Clinical Neuroscience

[The role of intravenous thrombolysis before mechanical thrombectomy in the treatment of large vessel occlusion strokes ]

KALMÁR Péter János1, TÁRKÁNYI Gábor1, KARÁDI Zsófia Nozomi1, BOSNYÁK Edit1, NAGY Csaba Balázs2, CSÉCSEI Péter1, LENZSÉR Gábor2, BÜKI András2, JANSZKY József1, SZAPÁRY László1

JANUARY 30, 2022

Clinical Neuroscience - 2022;75(01-02)

DOI: https://doi.org/10.18071/isz.75.0023

Journal Article

[The efficacy of intravenous thrombolysis (IVT) is moderate in the proximal vascular segments of intracranial arteries, as opposed to mecha­nical thrombectomy (MT). In the management of acute ischemic stroke (AIS) caused by large vessel occlusions (LVO), IVT prior to MT is highly recommended based on the latest guidelines, but the necessity of IVT has been questioned by the latest studies of the past years. The aim of our study was to investigate and compare the efficacy and safety of direct mechanical thrombectomy (dMT) and combined therapy (CT) for patients who suffered an AIS with LVO and were treated in our department. We investigated patients with AIS caused by LVO who were admitted up to 4.5 hours after symptom onset and underwent MT in our department between November 2017 and August 2019. Patients’ data were collected in our stroke register. Patients enrolled in our study were divided into two groups depending on whether dMT or CT was used. Our primary outcome was the 30- and 90- day functional outcome measured by modified Rankin Scale (mRS). Mortality at 30- and 90- day, successful recanalization rates, and symptomatic intracranial hemorrhage were considered as secondary outcomes. A total of 142 patients (age: 68.3 ± 12.6 years, 53.5% female) were enrolled in our study, including 81 (57.0%) dMT cases, and 61 (43.0%) patients who received CT. The vascular risk factors and comorbidities were significantly higher in the dMT-treated group. At day 30, the rate of favorable functional outcomes was 34.7% in dMT vs. 43.6% among those who received CT (p = 0.307), by day 90 this ratio changed to 40.8% vs. 46.3% (p = 0.542). Mortality rates at day 30 were 22.2% and 23.6% (p = 0.851), and at day 90 33.8% and 25.9% (p = 0.343). The rate of effective recanalization was 94.2% for dMT-treated patients and 98.0% for CT-treated patients (p = 0.318). Symptomatic intracranial hemorrhage was detected in 2.5% of dMT-treated patients and 3.4% of CT-treated group (p = 0.757). Our results suggest that CT is associated with a moderately better outcome compared to dMT. IVT prior to MT did not increase the risk of symptomatic intracranial hemorrhages.]

AFFILIATIONS

  1. Pécsi Tudományegyetem, Neurológiai Klinika, Pécs
  2. Pécsi Tudományegyetem, Idegsebészeti Klinika, Pécs

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Comparison of pramipexole versus ropinirole in the treatment of Parkinson’s disease

GENCLER Onur Serdar , OZTEKIN Nese , OZTEKIN Fevzi Mehmet

Parkinson’s disease is a progressive neurodegenerative disease characterized by motor and non-motor symptoms. Levodopa is the most effective drug in the symptomatic treatment of the disease. Dopamine receptor agonists provide sustained dopamin-ergic stimulation and have been found to delay the initiation of levodopa treatment and reduce the frequency of various motor complications due to the long-term use of levodopa. The primary aim of this study was to compare the efficacy of potent nonergoline dopamine agonists pramipexole and ropinirole in both “dopamine agonist monotherapy group” and “levodopa add-on therapy group” in Parkinson’s disease. The secondary aims were to evaluate the effects of these agents on depression and the safety of pramipexole and ropinirole. A total of 44 patients aged between 36 and 80 years who were presented to the neurology clinic at Ministry of Health Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey and were diagnosed with idiopathic Parkinson’s disease, were included into this randomized parallel-group clinical study. Dopamine agonist monotherapy and levodopa add-on therapy patients were randomized into two groups to receive either pramipexole or ropinirole. The maximum daily dosages of pramipexole and ropinirole were 4.5 mg and 24 mg respectively. Patients were followed for 6 months and changes on Unified Parkinson’s Disease Rating Scale, Clinical Global Impression-severity of illness, Clinical Global Impression-improvement, Beck Depression Inven­tory scores, and additionally in advanced stages, changes in levodopa dosages were evaluated. Drug associated side effects were noted and compared. In dopamine agonist monotherapy group all of the subsections and total scores of Unified Parkinson’s Disease Rating Scale and Clinical Global Impression-severity of illness of the pramipexole subgroup showed significant improvement particularly at the end of the sixth month. In the pramipexole subgroup of levodopa add-on therapy group, there were significant improvements on Clinical Global Impression-severity of illness and Beck Depression Inventory scores, but we found significant improvement on Clinical Global Impression-severity of illness score at the end of the sixth month in ropinirole subgroup too. The efficacy of pramipexole and ropinirole as antiparkinsonian drugs for monotherapy and levodopa add-on therapy in Parkinson’s disease and their effects on motor complications when used with levodopa treatment for add-on therapy have been demonstrated in several previous studies. This study supports the effectiveness and safety of pramipexole and ropinirole in the monotherapy and levodopa add-on therapy in the treatment of Parkinson’s disease.

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The effect of starting a meal with salt and date palm on taste impairment caused by COVID-19

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This study was conducted to examine the effect of starting a meal with salt and date palm on the sense of taste in COVID-19 patients. This study was conducted using a randomized controlled method. Patient and disease information forms and Visual Analog Scale were used for data collection. Salt and date palm were used to stimulate the sense of taste in two different experimental groups. No procedure was made in the control group except for the practice of the clinic. The results were analyzed using SPSS version 25. The mean ages of all groups were between 43.42 ± 8.60 and 47.22 ± 12.04 years. Fever, sore throat, dry mouth, cough, muscle weakness, and similar symptoms were present in all groups. Significant improvements were found in patients with hypoageusia and ageusia after date palm and salt application (p<0.01). For taste impairment caused by COVID-19, consumption of date palm and tasting very little salt for therapeutic purposes may help to alleviate taste impairment. Based on the data obtained from this study, the pathophysiology of the effects of date palm and salt on taste complications should be investigated.

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Clinical Neuroscience

Uric acid: The role in the pathophysiology and the prediction in the diagnosis of Parkinson’s disease: A Turkish-based study

ARI Cagla Buse , TUR Kobak Esma , DOMAC Mayda Fusun , KENANGIL Ozgen Gulay

Oxidative stress has been associated as an essential contributor to the development of neurodegenerative diseases. Recent developments in the field of Parkinson’s Disease (PD) pathophysiology have led to a renewed interest in this field. As an antioxidant, uric acid (UA) has arisen as a potential neuroprotectant. Higher concentrations of UA are linked to reducing the risk of the development of the disease and preventing its progression. However, the expositions are unsatisfactory because the outcomes of these reports have not been consistent. This study is set out to assess the association of whether lower UA concentrations increased the PD risk by investigating its relationship with patients’ demographic and clinical data, and to determine whether previous studies are compatible with the Turkish-sampled population. Furthermore, we aimed to determine UA’s probability of being an early-stage diagnostic marker. A total of 305 patients and 100 healthy controls were included. Serum UA levels of patients and controls were compared with clinical features. We classified the patients into three motor subtypes and determined the disease severity by modified Hoehn&Yahr Staging Scale (mH&Y) and Unified Parkinson’s Disease Rating Scale (UPDRS). Standardized Mini-Mental State Examination (MMSE-TR) was assessed for cognition. There were not any significant differences of age and sex between patients and controls (p=0.030, p=0.132). The mean UA was 5.06±1.33 mg/dL in patients and 5.46±1.44 in controls, and a statistical significance was detected (p=0.022). The mean MMSE-TR were 24.83±4.35 in patients and 27.09±2.13 in controls, and statictical significance was revealed (p=0.001). The mean duration of the disease was 6.31±4.16 years, mean UPDRS scores were 59.74±22.33, and mH&Y scores were 2.29±0.91. In binary comparisons, patients with tremor-dominant motor subtype had lower UA concentrations than controls (p=0.014). ROC curve analysis revealed UA’s cut-off as ≤9.15, the specificity was 99.3, the sensitivity was 10.0, and the area under the curve was 0.576 (p<0.005). Regression analysis revealed age as an independent risk factor on UA values. Oxidative stress might be a factor in the development of PD, and UA may be a possible prospective protecting factor in the clinical course of the disease. However, it does not affect the severity. Our results support that lower uric acid concentrations are associated with PD; however, it is not a powerful indicator for predicting PD risk. As we reveal more about UA and its effect in further investigations, its significant role will become well-defined.

Clinical Neuroscience

Lower / upper extremity F-wave ratio for detecting early diabetic neuropathy

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Lege Artis Medicinae

[The history of acute stroke care in Hungary ]

BERECZKI Dániel

[Stroke is one of the most frequent causes of death and the most important cause of permanent disability worldwide and also in Hungary. The Hungarian medical literature has mentioned this disease and has been giving recommendations for its treatment since 1690. Initially folk medicines, herbal preparations and phlebotomy were used as standard therapy. Later, cooling the head joined these methods. Pharmacy preparations emerged at the middle of the 19th century. From the middle of the 20th century, products of the pharmaceutical industry like blood flow enhancers and neuroprotective drugs were in the frontline of the acute care. Anti­hy­per­ten­sive, antithrombotic and lipid-lowering medications became part of stro­ke prevention. Imaging techniques – mainly computer tomography of the brain and ultrasound examination of the cervical large arteries – have radically changed the diagnostics of cerebrovascular diseases from the middle of the 1980s. Since the 1990s, diagnostic and therapeutic decisions are based on reliable evidence from good quality clinical trials. Since the beginning of the 21st century, reperfusion treatments (intravenous thrombolysis and mechanical thrombectomy) re­present the most effective emergency care. The current direction is the extension of the therapeutic time-window of reperfusion treatments based on sophisticated neruoimaging. This review provides a brief summary of the development of stroke care in the last three and a half centuries as reflected in the Hungarian medical literature. ]

Clinical Neuroscience

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[Introduction - There are no previously published cases about intravenously applied recombinant tissue plasminogen activator in acute ischemic stroke during puerperium. Case presentation - We report a 40-year-old woman with postpartum acute ischemic stroke caused by multiple cervical artery dissections treated by systemic thrombolysis and endovascular intervention. Discussion - There are only limited data regarding thrombolytic treatment in acute stroke during pregnancy and puerperium. Current acute stroke treatment guidelines - while considering pregnancy as a relative exclusion criterion - do not deal with the postpartum state. Conclusion - As the condition is rare, randomized controlled trials are not feasible, therefore further reports on similar cases could eventually help us suggest guidelines or at least propose recommendations for the acute thrombolytic treatment of strokes occurring in pregnancy and puerperium.]

Clinical Neuroscience

Is stroke indeed a “Monday morning disease”?

FOLYOVICH András, BÉRES-MOLNÁR K Anna, GIMESI-ORSZÁGH Judit, KATONA Lajos, BICZÓ Dávid, VÖRÖS Károly, GŐBL Gábor, AJTAY András, BERECZKI Dániel

Introduction - The therapeutic time window of acute stroke is short. Decision on the use of intravenous thrombolysis is based on well-defined criteria. Any delay in the transport to a designated stroke centre decreases the odds of therapeutic success. In Hungary, the admission rate of stroke patients peaks on Monday, the number gradually decreasing by the end of the week. This phenomenon has long been suggested to be due to the lack of emergency care approach. According to the literature, however, returning to work following a holiday is a risk factor for acute stroke. A similar phenomenon is well-known in veterinary medicine, a condition in horses referred to as ‘Monday morning disease’. In our study, we analysed the distribution of admissions due to acute stroke by the day of the week in 4 independent data sources. Patients and methods - The number of patients admitted to the Szent János Hospital, Budapest, Hungary with stroke and that of emergency ambulance transports in the whole city of Budapest due to acute stroke were analysed in the period between January 1 and March 31, 2009. The distribution of thrombolytic interventions reflecting hospitalizations for hyperacute stroke was analysed based on data of the Szent János Hospital in 2009-2012, and on national data from 2006-2012. Descriptive statistics was used to present the data. The variation between daily admission was compared by chi-square test. Results - The proportion of daily admission of stroke patients admitted to the Szent János Hospital was the highest at the beginning of the week (18% on Monday, and 21% on Tuesday) and the lowest on the weekend (9% and 9% on Saturday and Sunday, respectively). The distribution of ambulance transports in Budapest due to acute stroke tended to be similar (15% and 15% on Monday and Tuesday, whereas 13% and 12% on Saturday and Sunday, respectively) on different days of the week. No such Monday peak could be observed in a single centre regarding thrombolytic interventions: 18% and 19% of the total of 80 thrombolytic interventions in the Szent János Hospital were performed on Monday and Sunday, respectively. At the national level the higher Monday rate is obvious: during a 7-year period 16.0%, 12.7%, and 13.5% of all thrombolytic interventions in Hungary were performed on Monday, Saturday and Sunday, respectively. Conclusion - Monday preference of stroke is not exclusively caused by the lack of emergency care approach, and the phenomenon is not consistent at the individual hospital level in cases undergoing thrombolysis.