Maher Saqqur’s research while affiliated with University of Toronto and other places

Objectives To highlight the significance of various clinical and radiological parameters in association with specific electroencephalographic (EEG) patterns in order to prioritize EEG referrals. Method This retrospective, cross-sectional study was conducted in the neurology department of King Fahad University Hospital, Alkhobar, and involved a review and analysis of EEG and medical records pertaining to 604 patients referred for routine EEG. The data were analyzed using SPSS version 22. An association between various parameters and EEG yield was established. Results Factors associated with the yield of abnormal EEG patterns were diverse, like generalized tonic-clonic seizures (GTCs) ( P =.05), status epilepticus (SE) ( P =.05), altered level of consciousness (ALC) ( P =.00), abnormal movement ( P =.00), cardiac arrest ( P =.00), prior history of epilepsy ( P =.04), chronic renal disease (CRD) ( P =.03), abnormal neurological exam ( P =.00), and cortical lesions on brain imaging ( P =.00). Among the abnormal EEG patterns, epileptiform activity (EA) in EEG was associated with focal seizures ( P =.03), GTCs ( P =.00), falls ( P =.05), cardiac arrest ( P =.00), a history of epilepsy ( P =.00), and hypoxic ischemic injury ( P =.03). Encephalopathy in EEG was also associated with focal sz ( P =.02), GTCs ( P =.00), SE ( P =.01), ALC ( P =.00), cardiac arrest ( P =.00), history of stroke ( P =.01), and epilepsy ( P =.00). Conclusion Among the studied parameters, patient level of consciousness, neurological exam findings, and neuroimaging findings, with some discrepancies, were found to be the most consistent in predicting the EEG yield. The study demonstrated the value of a proper neurological exam and careful selection of patients to gain the optimum benefit from the routine EEG.

Background: Non-contrast CT (NCCT) and CT angiogram (CTA) have become essential for endovascular treatment (EVT) in acute stroke. Patient selection may improve when CT perfusion imaging (CTP) is also added for patient selection. We aimed to analyze the effects of implementing CTP in acute ischemic stroke (AIS) patients' treatment to assess whether stroke outcomes differ in the late window. Methods: We searched the PubMed, Embase, and Web of Sciences databases to obtain articles related to CTA and CTP in EVT. Collected patient data was split into two groups: the CTP and control (NCCT+CTA) cohorts. Primary outcomes evaluated were modified Rankin Scale (mRS) scores, symptomatic intracranial hemorrhages (sICH), mortality, and successful recanalization. Results: There were 14 studies with 5,809 total patients in the final analysis: 2,602 received CTP and 3,202 were in the control group. CTP/CTA patients showed significantly lower rates of 90-day stroke-related mortality (OR: 0.72, 95% CI 0.60-0.87, p<0.01) and significantly higher successful recanalization (OR: 1.42, 95% CI 1.06-1.94, p<0.01) compared to CTA-only patients. Analysis of other outcomes including functional independence (mRS 0-2), critical times, and intracranial hemorrhages were non-significant (p > 0.05). Conclusion: The study highlights the usefulness of CTP-guided therapy as a supplementary tool in EVT selection in the late window. Although the addition of CTP resulted in lower mortality, the favorable outcomes did not improve. Further evidence is required to establish a clearer understanding of the potential advantages or limitations of incorporating CTP in stroke imaging.

Background Coronavirus disease-2019 (COVID-19) infection originated in China and was very quickly seen in the Middle East North Africa (MENA) region. This study was undertaken to evaluate COVID-19-related cerebrovascular involvement in the MENA+ region. Methods Retrospective observational regional multicenter study aiming to identify acute stroke presentation and functional independency in patients with COVID-19 infection in the MENA region. The diagnosis of COVID-19 was established by polymerase chain reaction testing in all patients. The National Institute of Health Stroke Scale (NIHSS) was used to evaluate the severity of stroke symptoms. Functional independency was assisted by a modified Rankin Scale (mRS) at 90 days. Results There were 209 patients including 65 COVID-19-related stroke group (CRSG). The mean age was 62.85 ± 15.94 for (CRSG) and 58.69 ± 14.73 in non-COVID-19 stroke group (NCSG). The most prevalent risk factor for both groups was hypertension 45 (69.2%) and 105 (72.9) respectively. Intravenous thrombolysis therapy was delivered to 6/65 (9.2%) in (CRSG) compared to 11 (7.6) in (NCSG). The mean NIHSS at baseline for the (CRSG) was 12.94 ± 9.46, versus 6.08 ± 4.9 in (NCSG). This was statistically significant ( P < 0.001). Functional outcome at the 90-day measured using mRS was worse in the (CRSG) compared to (NCSG) 3.61 ± 2.53, 2.20 ± 2.60 respectively and this was statistically significant ( P = 0.001). Conclusion In this study from multiple countries from the MENA+ region, we showed that acute stroke in patients with active COVID-19 had more severe symptoms at onset and worse 90 days’ outcomes despite the young age. There were no regional differences noted in severity and outcome in the MENA region.

Objective As stroke is still considered a significant cause of mortality and morbidity, it is crucial to find the factors affecting the outcome in these patients. We aimed to interpret the various clinical and investigational parameters and establish their association with the outcome in stroke patients. Materials and Methods This is a retrospective, cross-sectional study, conducted in the Department of Neurology between June 2019 to November 2021. The study involved the review and analysis of medical records pertaining to 264 patients, admitted with the diagnosis of stroke. Various clinical, radiological, and electroencephalographic (EEG) patterns in stroke patients were analyzed and their association with outcome was established. The association between the studied variables was performed by the logistic regression (LR) and presented as odds ratio (OR) and 95% confidence interval (CI). Results The study sample consisted of 264 patients. Males comprised 165 (62.5%) with the mean participant age of 57.17 ± 18.7 3 years (range: 18–94). Patients younger than 50 years had a better likelihood of a good outcome in comparison to patients older than 50. The admission location was the most significant factor in predicting the outcome ( P = 0.00) in favor of inpatient department and outpatient department (OPD), in contrast to patients admitted directly to intensive care unit (ICU). Normal EEG was associated with good outcome ( P = 0.04; OR, 3.3; CI, 1.01–10.88) even after adjustment of the confounders, whereas patients having marked EEG slowing had a poor outcome ( P = 0.05; OR, 2.4; CI, 0.65–8.79). Among the clinical parameters, hemiparesis ( P = 0.03), trauma ( P = 0.01), generalized tonic-clonic seizures (GTC) ( P = 0.00), and National Institutes of Health Stroke Scale of more than 4 were more likely associated with a poor outcome as well as the presence of intracranial hemorrhage (ICH) or infarction in the cortical and cortical/subcortical locations were associated with poor outcomes. After adjustment of confounders, the factors found to have prognostic significance in favor of good outcomes were inpatients or OPD referrals and normal EEG while direct admission to ICU, marked slowing on EEG, and presence of ICH were found to be associated with poor outcome. Conclusion Certain patterns are predictive of good or worse outcomes in stroke patients. Early identification of these factors can lead to early intervention, which in turn might help in a better outcome. The results of the study, therefore, have some prognostic significance.

Background: Previous research demonstrates that for acute ischemic stroke (AIS) cases, rapid endovascular therapy (EVT) performance improves outcomes. This study provides updated metrics summarizing estimates for modified Rankin Scale (mRS) gains accrued by streamlining time to EVT. Methods: A systematic review and meta-analysis (MA) was conducted using electronic databases. Eligible studies reported time-benefit slope with times from AIS onset (or time last-seen-normal) to EVT commencement; the predictor was onset-to-groin (OTG) time. Primary and secondary outcomes were 90-day functional independence (mRS 0-2) and 90-day excellent function (mRS 0-1), respectively. Results: The five included studies showed increased chance of good outcome with each hour of pre-EVT time savings for mRS 0-2 for 0-270’ (OR 1.25, 95% CI 1.16-1.35, I2 40%) and 271-360’ time frame (1.22, 95% CI 1.12-1.33, I2 58%). For studies assessing mRS 0-1, pooled effect estimates were appropriate for the 0-270’ time frame (OR 1.34, 95% CI 1.19-1.51, I2 27%) and the 271-360’ time frame (OR 1.20, 95% CI 1.03-1.38, I2 60%). Conclusions: Each hour saved from AIS onset to EVT start is associated with a 22-25% increased odds of functional independence, a useful metric to inform patient-specific and systems planning decisions.

Background and Purpose: Transcranial Doppler (TCD) identifies acute stroke patients

Introduction: Since 2011, the Syrian war has produced a mounting toll in terms of deaths and displaced persons. We present an analysis of demographic and temporal patterns of trauma patient presentations to Syrian hospitals in non-governmental, non-Islamic State (NGNI) regions from 2013 - 2015. Methods: We analyzed an administrative dataset of patient presentations to 95 NGNI Syrian hospitals in regions outside of Syrian government control from July 2013 - July 2015. Descriptive analysis of this secondary data is reported and logistic regression was performed to assess for factors associated with inpatient mortality. Results: 193,618 trauma patients presented to 95 NGNI hospitals from July 2013 - July 2015 (154,225 male, 79.7%; 39,393 female, 20.4%). Age information was complete for 160,237 encounters (82.8%): 0-2y: 8,257 (4.3%), 3-12y: 24,199 (12.5%), 13-18y: 22,482 (11.6%), 19-60y: 100,553 (51.9%), and elders over 60 years: 4,746 (2.5%). 59,387 patients were admitted (Ward 57,625; ICU 1,762) for an average length of stay of 3.80 days. There were 2,694 inpatient deaths (4.5% of admitted) and 4,758 patients (8.0%) required transfer to another facility for definitive care. Shrapnel (81,946; 42.3%) and blunt/crush injuries (71,477; 36.9%) were dominant injury mechanisms with an increasing proportion of these injuries over time. Inpatient mortality was most associated with extremes of age (age less than 2 aOR 2.92; age greater than 60 aOR 2.48), penetrating chest trauma (gunshot-chest aOR 6.03) and neurotrauma (blast-head aOR 13.42; blast-spine aOR 11.31; gunshot-head aOR 10.07; shrapnel-head aOR 6.34). Civilians presentations increased from 20% at start of data collection to a peak of 50% in June 2015. Conclusion: The Syrian war has resulted in large volumes of trauma patients and significant mortality at NGNI Syrian hospitals. Mortality was most associated with neurotrauma and penetrating chest trauma. There was an increasing trend over time towards blunt/crush and shrapnel injuries consistent with the transition to the widespread use of aerial bombardment with resultant explosions and building collapse. Civilians including children and the elderly represent high proportions of the injured in NGNI Syrian hospitals. Additional work is needed to improve documentation of clinical service and to assess outcomes of care to improve quality of services provided to Syrian war trauma patients.

Importance Age is a leading predictor of poor outcomes after brain injuries like stroke. The extent to which age is associated with preexisting burdens of brain changes, visible on neuroimaging but rarely considered in acute decision-making or trials, is unknown. Objectives To explore the mediation of age on functional outcome by neuroimaging markers of frailty (hereinafter neuroimaging frailty) in patients with acute ischemic stroke receiving endovascular thrombectomy (EVT). Design, Setting, and Participants This cohort study was a post hoc analysis of the Safety and Efficacy of Nerinetide (NA-1) in Subjects Undergoing Endovascular Thrombectomy for Stroke (ESCAPE-NA1) randomized clinical trial, which investigated intravenous (IV) nerinetide in patients who underwent EVT within a 12-hour treatment window. Patients from 48 acute care hospitals in 8 countries (Canada, US, Germany, Korea, Australia, Ireland, UK, and Sweden) were enrolled between March 1, 2017, and August 12, 2019. Markers of brain frailty (brain atrophy [subcortical or cortical], white matter disease [periventricular or deep], and the number of lacunes and chronic infarctions) were retrospectively assessed while reviewers were blinded to other imaging (eg, computed tomography angiography, computed tomography perfusion) or outcome variables. All analyses were done between December 1, 2022, and January 31, 2023. Exposures All patients received EVT and were randomized to IV nerinetide (2.6 mg/kg of body weight) and alteplase (if indicated) treatment vs best medical management. Main Outcome and Measures The primary outcome was the proportion of the total effect of age on 90-day outcome, mediated by neuroimaging frailty. A combined mediation was also examined by clinical features associated with frailty and neuroimaging markers (total frailty). Structural equation modeling was used to create latent variables as potential mediators, adjusting for baseline, early ischemic changes; stroke severity; onset-to-puncture time; nerinetide treatment; and alteplase treatment. Results Among a total of 1105 patients enrolled in the study, 1102 (median age, 71 years [IQR, 61-80 years]; 554 [50.3%] male) had interpretable imaging at baseline. Of these participants, 549 (49.8%) were treated with IV nerinetide. The indirect effect of age on 90-day outcome, mediated by neuroimaging frailty, was associated with 85.1% of the total effect (β coefficient, 0.04 per year [95% CI, 0.02-0.06 per year]; P < .001). When including both frailty constructs, the indirect pathway was associated with essentially 100% of the total effect (β coefficient, 0.07 per year [95% CI, 0.03-0.10 per year]; P = .001). Conclusions and Relevance In this cohort study, a secondary analysis of the ESCAPE-NA1 trial, most of the association between age and 90-day outcome was mediated by neuroimaging frailty, underscoring the importance of features like brain atrophy and small vessel disease, as opposed to chronological age alone, in predicting poststroke outcomes. Future trials could include such frailty features to stratify randomization or improve adjustment in outcome analyses.

Background Telestroke systems operate through remote communication, providing distant stroke evaluation through expert healthcare providers. The aim of this study was to assess whether the implementation of a telestroke system influenced stroke treatment outcomes in acute ischemic stroke (AIS) patients compared with conventional in-person treatment. Aims The study group evaluated multiple studies from electronic databases, comparing telemedicine (TM) and non-telemedicine (NTM) AIS patients between 1999 and 2022. We aimed to evaluate baseline characteristics, critical treatment times, and clinical outcomes. Summary of review A total of 12,540 AIS patients were included in our study with 7936 (63.9%) thrombolyzed patients. Of the thrombolyzed patients, 4150 (51.7%) were treated with TM, while 3873 (48.3%) were not. The mean age of TM and NTM cohorts was 70.45 ± 4.68 and 70.42 ± 4.63, respectively (p > 0.05). Mean National Institute of Health Stroke Scale scores were comparable, with the TM group reporting a non-significantly higher mean (11.89 ± 3.29.6 vs. 11.13 ± 3.65, p > 0.05). No significant difference in outcomes was found for symptoms onset-to-intravenous tissue plasminogen activator (ivtPA) times (144.09 ± 18.87 vs. 147.18 ± 25.97, p = 0.632) and door-to-needle times (73.03 ± 20.04 vs. 65.91 ± 25.96, p = 0.321). Modified Rankin scale scores (0–2) were evaluated, and no significant difference was detected between cohorts (odds ratio (OR): 1.06, 95% confidence interval (CI): 0.89–1.29, p = 0.500). Outcomes did not indicate any significance between both cohorts for 90-day mortality (OR: 1.16, 95% CI: 0.94–1.43, p = 0.17) or symptomatic intracranial hemorrhage (OR: 0.99, 95% CI: 0.73–1.34, p = 0.93). Results between groups were also non-significant when analyzing the rate of thrombolysis with ivtPA (30.86%± 30.7 vs. 20.5%± 18.6, p = 0.372) and endovascular mechanical thrombectomy (11.8%± 11.7 vs. 18.7%± 18.9, p = 0.508). Conclusion The use of telestroke in the treatment of AIS patients is safe with minimal non-significant differences in long-term outcomes and rates of thrombolysis compared with face-to-face treatment. Further studies comparing the different methods of TM are needed to assess the efficacy of TM in stroke treatment.