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Volume 65, Issue 4 (7-2007)
Background: Ultrasound (US) has been used in neuroprotection after cerebral ischemia however, its use is controversial. Application of US in combination with fibrinolytic agents may improve fibrinolytic effects. In this study the effects of US, alone or in combination with tissue plasminogen activator (tPA), on brain ischemic injury were examined and we studied whether US is protective in the brain injured by ischemia under normothermic conditions.
Methods: We performed two studies. In the first study, rectal and brain temperatures were compared. In the second study, we studied whether US alone or in combination with tPA is neuroprotective in thromboembolic stroke. To induce focal cerebral ischemia, a clot was formed in a catheter. Once the clot had formed, the catheter was advanced 17 mm in the internal carotid artery until its tip was 1-2 mm away from the origin of the middle cerebral artery (MCA). The preformed clot in the catheter was then injected, and the catheter was removed. The wound was then closed and the infarction volume, edema and neurological deficits were measured after MCA occlusion.
Results: The temperature in the brain was approximately 0.50 ºC lower than the rectal temperature. In the control, US+low tPA, low tPA, US+high tPA and, high tPA groups, the infarct volume (%) was 34.56±4.16, 17.09±6.72, 21.25±7.8, 13.5±10.72 and 20.61±6.17 (mean ±SD) at 48 h after MCA occlusion, respectively. The results indicate that US alone reduces the infarct volume by 30% compared to that of the control group (P<0.05). US improved neurological deficits and reduced brain edema significantly (p<0.05).
Conclusions: This study indicate that US appears to have a protective effect, alone and in combination with tPA, in an embolic model of stroke.
Volume 65, Issue 12 (3-2008)
Background: Ultrasound (US) has been used in neuroprotection after cerebral ischemia, however the mechanism of action remains unclearly. We have previously shown the protective effect of ultrasound on infarction volume and brain edema in ischemic brain injured at normothermic condition. Ultrasound may also amplify the effect of fibrinolytic medications in thrombolysis process .We have also shown that hyperthermia can exacerbate cerebral ischemic injury and that the efficacy of tissue plasminogen activator (tPA) is reduced in the presence of hyperthermia. In this study, the effects of US alone or in combination with tPA on brain ischemic injury were evaluated.
Methods: Focal ischemic brain injury was induced by emblazing a pre-formed clot into the middle cerebral artery in rats. Principally, we examined whether US can reduce the perfusion deficits and, the damage of blood- brain barrier (BBB) in the ischemic injured brain. There are two series of experiments at this study .in the first series, animals were randomly assigned to four groups (n=7 per group) as follows: 1-control (saline), 2-US (1W/cm2, 10 duty cycle ), 3- US+high- tPA (1W/cm2, 10 duty cycle +20 mg/kg) and 4- high -tPA (20 mg/kg). We also examined the effects of US and tPA on BBB integrity after ischemic injury. The animals were assigned into four groups (n=7 per group), treatment is the same as above. BBB permeability was assessed by the Evans blue (EB) extravasations method at 8 h after MCA occlusion. BBB permeability was evaluated by fluorescent detection of extravagated Evans blue dye and Perfusion deficits were analyzed using an Evans blue staining procedure. The perfused microvessels in the brain were visualized using fluorescent microscopy. Areas of perfusion deficits in the brain were traced, calculated and expressed in mm2.
Results: The results showed that US improved neurological deficits significantly (p<0.05). The administration of US significantly decreased perfusion deficits and BBB permeability. In the control set, for the US+high tPA, high tPA only and US only groups, the mean perfusion deficits (±SD) were 14.32±3.15, 7.03±4.08, 5.92±1.90 and 9.14±3.37 mm2, respectively, 8 h after MCA occlusion (P<0.05).
Conclusions: These studies suggest that US is protective in a rat embolic model of stroke due to decreased perfusion deficits.
Volume 66, Issue 4 (7-2008)
Background: Hyperglycemia after acute stroke is a common finding that has been associated with an increased risk of death. For the last several years, it was believed that post-stroke hyperglycemia may worsen brain infarction in animal models. According to previous studies, the anti-inflammatory effect of insulin has a protective role on ischemic tissues. Glucose-insulin-potassium (GIK) infusions can be safely administered to acute stroke patients with mild to moderate hyperglycemia producing a physiological but attenuated glucose response to acute stroke, the effectiveness of which remains to be elucidated. In this study, we compared the effects of GIK infusion vs. placebo in ischemic stroke patients.
Methods: In this double blind randomized controlled trial, the intervention group consisted of 48 patients who received GIK infusion for 24 hours and the control group included 50 patients who received normal saline infusion for 24 hours. All patients had been admitted to Shariati Hospital during the first 24 hours after the onset of ischemic stroke. At one and three months after the treatment, patients were examined for morbidity and mortality using the Bethel and Modified- Rankin-Scale (MRS) questionnaires.
Results: GIK infusions significantly reduced plasma glucose concentrations. Statistically significant differences between the two groups were observed for disability and mortality. However, in spite of the protective effects of insulin and adverse effect of hyperglycemia in ischemic tissues, we observed no significant therapeutic effect from the GIK solution on patient outcome.
Conclusions: Although hyperglycemia following acute stroke has been associated with subsequent mortality and impaired neurological recovery, the maintenance of euglycemia in the acute phase has not been shown to improve prognosis. According to this study, GIK infusion has no significant clinical benefit on the outcome of stroke patients. Thus, we cannot recommend routine use of GIK infusion in post-stroke hyperglycemia as an adjuvant treatment for ischemic stroke.
Volume 68, Issue 7 (10-2010)
Background: Cerebrovascular ischemic accident is the third most common cause of death in community. Management of high-risk patients reduces complications and mortality. Serum lipid profile is one of the most important factors influencing the prognosis.
Methods: In this cross sectional study, 123 (58 female and 65 male) patients with acute ischemic stroke, mean aged 65.1± 11.16 years, were admitted to Sina Hospital between September 2008 and September 2009. The inclusion criteria were age between 40-90 years and ischemic stroke within the anterior or posterior brain blood system. The exclusion criteria were brain tumor or abscess, venous sinus thrombosis, liver disease, renal failure, hypothyroidism or metabolic problems. Serum lipid profile was evaluated during the first 24 hours after stroke and after 12 hours of fasting. Furthermore, the patients' inability was evaluated on the first and fifth day of hospitalization by NIH Stroke Scale (NIHSS).
Results: Patients' total serum cholesterol was 189.93± 51.46 mg/dl and mean total serum triglycerides was 157.72± 72.67 mg/dl. The mean HDL and LDL was 47.70± 14.43 and 105.98± 37 mg/dl, respectively. In the analysis, a significant inverse relationship was found between serum triglyceride levels and fifth day's NIHSS. In addition, age and a history of heart disease had a significant direct relationship with the first day's NIHSS. (p< 0.05)
Conclusion: The study showed a better prognosis in cases with increased plasma triglyceride levels, after cerebral ischemic stroke. Besides, older age and a history of ischemic heart disease were associated with a worse prognosis.
Volume 70, Issue 3 (6-2012)
Background: Carotid endarterectomy (CEA) is a standard method for patient with significant carotid stenosis but direct surgical repair via carotid endarterectomy may not be a good option in some patients because of the overall health status that may make the surgery too risky. Carotid angioplasty and stenting (CAS), is a relatively new procedure for the treatment of carotid artery disease in patients who may not be fit enough to undergo surgery. In this investigation, we determined short- and long-term outcomes of stent angioplasty in high-risk patients for whom the risk of perioperative morbidity and mortality is high.
Methods: We have followed 82 consecutive symptomatic patients with a ≥50% and asymptomatic patients with a ≥70%- 80% carotid stenosis within 15.9 months of angioplasty and stenting in Baqiyatallah and Jamaran hospitals from 2008-2010. All the patients were considered poor surgical candidates by experienced surgeons and anesthesiologists upon pre-surgical consultation.
Results: This descriptive cross-sectional study was performed on 28 women and 54 men with a mean age of 69.7±9.2 years. The procedure was technically successful in 79 (96.3%) cases. There were 6 (7.3%) deaths, 5 (6.1%) strokes, 4 (4.9%) MIs and 4 (4.9%) TIAs during the follow-up period.
Conclusion: The clinical results during the short available follow-up period suggested stent angioplasty to be useful, effective, reliable and safe in the treatment of significant cervical carotid stenosis in high-risk patients. Further analytical investigations with longer follow-up periods for predicting risk factors are recommended.
Volume 75, Issue 1 (4-2017)
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Background: Nowadays, stroke can be considered as the one of the major causes of disability and mortality worldwide. However, relationship between serum C-reactive protein (CRP) level with stroke early prognosis has not been well studied, especially in Iran. Therefore, the present study aimed to study the relationship between CRP level of serum in patients with acute stroke at first 24h of admission and stroke early prognosis. Methods: This prospective cross-sectional study was performed on 50 patients with acute stroke who were admitted at Emergency Ward of Shahid Rajaie Hospital, in Tonekabon City, Iran, between May 2013 to July 2014. In first step, valid clinical diagnosis was made based on CT scan and magnetic resonance imaging (MRI) of the patients. The ethical observations were considered for all patients. The serum level of CRP was measured by standard method, at first 24h of the admission. Clinical information and risk factors (age, gender, type of stroke, high blood pressure, diabetes mellitus) was detected for each patient. On discharge, early prognosis by modified Rankin Scale (mRS) (mRS< 3= good and mRS≥ 3= bad) was also recognized. In this study, statistical analysis was performed using SPSS software, and logistic regression method was used (P< 0.05). Results: The results of this study showed that 38% of the patients were 70-80 years old. Also, 52% of the patients were male and 48% were female. The serum CRP level of patients at the first 24h of admission increased in all studied patients. The mean of the serum CRP level was 12.82 that were higher than the normal range. The statistical analysis showed that there was no significant relationship between the serum CRP level and the stroke early prognosis. Conclusion: Although the serum CRP level was not recognized as an anticipator factor for stroke prognosis at this study, it is recommended to performance of more studies by case-study method on this setting. |
Volume 75, Issue 5 (8-2017)
Methods: All primary reports of spasticity indexed in PubMed, MEDLINE, Science Direct, Scopus and search engine of Google Scholar from January 2000 to December 2016 were searched. The following terms were used as keywords: Spasticity, muscle hypertonicity, ESWT, stroke and hemiplegia. Any report was included if it met the following criteria: involving clinical trials, full-version availability, and being written in english. Two reviewers selected articles independently and reviewed the studies considering quality and eligibility, and then they extracted general information on objectives, design, participants, and outcomes. The methodologic quality of each study was assessed using the Pedro Scale. In the statistical analyses, we considered two outcomes; Modified Ashworth scale (MAS) grade and passive rang of movement (PROM). The meta-analysis was done using random effect model in Stata, version 11 (Stata Corp., TX, USA).
| Results: Eleven studies within a total of 261 patients were included in this review. In seven studies the shock waves were applied to the upper limb muscles, and in four other studies, the effects of ESWT on the spasticity of the lower limb muscles were assessed. Immediately after applying the ESW, MAS grade was significantly decreased in comparison to the baseline values. (Standardized mean difference [SMD], -1.62; 95% confidence interval [CI], -2.2 to -1.04). The PROM was significantly increased immediately after ESWT in comparison to the baseline values (SMD, 3.23; CI 95%, 1.35 to 5.12). Conclusion: The results of this study showed that ESWT can immediately improve the spasticity and increased PROM, but it seems that the mechanism of action of shock waves on spasticity is still unclear. Further clinical trial studies with higher methodological quality should be recommended. |
Volume 76, Issue 1 (4-2018)
Methods: Patients with stroke recruited from the Tehran University of Medical Sciences Physiotherapy Clinics in Tehran participated in this cross-sectional study. Patients were included in the study with first ever stroke, able to follow instructions, able to walk without aid, and willingness to participate in the study. The study was conducted from August to December 2016. Two physiotherapists independently scored the videotaped performance of patients on Persian Brief-BESTest in one session for inter-rater reliability. The first physiotherapist recorded the patients’ performance on Persian Brief-BESTest after 1 week for intra-rater reliability. The physiotherapists were blinded to each other’s scores. Intraclass correlation coefficient (ICC) was used to assess the reliability. SPSS statistical software, version 18 (IBM, Armonk, NY, USA) was used for all analyses.
Results: Thirty patients with stroke (10 males, 20 females, mean age 57.3±13.5 years, duration 40.7±47.3 months) participated in this study. The ICC values for inter-rater reliability and intra-rater reliability of total scores were 0.98 (95% CI: (0.95-0.99)) and 0.99 (95% CI: (0.98-0.99)), respectively. The ICC values for inter- and intra-rater reliability of each item score were 0.72-1.0, and 0.87-1.0 respectively.
Conclusion: The Persian version of Brief-BESTest has high inter- and intra-rater reliability for evaluation of balance in patients with stroke. Therefore, it is recommended for use by clinicians in the clinic and for research purposes in the clinical trials.
Volume 76, Issue 12 (3-2019)
Methods: This prospective cross-sectional study was done in Neurologic Department, Tehran University of Medical Sciences, Tehran, Iran, from April 2015 to April 2016. Second evaluation was done about new neurologic signs and symptoms ten days after stroke. In addition, brain CT scan was used to diagnose of hemorrhagic event in infarct area. If the hemorrhagic event was occur in different area, the patient was consider as a non-hemorrhagic transformation and excluded from the study. Other exclusion criteria include intracranial hemorrhage (ICH), trauma to the head during admission, cerebral vein thrombosis, coagulation disorder, anti-coagulant (heparin, warfarin) administration, induced transformation within 10 days of onset of ischemia, lacunar ischemic and unobservable in thirty T-brain scan, patient's lack of referral for examination and CT scan 10 days after the onset of symptoms, died before CT was considered.
Results: Three hundred and eighty seven patients had inclusion criteria. 249 cases were excluded due to lost following, vein thrombosis of the brain, lacunar ischemia, anti-coagulants recipient (heparin, warfarin), asymptomatic hemorrhagic transformation and death. Finally, 138 cases (86 men, 52 women) with 66.61±9.37 years (50-101 years) were participated in data analysis. Frequency of positive CT scan was evaluated for ischemic stroke evidence in two stages. Of the 138 patients who participated in the study, 75 (54.3%) were positive in the first and 63 (45.7%) cases in the second time. 27 cases (19.6%) had AHTI.
Conclusion: Coronary artery bypass graft (CABG) had significant correlation with ATHI in acute ischemic attack. However, stroke history correlated with decreasing of ATHI. Concerning smoking and consuming the results showed that smoking did not affect the asymptomatic hemorrhagic transformation. Also, the results showed that the use of aspirin and Plavix also had no significant effect on increasing the incidence of ATHI.
Volume 77, Issue 7 (10-2019)
Methods: In the present systematic review study, we investigated the neuroplasticity interventions in stroke individuals. Articles published between January 2005 and January 2017 were reviewed. We searched for five keywords (neuroplasticity, motor learning, muscle synergy, rehabilitation, and stroke) using ProQuest, PubMed, Web of Science, and Google Scholar.
Results: After initial screening and deleting irrelevant studies, 41 studies were chosen for the analysis. Studies were assessed and analyzed methodologically. Proper interventions were selected according to the least error criteria and outcome. Using a targeted selection approach. During the review process, eight articles were selected as the main articles for the review.
Conclusion: Considering the results of the current study, it seems that the neuroplasticity affects the domain of rehabilitation and muscle synergy in individuals with stroke and provides a desirable environment for plasticity-based intervention aimed at motor learning in this population. Large studies with long follow-ups are needed to explain the beneficial effects of neuroplasticity based training combined with rehabilitation protocols.
Volume 78, Issue 1 (4-2020)
Methods: This study was a clinical pretest-posttest study. Twenty patients with stroke (12 males and 8 females), the mean age of 56.5±13 years were included. The assessments were performed before dry needling, immediately after dry needling and 15 minutes after that. Dry needling was used to treat gastrocnemius (ankle plantar flexor) muscles, flexor digitorum longus, and flexor digitorum brevis of the affected lower limb of the patients, for one session. Each muscle was needled for one minute with fast in-fast out technique. The outcome measures of the study were modified modified Ashworth scale (MMAS) for the assessment of the severity of muscle spasticity, timed up and go test and one leg stance test, for balance evaluation. The study was conducted in neurological physical therapy, Clinic of Rehabilitation School, Tehran University of Medical Sciences in Iran, from April 2017 to April 2018.
Results: The results showed a significant decrease in the ankle and toe plantar flexor muscles spasticity both immediately after dry needling and at 15 minutes follow-up (P=0.001). The duration of timed up and go test (P=0.001) and one leg stance test (P=0.001) improved significantly after dry needling and this improvement persisted for 15 minutes after dry needling. The effect size for timed up and go test and one leg stance test was small (Cohen'sd=0.33 and 0.32 respectively).
Conclusion: This study suggests that dry needling is effective in improving spasticity of ankle and toe plantar flexor muscles and the balance of patients with stroke. Further research with larger sample size and control group is necessary.
Volume 80, Issue 9 (12-2022)
Methods: This study is a descriptive cross-sectional study that was conducted to evaluate the knowledge of patients with hemorrhagic stroke about the use of antihypertensives. The study population consists of all patients with hemorrhagic stroke, who were admitted to the intensive care unit of Imam Hossein Hospital in Tehran from September 2020 to March 2021. Data related to blood pressure awareness and drug history was completed by the researcher through the method of direct contact with the patients or their relatives. In this study, 17 patients diagnosed with hemorrhagic stroke due to hypertension who were admitted to the intensive care unit of Imam Hossein Hospital in Tehran, were included. The extent of the exact treatment adherence was assessed using the Morisky questionnaire.
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Results: In this study, the median of patients age was 67 and 10 (58.82%) of them were women. The median systolic and diastolic blood pressures were 170 and 95 mmHg on admission. 4(23.53%) subjects were not aware of the disease. Out of 13 people who were aware of their hypertension, 11(64.71%) were under the supervision of a physician. However, 7(63.64%) of the subjects, despite being under the supervision of a physician and acceptable drug adherence, did not have controlled blood pressure and expired.
Conclusion: This study is a warning for patients and health care providers to pay more attention to blood pressure control. Furthermore, educating the community as well as medical staff about the importance of timely diagnosis and accurate treatment of hypertension is highly recommended. |
Volume 81, Issue 4 (7-2023)
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Case Presentation: A 51-year-old male presented with sudden-onset left side hemiparesis and impaired sensation on the left side of the body, eight years ago. He complained of gradually developing pain on the left side of the body, adding to his symptoms. In his examination, he had dysarthria and his left extremities were spastic and their forces were decreased. Despite numerous medical treatments with gabapentin, pregabalin, duloxetine, carbamazepine and the replacement of an intrathecal baclofen pump during the last few years, he didn't respond very well. This goes so far as to induce severe depression symptoms, which disturbed his daily routine and even induced suicidal ideas. Due to the debilitating symptoms which were resistant to medical treatment, the patient underwent deep brain electrode implantation and deep brain stimulation in the ventral posterior lateral/posterior medial nucleuses in April 2023 at Imam Khomeini Hospital. No remarkable adverse effects were observed after implantation. In the patient’s follow-up, he had a significant improvement in pain and some other symptoms.
Conclusion: Deep brain stimulation of the thalamus nucleus is a known treatment in patients with Parkinson's disease and dystonia. However, for patients with chronic refractory pain, deep brain stimulation is a controversial therapy and has been introduced recently as an effective alternative treatment. In our patient, who suffers from severe unilateral refractory pain after stroke, a deep brain electrode was implanted and after deep brain stimulation significant improvement in pain was seen. |
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