BackgroundThe use of intravenous recombinant tissue plasminogen activator (IV r-tPA) in early acute ischemic stroke (AIS) management faces a lot of difficulties in developing countries due to lessened guideline development with consecutive pre- and intra-hospital delay.ObjectivesThe objective was to identify the barriers facing proper utilization of IV r-tPA for AIS in Tanta University Hospitals.MethodsThe study was conducted on 4124 AIS patients eligible to use IV r-tPA divided to group-I consisting of 442 patients who arrived the hospital within <3.5 h from the stroke onset and group-II consisting of 3682 patients who arrived >3.5 h from the stroke onset. The former group was further subdivided to 238 patients who received IV r-tPA (group-Ia) and 204 patients who did not receive IV r-tPA (group-Ib) due to different obstacles.ResultsThe main causes of pre-hospital onset to arrival delay were stroke unawareness, long travel time, incorrect beliefs, non-available neurologists, stroke onset during sleep and multiple causes (18.2%, 20.5%, 12.7%, 9.1%, 16% and 23.5% of cases, respectively). Causes of non-administration of IV r-tPA in eligible patients includes prolonged door-to-needle time, financial restraints, minor strokes, unavailable beds and fear of complications (41.2%, 26%, 12.7%, 11.3% and 8.8%, respectively).ConclusionIncreasing the chance of utilizing IV r-tPA for AIS patients' needs regular updating of the stroke chain of survival system to get the highest benefits from the available resources.

Introduction: The non-motor symptoms (NMSs) in Parkinson's disease (PD) patients have greater effects on their quality of life compared to the motor symptoms; however, they are under-recognized. The aim: The study aims to evaluate the prevalence and severity of NMS in newly diagnosed PD patients in Tanta University hospitals. Patients and methods: The study included 41 newly diagnosed PD patients. All patients were screened for NMS by the non-motor symptoms questionnaire (NMS-Quest). According to the NMS-Quest response, patients were further evaluated by Sialorrhea Clinical Scale for PD (SCS-PD), Scales for Outcomes in Parkinson's disease for Autonomic symptoms (SCOPA-AUT), Rome III Questionnaire, Nocturnal voiding and Sleep-Interruptions Questionnaire, Brief Pain Inventory, Montreal Cognitive Assessment (MoCA), Scale for Evaluation of Neuropsychiatric Disorders in Parkinson's Disease (SEND-PD), Pittsburgh Sleep Quality Index (PSQI), and questionnaires based upon the International Restless Legs Study Group criteria. The results: The study included 22 female and 19 male patients; the duration of illness was 2.7 ± 2.08 years. Constipation was the most common symptoms as it was present in 73.1% in the studied patients; 61% suffered loss of sexual interest. 47.5% of patients had depressive symptoms. Sleep disturbance was present in 36.6% of the patients. Anxiety was reported by 30% of the patients. Conclusion: All newly diagnosed PD patients suffered one or more NMSs; constipation was the most frequent followed by sexual dysfunction, depressive symptoms, and sleep disturbance, while pain, sialorrhea, and restless leg were the least reported.

BackgroundVasospasm of the cerebral blood vessels is a common complication of aneurysmal subarachnoid hemorrhage (aSAH) which results in delayed cerebral ischemia (DCI) and worsening of the outcome.MethodsThis study was performed on 41 aSAH patients diagnosed by non-contrast brain CT, CT angiography, and digital subtraction angiography followed by interventional aneurysmal embolization. Patients were followed up for 20 days by clinical assessment, EEG monitoring, and transcranial duplex studies (TCD) for early detection of vasospasm and DCI.ResultsThe most common ruptured aneurysmal sites were middle cerebral, anterior communicating, posterior communicating, terminal internal carotid, and anterior cerebral arteries respectively. The incidence of vasospasm was 36.8% of the included cases; 57% progressed to DCI while 43% passed a spontaneous regressive course. The most common arteries undergoing vasospasm were the MCA followed by the ACA, ICA, and lastly the basilar arteries. The mean time of vasospasm development as detected by EEG monitoring and/or TCD was 8.4 ± 2.8 days which was earlier than clinical signs by 12.5 ± 5.3 h in those progressed to DCI.ConclusionContinuous EEG monitoring and TCD are valuable methods for early detection of vasospasm and they allow for early therapeutic intervention before irreversible ischemic neurological deficits take place.

BackgroundThe sensori-motor manifestations of Guillain Barré Syndrome (GBS) are usually severe enough to mask the psychiatric and sleep problems which are in need for more attention for better functional outcome.MethodsThis study was performed on 20 GBS patients and 10 healthy controls. Patients were evaluated initially before immunotherapy using the Overall Disability Sum Score (ODSS), Neuropathy Pain Scale (NPS), Hamilton Anxiety Scale (HAS), Montgomery–Åsberg Depression Rating Scale (MADRS) and one-night polysomnography (PSG) followed by the multiple sleep latency test (MSLT) to evaluate the mean sleep latencies. Reevaluation was done using the same parameters 1 month after completing immunotherapy.ResultsThe study showed significant increase in HAS in GBS patients which were positively correlated with the degree of motor disability. The mean sleep latencies of MSLT were significantly shortened and PSG showed shortening of the total sleep time, sleep efficiency, lowest O2 saturation and pulse transit time with increased wake after sleep onset, sleep stage transition index, apnea hypopnea index, desaturation index, arousal index, snore index and periodic limb movement index. One month after immunotherapy, the anxiety symptoms and sleep abnormalities showed non-significant improvements which were not correlated with the improvements in the sensori-motor manifestations.ConclusionsGBS patients usually have sleep and psychiatric abnormalities which may take longer time to improve than the sensori-motor manifestations. So, they need more attention in the management protocol for early patients’ independence and return to usual daily activities.

BackgroundDisordered sleep breathing is a common complication of diabetic peripheral neuropathy (DPN) manifested by excessive daytime sleepiness, morning headache, morning dizziness, cognitive decline, and mood changes.MethodsThis study was performed on 30 non-obese type 2 diabetic patients; 20 with clinically evident DPN and 10 without. Ten age-, sex-, and body mass index-matched healthy control subjects were also included. Patients and control were subjected to history taking, neurological examination, glycated hemoglobin, and clinical assessment of the sensori-motor manifestations by the neuropathy symptom score and neuropathy disability score. The autonomic nervous system was evaluated clinically by the systolic blood pressure response to standing and heart rate response to each of standing, Valsalva, and deep breath. Finally, sleep was assessed by one-night polysomnogram (PSG) followed by multiple sleep latency test in the next day.ResultsThe study showed significant increase in sleep apnea syndromes in diabetic peripheral neuropathy patients compared to diabetic neuropathy free patients and healthy control (p < 0.0001). The sleep apnea was mainly obstructive and to a little extent mixed (obstructive/central) sleep apnea. The severity of sleep PSG abnormalities was positively correlated with the severities of sensory, motor, and autonomic manifestations.ConclusionsNon-obese type 2 diabetic patients complicated by peripheral neuropathy especially those having dysautonomia are at increased risk of developing sleep disordered breathing resulting in their excessive daytime sleepiness, decreased productivity, and poor glycemic control.

Background: Migraine is a primary headache that commonly starts in childhood and adolescent's periods with great negative impacts on the educational and psychosocial performances of its sufferers. The objectives of this work were to study the existence and types of sleep and psychiatric abnormalities in school-age children with migraine (SCM). Methods: The study was conducted on 40 SCM and 20 age-and sex-matched healthy control subjects (HCS) submitted to history taking, neurological examination, Pediatric Migraine Disability Assessment (PedMIDAS) questionnaire, Child Behavior Checklist (CBCL), Epworth Sleepiness Scale for Children and Adolescents (ESS-CHAD), Pittsburgh Sleep Quality Index (PSQI) and one-night polysomnography (PSG). Results: The study showed a high incidence of psychiatric and sleep abnormalities in SCM. The most common psychiatric disorders were anxious depressed symptoms, withdrawal depressed symptoms, social problem, somatic complaints, and attention problems. At the same time, SCM experienced decreased sleep quality, excessive daytime sleepiness (EDS), and PSG abnormalities in the form of decreased total sleep time (TST) and sleep efficiency (SE) in addition to increased sleep latency, wake after sleep onset (WASO), arousal index (AI), and REM sleep without atonia index. Conclusion: Sleep and psychiatric abnormalities are common underdiagnosed pediatric migraine comorbidities greatly reducing headache control and school performance in this very important period of psychosocial development.

BackgroundBorder zone infarcts (BZI) are ischemic lesions at the junction between two main arterial territories which may be either cortical or internal BZI.MethodsThis study was conducted on 76 cerebral BZI patients and 20 healthy control subjects. Patients were divided to group I included 26 internal BZI, group II included 19 cortical BZI and group III included 21 mixed internal/cortical BZI patients. Included subjects were submitted to neurological examination, laboratory investigations, ECG, echocardiogram, brain CT and/or MRI and extra and intracranial blood vessels imaging by duplex and CT angiography.ResultsHypertension was significantly higher among groups I and III compared to group II while atrial fibrillation (AF) was significantly higher in groups II and III than group I (p < 0.05). Sonographic duplex assessment of extra and intracranial blood vessels revealed significant increase in mean flow velocities of CCA, ICC and MCA on both side in groups I and III compared to group II (p < 0.05). CT angiography revealed non-significant differences between BZI patients and control as well as in between the three BZI patient’s groups regarding the existence of vertebral artery hypoplasia and/or circle of Willis anomalies.ConclusionsVascular stenosis is the main etiological factor in internal BZI while AF is the predominant etiological factor of cortical BZI. Congenital vascular anomalies play roles in the localization of BZI but cannot predispose to it except when comorbid with hemodynamic disturbances.

Background: Idiopathic intracranial hypertension (IIH) is a disorder of unidentified etiology characterized by raised intracranial pressure (ICP) without clinical, laboratory, or radiological evidence of intracranial pathology. The aim of this work was to determine the visual outcome in newly diagnosed IIH patients. Methods: The study included 68 IIH patients; 59 responded to medical treatment and nine needed lumboperitoneal shunting (LPS). Patients were submitted to papilledema grading using Frisén Scale, water CSF manometry, brain MRI/ MRV, mean deviation of visual field examination (MD-VFE), optic nerve sheath diameter (ONSD), average optic disc optical coherence tomography-retinal nerve fiber layer (OCT-RNFL) thickness, and pattern-reversal visual evoked potential (VEP). Results: Patients needed LPS showed statistically significant increase in baseline papilledema grade, MD-VFE, ONSD, average OCT-RNFL thickness, and P100 VEP latency. On the other hand, both studied groups showed statistically nonsignificant differences regarding the patients' ages and opening CSF pressure. Conclusion: Newly diagnosed IIH patients' evaluation must be based on multimodality neuro-ophthalmological assessment where papilledema grade, MD-VFE, and OCT-RNFL are valuable biomarkers of PVD while P100 VEP latency delay is a predictor of poor visual outcome and ONSD is an early indicator of elevated ICP regression after LPS surgery.