Medicine and Health Sciences Commons^™

Emerging Stroke Risk Factors: A Focus On Infectious And Environmental Determinants, Sajid Hameed, Nurose Karim, Mohammad Wasay, Narayanaswamy Venketasubramanian

Section of Neurology

This review focuses on emerging risk factors for stroke, including air pollution and climate change, gut microbiota, high altitude, and systemic infection. Up to 14% of all stroke-associated mortality is attributed to air pollution and is more pronounced in developing countries. Fine particulate matter and other air pollutants contribute to an increased stroke risk, and this risk appears to increase with higher levels and duration of exposure. Short term air pollution exposure has also been reported to increase the stroke risk. The gut microbiota is a complex ecosystem of bacteria and other microorganisms that reside in the digestive system and …

Practical Needs And Considerations For Refugees And Other Forcibly Displaced Persons With Neurological Disorders: Recommendations Using A Modified Delphi Approach, Shawheen Rezaei, Foksouna Sakadi, Fu-Liong Hiew, Ildefonso Rodriguez-Leyva, Jera Kruja, Mohammad Wasay, Osheik Abuasha Seidi, Saad Abdel-Aziz, Shahriar Nafissi, Farrah Mateen

Section of Neurology

Background: There are >70 million forcibly displaced people worldwide, including refugees, internally displaced persons, and asylum seekers. While the health needs of forcibly displaced people have been characterized in the literature, more still needs to be done globally to translate this knowledge into effective policies and actions, particularly in neurology.
Methods: In 2020, a global network of published experts on neurological disease and refugees was convened. Nine physician experts from nine countries (2 low, 1 lower-middle income, 5 upper-middle, 1 high income) with experience treating displaced people originating from 18 countries participated in three survey and two discussion rounds in …

Antiplatelet Use In Ischemic Stroke, Marharyta Kamarova, Sheharyar Baig, Hamish Patel, Kimberley Monks, Mohammad Wasay, Ali Ali, Jessica Redgrave, Arshad Majid, Simon M. Bell

Section of Neurology

Objective: A literature review of antiplatelet agents for primary and secondary stroke prevention, including mechanism of action, cost, and reasons for lack of benefit.
Data sources: Articles were gathered from MEDLINE, Cochrane Reviews, and PubMed databases (1980-2021). Abstracts from scientific meetings were considered. Search terms included ischemic stroke, aspirin, clopidogrel, dipyridamole, ticagrelor, cilostazol, prasugrel, glycoprotein IIb/IIIa inhibitors.
Study selection and data extraction: English-language original and review articles were evaluated. Guidelines from multiple countries were reviewed. Articles were evaluated independently by 2 authors.
Data synthesis: An abundance of evidence supports aspirin and clopidogrel use for secondary stroke prevention. In the acute …

Intensive Care Bundle With Blood Pressure Reduction In Acute Cerebral Hemorrhage Trial (Interact3): Study Protocol For A Pragmatic Stepped-Wedge Cluster-Randomized Controlled Trial, Lili Song, Xin Hu, Lu Ma, Xiaoying Chen, Menglu Ouyang, Laurent Billot, Qiang Li, Paula Muñoz-Venturelli, Carlos Abanto, Mohammad Wasay

Section of Neurology

Background: Early intensive blood pressure (BP) lowering remains the most promising treatment for acute intracerebral hemorrhage (ICH), despite discordant results between clinical trials and potential variation in the treatment effects by approach to control BP. As the third in a series of clinical trials on this topic, the INTEnsive care bundle with blood pressure Reduction in Acute Cerebral hemorrhage Trial (INTERACT3) aims to determine the effectiveness of a goal-directed care bundle protocol of early physiological control (intensive BP lowering, glycemic control, and pyrexia treatment) and reversal of anticoagulation, in acute ICH.
Methods: INTERACT3 is a pragmatic, international, multicenter, stepped-wedge (4 …

Stroke Care In Pakistan, Anjum Farooq, Narayanaswamy Venketasubramanian, Mohammad Wasay

Section of Neurology

Increasing incidence of stroke and lack of infrastructure in both urban and rural areas needs immediate attention in Pakistan. There is a high proportion of young stroke with poor stroke outcomes. Acute stroke care is scarce in Pakistan due to the small number of neurologists (1 neurologist per 1 million population), few stroke units, and limited availability of alteplase (recombinant tissue plasminogen activator) in the country.

Cerebral Venous Thrombosis Associated With Covid-19 Infection: An Observational, Multicenter Study, Sajid Hameed, Mohammad Wasay, Bashir A. Soomro, Ossama Mansour, Foad Abd-Allah, Tianming Tu, Raja Farhat, Naila Shahbaz, Husnain Hashim, Wasim Alamgir

Section of Neurology

Background and purpose: Coronavirus disease 2019 (CO-VID-19) has an increased propensity for systemic hypercoagulability and thromboembolism. An association with cerebrovascular diseases, especially cerebral venous thrombosis (CVT), has been reported among these patients. The objective of the present study was to identify risk factors for CVT as well as its presentation and outcome in COVID-19 patients.
Methods: This is a multicenter and multinational observational study. Ten centers in 4 countries (Pakistan, Egypt, Singapore, and the United Arab Emirates) participated in this study. The study included patients (aged >18 years) with symptomatic CVT and recent COVID-19 infection.
Results: Twenty patients (70% men) …

Focal Cortical Dysplasia With Prolonged Ictal Asystole, A Case Report, Ahmad Wali, Fowzia Siddiqui

Section of Neurology

Introduction: Cortical dysplasia carries significant morbidities such as seizures and delayed milestones. Focal cortical dysplasia (FCD) causes refractory epilepsy with various seizure types depending on the location and extent of the dysplasia. FCD in the temporal region and the insular cortex may cause ictal bradycardia (IB) and ictal asystole (IA). Video EEG (VEEG) with simultaneous EKG recording can better diagnose these cardiac abnormalities in FCD. We describe a case of refractory epilepsy. The patient's clinical seizures were usually followed by syncope. VEEG revealed frequent seizures some of which were associated with prolonged ictal asystole.
Results: A 15 years old female …

Consequences Of A Missed History: A Case Of Antidepressant Discontinuation Syndrome, Sajid Hameed, Mukesh Kumar, Piyush Puri, Fnu Sapna, Pal Satyajit Singh Athwal

Section of Neurology

Antidepressant discontinuation syndrome (ADDS) is reported to occur in almost 30-50% of the patients who take antidepressants for a duration of at least four to six weeks and then suddenly discontinue the drug. Since there is an increase in the use of antidepressants for various reasons by general practitioners, patient education about when and how to discontinue a drug is not acknowledged enough. It is reported to occur with the use of different classes of antidepressants - selective serotonin reuptake inhibitor (SSRI), monoamineoxidase inhibitor (MAOI), tricyclic antidepressants (TCAs), and atypical antipsychotics like risperidone, trazodone, clozapine, and venlafaxine. Slow tapering off …

Postinfectious Cerebellar Syndrome With Paraneoplastic Antibodies: An Association Or Coincidence?, Sajid Hameed, Mukesh Kumar, Pal Satyajit Singh Athwal, Sukhmanii Kahlon, Nimit Dalal

Section of Neurology

Cerebellar ataxia has a very broad differential diagnosis in adults, including paraneoplastic and postinfectious etiologies. We report a case of a 56-year-old male presented with right-sided cerebellar dysfunction preceded by fever and headache. He was diagnosed with subacute postinfectious cerebellar ataxia. Blood serology showed the presence of anti-amphiphysin and anti-Ri (ANNA-2, antineuronal nuclear autoantibody type 2) antibodies, which have a known association with cerebellar syndrome. The patient subsequently improved with the steroids. Although no evidence of an underlying tumor was found in the patient, the presence of the paraneoplastic antibodies remains a mystery. We suggest a probable association of these …

The Neurology Of Covid-19 Revisited: A Proposal From The Environmental Neurology Specialty Group Of The World Federation Of Neurology To Implement International Neurological Registries, Gustavo C. Román, Peter S. Spencer, Jacques Reis, Alain Buguet, Mostafa El Alaoui Faris, Sarosh M. Katrak, Miguel Láinez, Marco Tulio Medina, Chandrashekhar Meshram, Mohammad Wasay

Section of Neurology

A comprehensive review of the neurological disorders reported during the current COVID-19 pandemic demonstrates that infection with SARS-CoV-2 affects the central nervous system (CNS), the peripheral nervous system (PNS) and the muscle. CNS manifestations include: headache and decreased responsiveness considered initial indicators of potential neurological involvement; anosmia, hyposmia, hypogeusia, and dysgeusia are frequent early symptoms of coronavirus infection. Respiratory failure, the lethal manifestation of COVID-19, responsible for 264,679 deaths worldwide, is probably neurogenic in origin and may result from the viral invasion of cranial nerve I, progressing into rhinencephalon and brainstem respiratory centers. Cerebrovascular disease, in particular large-vessel ischemic strokes, …

Neurological Manifestations Of Covid-19, Dureshahwar Kanwar, Abdul Mannan Baig, Mohammad Wasay

Section of Neurology

Coronavirus disease (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS CoV-2) has turned out to be a formidable pandemic. Upcoming evidence from confirmed cases of COVID-19 suggests an anticipated incursion of patients with neurological manifestations in the weeks to come. An expression of the angiotensin-converting enzyme 2 (ACE 2), the cellular receptor for SARS-CoV-2 over the glial cells and neurons have made the brain a potential target. Neurotoxicity may occur as a result of direct, indirect and post-infectious complications. Attention to neurological deficits in COVID-19 is fundamental to ensure appropriate, timely, beneficial management of the affected patients. Most …

Effect Of 5-Minute Movies Shown Via A Mobile Phone App On Risk Factors And Mortality After Stroke In A Low- To Middle-Income Country: Randomized Controlled Trial For The Stroke Caregiver Dyad Education Intervention (Movies4stroke), Ayeesha Kamran Kamal, Adeel Khoja, Bushra Usmani, Shahvaiz Magsi, Aresha Malani, Zahra Peera, Saadia Sattar, Masood Ahmed Akram, Sumaira Shahnawaz, Maryam Zulfiqar, Abdul Muqeet, Fabiha Zaidi, Saleem Sayani, Azmina Artani, Syed Iqbal Azam, Sarah Saleem

Section of Neurology

Background: Pakistan is the sixth most populous nation in the world and has an estimated 4 million stroke survivors. Most survivors are taken care of by community-based caregivers, and there are no inpatient rehabilitation facilities.
Objective: The objective of this study was to evaluate the effectiveness and safety of locally designed 5-min movies rolled out in order of relevance that are thematically delivered in a 3-month program to deliver poststroke education to stroke survivor and caregiver dyads returning to the community.
Methods: This study was a randomized controlled, outcome assessor–blinded, parallel group, single-center superiority trial in which participants (stroke survivor-caregiver …

Utilization And Outcomes With Low Dose Tissue Plasminogen Activator As Intravenous Thrombolytic Therapy For Ischaemic Stroke At Aga Khan University Hospital, Karachi: A Retrospective Analysis, Masood Uz Zaman Babar, Ammar Zaman Khan, Haris Hakeem, Jaleed Gilani, Mohammad Wasay

Section of Neurology

Objective: To determine the utilisation of intravenous tissue plasminogen activator at a certain dose for ischaemic stroke thrombolysis and to compare the outcomes with those of a different dosage mentioned in literature.
Methods: The retrospective study was conducted at the Aga Khan University Hospital, Karachi, and comprised medical records from January, 2007, to October, 2016, of all patients having received intravenous tissue plasminogen activator for ischaemic stroke thrombolysis. Primary safety outcome variables included symptomatic intracerebral haemorrhage after the start of treatment (0.6mg/kg) and death within three months as per the modified Rankin scale 6. Secondary efficacy outcome variable was functional …

Current State Of Knowledge Of Basic Life Support In Health Professionals Of The Largest City In Pakistan: A Cross-Sectional Study, Babar Irfan, Ibrahim Zahid, Muhammad Sharjeel Khan, Omar Abdul Aziz Khan, Shayan Zaidi, Safia Awan, Sobia Bilal, Omar Irfan

Section of Neurology

Background: Basic Life Support (BLS) is the recognition of sudden cardiac arrest and activation of the emergency response system, followed by resuscitation, and rapid defibrillation. According to WHO, Pakistan has one of the highest mortality rates from accidental deaths therefore assessment and comparison of BLS knowledge in health professionals is crucial. We thereby aim to assess and compare the knowledge of BLS in doctors, dentists and nurses.

Methods: A multi-centric cross-sectional survey was conducted in Karachi at different institutions belonging to the private as well as government sector from January to March 2018. We used a structured questionnaire which was …

Longitudinally Extensive Transverse Myelitis With Seropositive Chikungunya, Sajid Hameed, Mubashar Memon, Hina Imtiaz, Dureshahwar Kanwar

Section of Neurology

Chikungunya viral (CHIKV) fever is often a self-limiting febrile illness associated with severe debilitating arthralgia. Neurological complications associated with CHIKV, although rare, have been reported in literature; however, longitudinally extensive transverse myelitis (LTEM) is rarely associated with it. We present a case of a middle-aged man with a 1-week history of low-grade fever and arthralgia followed by urinary retention and quadriplegia. A sensory level was noted at T2. On subsequent investigations, he was diagnosed with LETM. Although LETM is commonly seen in patients with neuromyelitis optica, the other possible etiologies are inflammatory and parainfectious. To date, only two cases of …

Spectrum Of Neurological Disorders In Neurology Outpatients Clinics In Urban And Rural Sindh, Pakistan: A Cross Sectional Study, Safia Awan, Alam Ibrahim Siddiqi, Ahmed Asif, Naveeduddin Ahmed, Hazim Brohi, Sajad Jalban, Mohammad Wasay

Section of Neurology

Background: Neurological disorders are the most common cause of morbidity and mortality in developing countries. Available evidence on urban–rural differences on neurological diseases is scare in such countries. Our study objective was to determine the prevalence of neurological diseases in urban and rural tertiary care hospitals of Sindh, Pakistan.

Methods: This was a cross sectional study conducted in selected urban and rural region of tertiary care hospitals of Sindh, Pakistan. The outpatients medical records of adults (18 years and above) was obtained from January 1st, 2014 to December 31st, 2014.

Results: A total of 10,786 outpatients visit were recorded in …

Guillain-Barre Syndrome Following A Snakebite: A Case Report And Review Of Literature, Sajid Hameed, Mubashar Memon, Sara Khan

Section of Neurology

Guillain-Barre syndrome (GBS) is preceded by a respiratory or gastrointestinal illness in more than 50% of the patients. A rare association of GBS with a preceding snakebite is reported in the literature in only four previous cases. We present a case report of a patient diagnosed with GBS following the bite of a yellow-bellied sea snake (Hydrophis platurus) and a brief review of the available literature.

Yield Of Muscle Biopsy In Patients With Findings Of Myopathy On Electrodiagnostic Testing, Sarah H. Siddiqui, Raheel Ahmed, Safia Awan, Ambreen Zain, Sara Khan

Section of Neurology

Background: The evaluation of neuromuscular diseases includes detailed clinical assessment, blood testing, electrodiagnostic studies (EDS), biopsy, and genetic tests. EDS alone cannot provide a specific diagnosis. Further testing in the form of genetic tests or muscle biopsy (MB) is required. Objective The objective of the study is to evaluate the yield of MB in patients with findings of myopathy on electrodiagnostic testing and assess the factors affecting an abnormal biopsy outcome.

Methods: Electromyography (EMG)/nerve conduction studies (NCS) performed for suspected myopathy over 5 years from 2011 to 2016, at the neurophysiology department of a tertiary care center in Pakistan, were …

New Oral Anticoagulants Versus Warfarin For Cerebral Venous Thrombosis: A Multi-Center, Observational Study, Mohammad Wasay, Maria Khan, Haris Majid Rajput, Salman Farooq, Mohammed Ibrahim Memon, Suhail Abdulla Alrukn, Abdul Malik, Foad Abd-Allah, Raja Farhat Shoaib, Rizwana Shahid, Sadia Nishat, Safia Awan

Section of Neurology

No abstract provided.

A New Health Care Model For Pakistan, Mohammad Wasay, Ashar Malik

Section of Neurology

No abstract provided.

Rare Variant Of Guillain-Barré Syndrome After Chikungunya Viral Fever, Sajid Hameed, Sara Khan

Section of Neurology

Chikungunya (CHIK) viral fever is a self-limiting illness that presents with severe debilitating arthralgia, myalgia, fever and rash. Neurological complications are rare. We present a case of a 36-year-old woman who presented with acute onset progressive difficulty swallowing and left arm weakness. She was diagnosed with CHIK viral fever 4 weeks prior to admission. After investigations, she was diagnosed with a pharyngeal-cervical-brachial variant of Guillain-Barré syndrome. In hospital, she required ventilator support. Her condition improved after five sessions of intravenous immunoglobulin with almost complete resolution within 6 months of symptom onset. With frequent CHIK outbreaks, the neurological complications are increasingly …

Making Prescriptions “Talk” To Stroke And Heart Attack Survivors To Improve Adherence: Results Of A Randomized Clinical Trial (The Talking Rx Study), Ayeesha Kamran Kamal, Wardah Khalid, Abdul Muqeet,, Anum Jamil,, Kashfa Farhat, Sehar Rahim Ali Gillani, Maryam Zulfiqar, Mehreen Saif, Aliya Amin Muhammad, Fabiha Zaidi, Saleem Sayani, Salim S. Virani

Section of Neurology

Background: We developed and tested the effectiveness of a tailored health information technology driven intervention: "TalkingPrescriptions" (Talking Rx) to improve medication adherence in a resource challenged environment.
Methods: We conducted a parallel, randomized, controlled, assessor-blinded trial at the Aga Khan University (AKU), Karachi, Pakistan. Adults with diagnosis of cerebrovascular accident (CVA) or coronary artery disease (CAD) diagnosed least one month before enrollment, on anti-platelets and statins, with access to a mobile phone were enrolled. The intervention group received a) Daily Interactive Voice Response (IVR) call services regarding specific statin and antiplatelet b) Daily tailored medication reminders for statin and antiplatelet …

Genetics Of The Thrombomodulin-Endothelial Cell Protein C Receptor System And The Risk Of Early-Onset Ischemic Stroke, John W. Cole, Huichun Xu, Kathleen Ryan,, Thomas Jaworek, Nicole Dueke, Patrick Mcardle, Brady Gaynor,, Yu-Ching Cheng, Jeffrey O'Connell, Ayeesha Kamran Kamal

Section of Neurology

Background and Purpose: Polymorphisms in coagulation genes have been associated with early-onset ischemic stroke. Here we pursue an a priori hypothesis that genetic variation in the endothelial-based receptors of the thrombomodulin-protein C system (THBD and PROCR) may similarly be associated with early-onset ischemic stroke. We explored this hypothesis utilizing a multi-stage design of discovery and replication.

Methods: Discovery was performed in the Genetics-of-Early-Onset Stroke (GEOS) Study, a biracial population-based case-control study of ischemic stroke among men and women aged 15-49 including 829 cases of first ischemic stroke (42.2% African-American) and 850 age-comparable stroke-free controls (38.1% African-American). Twenty-four single-nucleotide-polymorphisms …

Evaluation Of Quality Of Warfarin Therapy By Assessing Patient's Time In Therapeutic Range At A Tertiary Care Hospital In Pakistan, Haris Hakeem, Ammar Zaman Khan, Kashif Aziz, Ayesha Abbasi, Anam Haider, Bushra Moiz, Mohammad Wasay

Section of Neurology

Objective: To assess the time in therapeutic range in patients on warfarin anti-coagulation therapy.

Methods: The retrospective chart review was conducted at Aga Khan University Hospital, Karachi, and comprised data of patients having undergone anti-coagulation with warfarin from January 2013 to April 2015. To determine the mean time in therapeutic range, Rosendaal method was used. Association of time in therapeutic range with the composite outcome, bleeding and thromboembolic events was also assessed. Percentage of patients with time in therapeutic range <60% was calculated.

Results: There were 92 patients whose median time in therapeutic range was 34.9% (interquartile range: 20.0- 55.7). Overall, 71(77.2%) …

Impact Of Airborne Pollutants On Stroke, Adeel Khoja, Fizzah Kazim

Section of Neurology

No abstract provided.

Environment, Pollution And Stroke, Maria Khan, Mohammad Wasay

Section of Neurology

No abstract provided.

Synovial Sarcoma Of Cervicodorsal Spine: A Case Report, Wali Umer Shah, Syeda Dania Shujaat, Naseeb Ullah, Salman Mansoor

Section of Neurology

Synovial sarcoma is a soft-tissue sarcoma. Its involvement of the spine is extremely rare. We report a 40 year old male who presented with shoulder pain and progressive weakness in all four limbs for six months with a visible, slowly growing bulge in his upper back. On examination he had quadriparesis and diffuse sensory deficit. MRI of the cervical spine showed a large soft tissue mass, iso to hypointense, extending into the neural canal, compressing the cord. The mass had a few internal areas of contrast enhancement with extension into the right paraspinal regions involving the vertebral bodies. Sub-periosteal spine …

Environment And Neurological Diseases: Growing Evidence For Direct Relationship, Mohammad Wasay, Adeel Khoja

Section of Neurology

No abstract provided.

The Advocacy Role Of The World Federation Of Neurology, Wolfgang Grisold, Mohammad Wasay

Section of Neurology

No abstract provided.

Acute Onset Of Quadriplegia Secondary To Hypoparathyroidism: Mimicker Of Aman Variant Of Gbs, Syeda Saba Zaidi, Tahira Siddiqui, Sarwar Jamil Siddiqui

Section of Neurology

Acute onset of quadriplegia is a rare phenomenon seen with hypocalcemia due to hypoparathyroidism. We describe a 33-year gentleman who presented with weakness of all four limbs and areflexia. ECG showed QT abnormality. Nerve conduction study revealed normal sensory and significantly low motor CMAP amplitudes in both the upper and lower extremities. This nerve conduction study can be seen in acute motor neuropathy of various etiologies, among which GBS is the most worrisome. Our patient found to have low calcium and parathyroid hormone level. His symptoms improved after calcium replacement. Occurrence of quadriplegia in hypoparathyroidism, and its improvement after correction …