online since February 18, 2020

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Multiphase adjuvant neuroprotection: A novel paradigm for improving acute ischemic stroke outcomes
Wenbo Zhao, Chuanjie Wu, David Dornbos III, Sijie Li, Haiqing Song, Yuping Wang, Yuchuan Ding, Xunming Ji
January-March 2020, 6(1):11-18
While several large pivotal clinical trials recently revealed a substantial benefit of endovascular thrombectomy for acute ischemic stroke (AIS) caused by large-vessel occlusion, many patients still experience mediocre prognosis. Enlargement of the ischemic core, failed revascularization, incomplete reperfusion, distal embolization, and secondary reperfusion injury substantially impact the salvaging of brain tissue and the functional outcomes of AIS. Here, we propose novel concept of “Multiphase Adjuvant Neuroprotection” as a new paradigm that may help guide our search for adjunctive treatments to be used together with thrombectomy. The premise of multiphase adjuvant neuroprotection is based on the diverse and potentially nonoverlapping pathophysiologic mechanisms that are triggered before, during, and after thrombectomy therapies. Before thrombectomy, strategies should focus on preventing the growth of the ischemic core; during thrombectomy, improving recanalization while reducing distal embolization and maximizing reperfusion are of significant importance; after reperfusion, strategies should focus on seeking targets to reduce secondary reperfusion injury. The concept of multiphase adjuvant neuroprotection, wherein different strategies are employed throughout the various phases of clinical care, might provide a paradigm to minimize the final infarct size and improve functional outcome in AIS patients treated with thrombectomy. With the success of thrombectomy in selected AIS patients, there is now an opportunity to revisit stroke neuroprotection. Notably, if the underlying mechanisms of these neuroprotective strategies are identified, their role in the distinct phases will provide further avenues to improve patient outcomes of AIS.
  32 41,833 6,984
Role of vinpocetine in ischemic stroke and poststroke outcomes: A critical review
Hayder M Al-Kuraishy, Ali I Al-Gareeb, Marwa Thaier Naji, Farah Al-Mamorry
January-March 2020, 6(1):1-10
Vinpocetine (VPN) is a synthetic ethyl-ester derivative of the alkaloid apovincamine from Vinca minor leaves. VPN is a selective inhibitor of phosphodiesterase type 1 (PDE1) that has potential neurological effects through inhibition of voltage-gated sodium channel and reduction of neuronal calcium influx. VPN has noteworthy antioxidant, anti-inflammatory, and anti-apoptotic effects with inhibitory effect on glial and astrocyte cells during and following ischemic stroke (IS). VPN is effective as adjuvant therapy in the management of epilepsy; it reduces seizure frequency by 50% in a dose of 2 mg/kg/day. VPN improves psychomotor performances through modulation of brain monoamine pathway mainly on dopamine and serotonin, which play an integral role in attenuation of depressive symptoms. VPN recover cognitive functions and spatial memory through inhibition of hippocampal and cortical PDE1 with augmentation of cyclic adenosin monophosphate and cyclic guanosin monophosphate ratio, enhancement of cholinergic neurotransmission, and inhibition of neuronal inflammatory mediators. Therefore, VPN is an effective agent in the management of IS and plays an integral role in the prevention and attenuation of poststroke epilepsy, depression, and cognitive deficit through direct cAMP/cGMP-dependent pathway or indirectly through anti-inflammatory and antioxidant effects.
  23 39,984 4,385
The prevalence and risk factors of stroke among Sudanese individuals with diabetes: Cross-sectional survey
Ahmed Omer Almobarak, Safaa Badi, Wadie M Elmadhoun, Hanan Tahir, Mohamed H Ahmed
January-March 2020, 6(1):26-30
INTRODUCTION: Diabetes complications in Sudan were increasing at an alarming rate. The aim of this study was to assess the prevalence of stroke among Sudanese individuals with diabetes. METHODOLOGY: This cross-sectional study recruited 283 individuals with diabetes from three diabetes centers in Sudan. Data were collected using a standardized pretested questionnaire, and data were analyzed using Chi-square and logistic regression analysis. RESULTS: The average age of participants was 51 (±12 standard deviation) and 35% were aged between 51 and 60 years. Females were 66.8%, and most of the participants (73.9%) were from urban areas and 66.1% received formal education between primary school and university. Body mass index (BMI) classification showed that 34.3% were obese, 31.8% overweight, and 30.4% normal BMI. Diabetes for 1-5 years were observed in 71.7% and for more than 10 years (12%). The majority, i.e., 94.3% had type 2 diabetes mellitus while only 5.7% had type 1. Only one-third of the participants were able to achieve glycosylated hemoglobin (HbA1c) target for diabetes control. The prevalence of cerebrovascular accident (CVA) was 2.5%, hypertension (HTN) was 20%, ischemic heart disease 3.2%, and neuropathy was 45.6%. Chi-square test showed significant association between HbA1c, serum creatinine, total cholesterol, triglyceride, low density lipoprotein, high density lipoprotein level, and the presence of CVA. Logistic regression analysis showed HbA1c, and the duration of diabetes are significantly associated with the presence of CVA (P = 0.010, 0.014). CONCLUSION: The prevalence of stroke among Sudanese individuals with diabetes was around 2.5%. The main risk factors were HbA1c, HTN, and duration of diabetes.
  7 34,081 3,273
Distal transradial access in the anatomical snuffbox for balloon guide-assisted stentriever mechanical thrombectomy: Technical note and case report
Gary B Rajah, Bryan Lieber, Ari D Kappel, Ali W Luqman
January-March 2020, 6(1):60-64
Recent trends in neuroendovascular surgery have seen a rise in alternative access utilization. Social media feeds such as #RadialFirst or #RadialForNeuro are the beacons of a growing movement among more and more endovascular neurosurgeons, as they venture away from the traditional femoral access gravitating toward radial access. We have previously shown our distal radial access technique utilizing the snuffbox to be a reliable means of endovascular access and in addition to traditional ventral radial access provides access to the entire cerebrum. Stroke thrombectomy often encounters reticence from those who prefer transfemoral access over the radial access. Thrombectomy has been performed radially in a few series and only once previously in a case report of distal radial access for thrombectomy. Hesitance to adopt radial access for mechanical thrombectomy is often related to perceived increased access times and a lack of suitable balloon guide catheters for radial techniques. Here, we present one of the first descriptions of a distal transradial access with balloon guide flow arrest for stentriever thrombectomy.
  6 3,064 299
Prevalence of atrial fibrillation in acute ischemic stroke patients:A hospital-based study from India
Deepak Goel, Rekha Gupta, Tulika Keshri, Sanyal Rana
January-March 2020, 6(1):19-25
BACKGROUND: Secondary stroke prevention is as important as the treatment of acute ischemic stroke in regards to halt neurological disability and to lower down mortality due to recurrent episodes. The effective secondary prevention depends on finding the specific risk factors leading to cerebro-vascular insult. AIMS AND OBJECTIVES: We aimed this study to find prevalence of persistent/Paroxysmal AF in stroke patients from single center hospital based study. METHODS: Hospital based study enrolled all prospective patients of acute ischemic stroke from January 2016 to December 2018. All patients were subjected to test for risk factors analysis after detail clinical history and examination of these patients. Following variables were recorded; age, gender, stroke territory, stroke severity by NIHSS (National Institute of Health Stroke Scale), LDL-C (Low Density Lipoprotein - cholesterol) of more than 100 mg/dl, HBA1C (Glycosylated Hemoglobin) of more than 6.5, Homocystine of more than 15 Mc Mol/L, 2D-Echocardiographic abnormalities, electrocardiography/24 hour Holter Monitoring, cerebral angiography of brain and neck findings and outcome of patients in 90 days follow-up based on Modified Rankin Scale. Results: Total 246 patients (69.5% men and 30.5% women) of Acute Ischemic stroke were recorded during study period. Mean age was 61.4 years, with 31 (12.4%) patients were below 45 years. Atrial fibrillation (AF) was detected either on conventional ECG or 24 hour Holter monitoring in 62 (25.2%) patients. CONCLUSION: Stroke with AF is found in 25% patients, more common in elderly, female large atrial size and associated with poor outcome.
  6 19,932 2,694
Demographic age-related variation in Circle of Willis completeness assessed by digital subtraction angiography
Ryan G Eaton, Varun S Shah, David Dornbos III, Orel A Zaninovich, Nicole Wenger, Travis M Dumont, Ciarán J Powers
January-March 2020, 6(1):31-37
OBJECTIVE: Incomplete circle of Willis (CoW) configuration is an important risk factor for cerebrovascular pathology, namely aneurysm formation and ischemic stroke. This study was performed to characterize CoW variation using digital subtraction angiography and to identify demographic and physiologic features that may influence the risk of having an incomplete CoW configuration. MATERIALS AND METHODS: A retrospective review of 274 patients who underwent cerebral angiography by a single surgeon for any indication was conducted. Each CoW branch was graded as normal, hypoplastic, or aplastic. Univariate and multivariate regression analyses were conducted to assess the impact of age, gender, race, and certain comorbidities on CoW configuration. RESULTS: A complete CoW was identified in 37.23% of patients. In univariate analysis, patients <40 years old were more likely to have a complete CoW (odds ratio [OR]: 4.973, 95% confidence interval [CI]: 2.610–9.476, P < 0.001) as were patients <70 years old (OR: 2.849, 95% CI: 1.131–7.194, P < 0.05). Univariate analysis on demographic factors and comorbidities revealed CoW completeness to decrease with hypertension (OR: 0.575, 95% CI: 0.347–0.951, P = 0.031) and diabetes mellitus (OR: 0.368, 95% CI: 0.180–0.754, P = 0.006). Multivariable logistic regression analysis used to assess the impact of age on CoW completeness showed age to be an independent predictor of complete CoW, with an inverse correlation between increasing age and CoW completeness (OR: 0.955, 95% CI: 0.937–0.973, P < 0.001) after controlling for potential confounders including hypertension and diabetes mellitus. CONCLUSIONS: CoW configuration shows considerable variation with age; however, further investigation is required to elucidate the full impact of other demographic and vascular risk factors on CoW anatomy.
  5 40,824 5,301
Teaching neurological disorders with ultrasound: A novel workshop for medical students
Varun S Shah, Maureen Cavalcanti, Seth Scheetz, David P Bahner, David L Dornbos III, Michael I Prats
January-March 2020, 6(1):38-46
INTRODUCTION: The goal of this study was to assess if a neurological disorder ultrasound workshop for the first-year medical students significantly enhanced the students' ability to retain and apply concepts related to neuroanatomy and neurophysiology. MATERIALS AND METHODS: We performed a prospective study to evaluate student performance before and after an optional ultrasound workshop. Data were collected through a within-population pretest–posttest design. Purposive sampling was used to recruit first-year medical students for this study. The six stations were transcranial doppler ultrasound, ocular ultrasound, ultrasound-guided external ventricular drain placement, high-intensity focused ultrasound for brain lesions, carotid artery scan with ultrasound, and ultrasound-guided central line placement. We used a pre–post workshop survey to identify opinions and perceptions about ultrasound and a pre–post workshop test to assess knowledge about neuroanatomy, neurophysiology, and related ultrasound topics. RESULTS: Twenty-two 22 first-year medical students consented to participate in this study. The Wilcoxon signed-rank test showed a statistically significant difference in pre- and posttest scores, suggesting that participants demonstrated higher levels of medical knowledge related to neurological physiology, anatomy, and ultrasound after participating in the workshop. The analysis of the pre–post survey showed participants attributed greater value to ultrasound as a useful tool for their future medical practice after participation in the event (Z = −2.45, P = 0.014). CONCLUSIONS: There is value in integrating experiences with ultrasound into the neurological disorder block of medical school. Future studies, with a larger sample size, are needed to further explore the efficacy of this workshop in enhancing knowledge retention.
  3 23,944 2,557
Complications following Encephalo-Duro-Arterio-Myo-Synangiosis in a case of Moyamoya disease
Darpa Narayan Hazra, Amit Kumar Ghosh
January-March 2020, 6(1):57-59
We report a case of an 18-year-old girl diagnosed to have Moyamoya disease (MMD), who underwent bilateral encephalo-duro-arterio-myo-synangiosis. Literature search has clearly inferred that in comparison to an adult patient, children with MMD can have a good prognosis if early diagnosis and active surgical intervention are achieved. Evidence has demonstrated that active surgical management, including indirect bypass surgery, may improve the cerebral circulation on a relatively larger scale than direct bypass surgeries, which can only improve the cerebral circulation in the area of the vascular reconstruction.
  2 2,260 203
Anesthetic challenges in pediatric moyamoya disease: A report of two cases
Vidhu Bhatnagar, SN Kulkarni, Ajay Sharma, Sandeep Basawaraj Dolla
January-March 2020, 6(1):47-51
Moyamoya disease (MMD), a rare cause of pediatric stroke, is a cerebrovascular occlusive disorder resulting from progressive stenosis of the distal intracranial carotid arteries and their proximal branches. In response to brain ischemia, there is the development of basal collateral vessels, which gives rise to the characteristic angiographic appearance of moyamoya (puff of smoke). If left untreated, the disease can result in overwhelming permanent neurological and cognitive deficits. Whereas MMD refers to the idiopathic form, moyamoya syndrome refers to the condition in which children with moyamoya also have a recognized clinical disorder. The classic pediatric presentation in moyamoya is recurrent transient ischemic attacks (TIAs) and/or completed/repeated ischemic strokes. Surgical revascularization, including direct and indirect techniques, remains the mainstay of treatment and has been shown to improve long-term outcome in children with MMD. Various risk factors identified for perioperative complications are as follows: history of TIAs, severity of disease, intraoperative hypotension, hypercapnia and hypovolemia, and substantial reduction in hematocrit intraoperatively. Thus, providing perianesthetic care to pediatric patients undergoing revascularization procedure for MMD is like walking a tightrope, and we present two such cases handled successfully.
  - 2,567 290
Therapeutic occlusion of the vertebral artery using a new penumbra occlusion device system and ruby coils (penumbra): A technical note
Jay P Kinariwala, Gary B Rajah, Rahul Vaidya, Sandra Narayanan
January-March 2020, 6(1):52-56
There are several methods to achieve the therapeutic sacrifice of the vessel, coiling brings the most commonly used. Penumbra occlusion device (POD) system is a newer modality for therapeutic large vessel occlusion, and it is the Food and Drug Administration approved only for peripheral vessels. We report a case where therapeutic vertebral artery (VA) occlusion was achieved with the POD system and Ruby coils for the first time. A patient was diagnosed with a new malignant-appearing tumor of the cervical spine. A conventional angiogram showed multiple tiny arterial feeders from the VA beyond scope of coil/onyx embolization, so we performed a balloon occlusion test followed by therapeutic sacrifice of the VA. A successful VA occlusion was achieved with significant reduction in the tumor blush, followed by open resection of the tumor. The patient had favorable postoperative course and without any neurological symptoms attributed to the VA occlusion.
  - 2,487 232