professor hossein pakdaman file final (oral).… · dr. reza boostani mashhad university of medical...
TRANSCRIPT
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Professor Hossein Pakdaman President of Iranian Neurological
Association
Dear Colleagues,
I am proud to welcome you to the 26th Iranian Congress of Neurology and Electrophysiology.
This congress is a great opportunity to meet and collaborate with colleagues and experts in various
fields of medical and paramedical sciences related to the neurological disorders.
During this conference, scientists and participants from different countries gathered to share their
experiences and findings.
It has been attempting to present a large amount of new information through various lectures,
workshops and posters over a short period of time.
We hope to meet you at a warmly atmosphere in Tehran and as always, let us know your comments and
suggestions in this regards.
Professor Hossein Pakdaman
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Dr. Mohsen Foroughipour
President of Congress Dr. Farzad Fatehi
Chairman of Congress
Dear Colleagues,
It is our pleasure to welcome all of the neurologists, scientists, academicians, and researchers from all
over the Iran and world to attend the 26th International Congress of Neurology and Clinical
Electrophysiology of Iran.
In this event, we will discuss the breakthroughs and developments in neurology from basic and research
to the clinical practice. Besides a top-rate scientific program, there will be many opportunities for hands-
on learning workshop and exciting social events.
26th Congress is unique in its approach of encouraging a dialogue between the basic and clinical
scientists.
Our remarkable program will be particularly educational and inspiring for young scientists who will get
an opportunity to interact with leading experts.
In this Congress, we have attempted to present the educational material including teaching courses and
invited oral presentations as videos in the designed application of the Congress and also iranneurology
website.
In addition, the Best Iranian Neurologist tournament would be an excellent opportunity for young
neurologists to participate in a fascinating contest.
We take immense pride to welcome you to this exciting international congress and hope you will have
satisfying academic and social interaction in Tehran, the beautiful and dynamic capital of Iran.
Dr. Mohsen Foroughipour and Dr. Farzad Fatehi
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Scientific Committee
Dr. Farhad Asarzadegan Shahid Beheshti University of Medical Sciences Dr. Nahid Ashjazadeh Shiraz University of Medical Sciences Dr. Farzad Ashrafi Shahid Beheshti University of Medical Sciences Dr. Hormoz Ayramloo Tabriz University of Medical Sciences Dr. Nahid BeladiMoghadam Shahid Beheshti University of Medical Sciences Dr. Afshin Borhani Haghighi Shiraz University of Medical Sciences Dr. Reza Boostani Mashhad University of Medical Sciences Dr. Saeid Charsouei Tabriz University of Medical Sciences Dr. Masoud Etemadifar Isfahan University of Medical Sciences Dr. Majid Ghaffarpour Tehran University of Medical Sciences Dr. Mohammad Hossein Harirchian Tehran University of Medical Sciences Dr. Hossein Delavar Kasmaei Shahid Beheshti University of Medical Sciences Dr. Fatemeh Khamseh Dr. Fariborz Khorvash Isfahan University of Medical Sciences Dr. Mahmoud Motamedi Tehran University of Medical Sciences Dr.Ehsan Mohamadianinejad Ahvaz Jundishapur University of Medical Sciences Dr. Mohammad Reza Motamed Iran University of Medical Sciences
Dr. Shahriar Nafissi Tehran University of Medical Sciences Dr. Alireza Nikseresht Shiraz University of Medical Sciences Dr. Maryam Noroozian Tehran University of Medical Sciences Dr. Ali Asghar Okhovat Tehran University of Medical Sciences Dr. Hossein Pakdaman Shahid Beheshti University of Medical Sciences Dr. Reza Rikhtegar Tabriz University of Medical Sciences Dr. Mohammad Rouhani Tehran University of Medical Sciences Dr. Mohammad Ali Sahraian Tehran University of Medical Sciences Dr. Mohammad Saadatnia Isfahan University of Medical Sciences Dr. Behnaz Sedighi Kerman University of Medical Sciences Dr. Gholamreza Shamsaei Ahvaz Jundishapur University of Medical Sciences Dr. Gholam Ali Shahidi Iran university of medical sciences Dr. Kaveh Shafiei Kerman University of Medical Sciences Dr. Mansoureh Togha Tehran University of Medical Sciences Dr. Mohammad Yazdchi Tabriz University of Medical Sciences Dr. Babak Zamani Iran University of Medical Sciences
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Executive Committee
Dr. Ebrahim Pourakbar
Mr. Hamid Ghasemi
Mrs. Hamideh Ansari
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Contents Cerebrovascular and Neurointervention ...................................................................................................... 6
Dementia ..................................................................................................................................................... 10
Headache .................................................................................................................................................... 16
Movement Disorders .................................................................................................................................. 24
Multiple Sclerosis ........................................................................................................................................ 28
Neuroimaging.............................................................................................................................................. 35
Neuromuscular ........................................................................................................................................... 36
Neurosciences ............................................................................................................................................. 46
Seizure ......................................................................................................................................................... 48
Others ......................................................................................................................................................... 55
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Cerebrovascular and Neurointervention Factors affecting the obliteration rate of Intracranial Aneurysms treated with a single
Pipeline Embolization Device
- Hanieh Moshayedi, Interventional Neuroradiology Department of Tehran University of Medical
Sciences
Background: To evaluate the clinical and angiographic outcomes of intracranial aneurysm treatment
using a single Pipeline Embolization Device (PED), and to evaluate the factors affecting the aneurysm
obliteration rate.
Methods: The demographic characteristics and anatomical features of 58 aneurysms in 47 patients
treated with a single Pipeline embolization device were reviewed retrospectively. All aneurysms treated
with one PED at a single center, and with follow-up angiograms of at least six months were included in
this study.
Results: The overall rate of complete and near-complete occlusion was 84% (49/58) after a mean
follow-up period of 18.3 months. The complete aneurysm obliteration rate was reduced when an
arterial branch arose from the aneurysm neck; 13% (1/8) compared with 68% (34/50) for aneurysms
without an arterial branch (P value: 0.0075). The overall complete and near-complete aneurysm
occlusion rate was 90% (45/50) in aneurysms without an arterial branch arising from its neck. There was
no statistically significant association between neck-width, aneurysm size, type, or history of prior coil
embolization on obliteration rate.
Conclusion: Our data suggest that a single PED is sufficient to induce complete or near-complete
obliteration of most aneurysms. The presence of a branching artery arising from the aneurysm neck is
highly predictive of incomplete occlusion after treatment with a single PED.
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Cerebrovascular and Neurointervention
Dose optimization study for recombinant tissue plasminogen activator in acute ischemic
stroke in Iranian society
- Helia Hemasian, Department of Neurology, Isfahan University of Medical Sciences, Isfahan, Iran
- Arvin Shahzamani, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
- Mohammad Saadatnia, Department of Neurology, Isfahan University of Medical Science, Isfahan, Iran
- Fariborz Khorvash, Department of Neurology, Isfahan University of Medical Sciences, Isfahan, Iran
Background: The guideline recommended dose of intravenous (i.v) recombinant tissue-type
plasminogen activator (rt-PA) for acute ischemic stroke is 0.9 mg/kg and 0.6 mg/kg in the American and
East Asia populations, respectively. This study conducted to evaluate if there is a need for a dose
optimization for i.v rt-PA study among Iranian.
Methods: This prospective study performed on acute stroke cases that presented to our referral
university hospital over a period of 1 year. Based on the dose of rt-PA received, the individuals were
divided into three groups; Group 1 (0.6 mg/kg), Group 2 (0.75 mg/kg), and Group 3 (0.9 mg/kg).
Improvement was assessed in each group and between the groups with MRS and NIHSS (National
Institutes of Health Stroke Scale score).The nonparametric Mann–Whitney U-test (Wilcoxon rank-sum
test) was applied for assessing improvement of NIHSS with significance level of α < 0.05 and compliance
level at 95%.
Results: Among 130 cases with ischemic stroke enrolled, 52(40%) were female and 78(60%) were male
with mean age of 67.36±11.39.There were 40(30.8%), 48(36.9%) and 42(42.3%) cases in Group 1, 2 and
3 respectively. The mean hospital stay 7.11±6.84, 6.48±8.18 and 9.07±9.63 days (P value=0.58).
Hemorrhagic change was found in 2, 5 and zero cases in Group 1, 2 and 3 respectively. And early
hospital death was seen in 4, zero and 2 cases Group 1, 2 and 3 respectively. The fisher exact result this
difference was not statistically significant. MRS and NIHSS at admission was not statistically significant
between groups. MRS at discharge was higher in group 1 (2.40 ±1.70 vs. 1.48±1.31 and 1.68±1.56, P
value:0.04).Although NIHSS was lower at admission and after 6 month follow up in group 3 ,
Kruskalwallis analysis results showed that this difference was not statistically significant (4.27±3.95
vs.5.85±5.37 and 4.35±3.85 P value:0.47).
Conclusion: We concluded higher dose of rt-PA (0.75-0.9 mg/kg) associated with better neurological
outcome at 6 months in the Iranian population with no excess risk of hemorrhage. We recommend
furthered study and a clinical trial with more significant sample size to optimize the dose of rt-PA in our
country.
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Cerebrovascular and Neurointervention
Secondary Stroke Prevention Protocol: Evaluation of the Role of Anticoagulants
- Seyed Amir Hejazi, Neuroscience research center of Qom University of Medical Sciences
Background: Since anticoagulants were released for clinical use, many studies have investigated their
effectiveness in stroke prevention and the others alarms about their major side effects. In the current
review, we reviewed the cost-benefits of secondary stroke prevention using Classic anticoagulants and
NOACs in comparison with other conventional agents.
Methods: Method: Accordingly, we derived clinically relevant relative and absolute benefit/harm
parameters for NOACs (apixaban, dabigatran, rivaroxaban, edoxaban) compared to warfarin from four
clinical trials involving atrial fibrillation (AF) patients. For each trial, we tabulated patient numbers
enduring four important outcomes and calculated unadjusted relative risk reduction (RRR) and number
needed to treat (NNT)/year values (and 95% confidence intervals) for the NAOC compared to warfarin.
Results: Each NOAC was non-inferior to warfarin for primary-outcome prevention; RRRs were 12-33%
and NNT/year values were 182-481, and all but one indicated statistically significant superiority. All the
NOACs yielded statistically significant reductions in hemorrhagic stroke risk; RRRs were 42-74% and
NNT/year values were 364-528. Major bleeding risk was comparable in both groups. Apixaban yielded a
lower NNT/year for preventing death than for primary-outcome prevention. Compared to warfarin,
NOAC acquisition costs were 70- to 140-fold greater. For the primary outcome, the absolute benefits of
NOACs were modest (NNT/year values being large). Reduced hemorrhagic stroke rates with NOACs
could be due to superior embolic infarct prevention and fewer consequential hemorrhagic
transformations. The substantially greater NOAC acquisition costs need viewing against probable greater
safety and the avoidance of monitoring bleeding risks.
Conclusion: In the secondary stroke prevention, non-inferiority of NOACs to warfarin have been
demonstrated in the most situation.
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Cerebrovascular and Neurointervention
Techniques for Endovascular Treatment of Acute Ischemic Stroke from Intra-Arterial
Fibrinolytics to Stent-Retrievers
- Mohammadreza Savoj, Neurologist
Background: Acute ischemic stroke (AIS) either by intravenous thrombolysis or endovascular
revascularization is associated with improved clinical outcome and reduced mortality. Initial works on
endovascular treatment of AIS was published in the 1980s. Since then, the endovascular techniques for
AIS treatment have tremendously improved, advancing from intra-arterial administration of
thrombolytic drugs to 1st-generation mechanical thrombectomy devices (Merci clot retriever and
Penumbra clot aspiration) and more recently to 2nd-generation mechanical thrombectomy devices
(stent-retrievers).
Methods: First pass complete (mTICI 3) reperfusion must be regarded as the ultimate goal in
mechanical thrombectomy (MT) in patients suffering from an emergent large vessel occlusion (ELVO).
With this in mind a technical modification of the previously published PROTECT (Proximal balloon
Occlusion Together with direct Thrombus aspiration during stent retriever thrombectomy) approach,
the PROTEC-TPLUS technique was evaluated. Under proximal flow arrest using a balloon guide catheter
(BGC), a stent retriever was only partially inserted into a large-bore aspiration catheter. This
construction was subsequently retracted as a unit into the BGC with aspiration both at the aspiration
catheter and at the BGC.
Results: Using the PROTECT-PLUS resulted in a higher rate of first pass complete reperfusions (59.4%
vs. 27.7%, p < 0.001) as compared with PROTECT. The PROTECT-PLUS also led to shorter procedure
times (21 min vs. 37 min, p = 0.001) and higher rates of overall complete reperfusion (73.5% vs. 49.5%,
p = 0.014) compared to PROTECT.
Conclusion: The PROTECT-PLUS technique is a promising technical modification to further optimize
endovascular stroke treatment.
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Dementia Neuro-Restorative Effect of Sertoli Cell Transplants in a Rat Model of Amyloid Beta Toxicity
- Mahdi Tizro, Shahid Beheshti University of Medical Sciences
Background: Alzheimer’s disease (AD) is a degenerative nerve disease which adversely affects memory
and learning skills. However, a growing body of literature suggests cell-based therapies as a promising
remedy for neurological disorders. Among the potential cell sources, testis-derived Sertoli cells (SCs)
appear to be an attractive choice due to their immune-privileged capacities.
Methods: Herein, we investigated the neuro-restorative/protective effects of SC transplants in a rat
model of amyloid beta toxicity. To this end, GATA-4 and vimentin positive SCs were transplanted into
rats with amyloid beta-induced hippocampal lesions.
Results: According to in-vivo results, implanted SCs survived exhibited reductions in both apoptoses as
well as astrocytic migration. Additionally, transplantation of SCs restored hippocampus-dependent
memory and learning, along with the recovery of long-term synaptic plasticity.
Conclusion: Taken together, these data indicate that SCs are a valuable source for cell-based therapies
mainly aimed at AD.
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Dementia
Adiponectin Serum Level as a Prognostic Factor for Dementia
- Ehsan Sharifipour, Neuroscience Research Center of Qom University of Medical Sciences
- Seyed Amir Hejazi, Neuroscience Research Center of Qom University of Medical Sciences
- Soroush Sharifimoghadam, Neuroscience Research Center of Qom University of Medical Sciences
- Navid Hassanzadeh, Neuroscience Research Center of Qom University of Medical Sciences
- Negin Ghasemian Mojarrad, Neuroscience research center of Qom University of Medical Sciences
Background: Alzheimer's Disease (AD) is known as the most common form of dementia in the elderly.
Impaired insulin signaling might contribute to AD pathogenesis, and therefore, AD might be considered
as a type of insulin resistance. Adiponectin is an important insulin-like hormone, increases sensitivity to
insulin and hence its expected functions. We aimed to evaluate the levels of plasma adiponectin in
dementia patients and its relation with plasma adiponectin level, insulin resistance and severity of
dementia.
Methods: In an observational, analytical study, 34 patients with AD and 26 healthy volunteers were
studied. All of the study cases were thoroughly examined, and the severity of dementia was determined
based on MMSE. Adiponectin concentration (µg/ml), fasting blood sugar and plasma insulin levels were
measured after appropriate preparation using special laboratory kits. The homeostatic evaluation model
for insulin resistance (HOMA-IR) was calculated.
Results: There was no statistical difference between the two groups regarding age, height, body weight,
BMI, Insulin, and adiponectin. The mean FBS of the participants were 103.00 and 146.50 mg/dl in the
control and case groups, respectively (P≤0.001). Also, the mean insulin resistance of the control group
participants was 2.90, while this value in the dementia patients was 5.10 (P=0.02). The mean MMSE
scores of the participants were 29.04 and 11.60 in the control and patients groups, respectively
(P≤0.001). Furthermore, A significant direct correlation between serum adiponectin level and HOMA-IR
in the AD group was detected (P<0.05, r=0.35).
Conclusion: Insulin resistance and serum levels of adiponectin seem to have a significant correlation
with dementia and its severity in AD patients.
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Dementia
Cognitive deficit in systemic disorders
- Dr Somayyeh Baghizadeh, MD, Neurologist
Background: There are a plethora of conditions that may contribute to cognitive impairment and
dementia. While systemic disorders can be associated with cognitive impairment and dementia, they
can also lead to encephalopathy or delirium. We are going to discuss systemic illnesses that can cause a
dementia or dementia-like illness, rather than delirium. We will also review the interaction of systemic
diseases and degenerative dementias.
Methods: The standard dementia assessment emphasizes routine screening for common medical
comorbidities or less common structural causes that may necessitate further evaluation or
management; it is meant to be applied to routine patients with probable neurodegenerative dementing
illnesses. The minimum workup for those with cognitive symptoms includes a complete blood count,
complete metabolic profile, thyroid function tests, vitamin B12 levels, as well as neuroimaging with
magnetic resonance imaging or computerized tomography of the brain. Detection of red flags on
history, examination, or investigations should trigger additional investigations, as appropriate. We can
summarize and categorize red flags as follows:
Rapid unexplained decline in function, younger than expected age at symptom onset, prominent
fluctuations, acute or chronic high-risk exposures, a history of high-risk behaviors (past or present),
unexplained or unanticipated findings on the neurologic examination, performance on neurocognitive
testing that is incongruent with the clinical history.
Optimal treatment of systemic disease may improve cognitive symptoms, though some systemic disease
may lead to irreversible changes. The efficacy of anticholinergic inhibitors in dementias associated with
systemic disease has not been well established. Further studies about the effect of treatments for
systemic disease on long-term cognitive outcomes need to be performed.
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Dementia
Neurology consultation in dementia
Dr. fatemeh khamseh, Neurologist
Because of the population ageing, an increasing number of elderly patients are attending healthcare
services, and this quantity is likely to grow in the future. A risk of dementia comes with increasing age,
although it also appears in patients below 65 years of age and Dementia is a growing problem in the
world and is an independent risk factor for experiencing hospitalization complications. People with
dementia present for emergency and, increasingly, elective surgery, but are poorly served by the lack of
available guidance on their perioperative management, particularly relating to pharmacological, medico-
legal, environmental and attitudinal considerations. Clinicians must assess whether the patient has the
capacity to make valid treatment choices in accordance with the principles of the Mental Capacity Act.
This lecture seeks to deliver such guidance, by providing information for perioperative care providers,
specific difficulties anaesthetising patients with dementia, medication interactions, organisational and
medico-legal factors, pre-, intra- and postoperative care considerations, training, sources of further
information, and care quality improvement tools.
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Dementia
Updates in Normal pressure hydrocephalus
- Davood Kashipazha, Neurology Department, Golestan Hospital, Ahvaz Jundishapur University
of Medical Sciences
Background: Idiopathic normal pressure hydrocephalus (iNPH) is a relatively rare progressive condition of the aged population, often featuring impairment of gait and cognition, as well as urinary incontinence and enlarged brain ventricles. The diagnosis of iNPH is challenging due to other conditions with overlapping symptomology. Methodes: This review was prompted by the large number of publications on iNPH. Results: MRI features of NPH include enlarged ventricular size and CSF fluid collection outside the ventricles not due to atrophy. The term disproportionately enlarged subarachnoid space hydrocephalus (DESH) has been used to describe prognostic MRI features in NPH, including a “tight high convexity” and enlargement of CSF spaces in the sylvian fissure. A new NPH scale has been published that provides an objective framework for evaluating patients. CSF shunting remains the only available treatment for iNPH. Shunt surgery results in a positive response in as many as 84% of patients. Programmable shunts can noninvasively manage overdrainage complications. Recent studies have led to improved recognition of overlapping diseases such as Alzheimer pathology, which co-occurs in about 30% of NPH cases. FDG-PET is a promising imaging modality for diagnosing NPH and detecting concomitant degenerative disease. Conclusions: Due to its reversibility, it is imperative that neurologists are more aware of iNPH. Treatment with shunting remains the gold standard. The efficacy of shunts for possible iNPH indicated a significant improvement, regardless of the surgical technique. Although the treatment is surgical, neurological input is important for the diagnosis and identification of suitable shunt candidates.
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Dementia
Updates in diagnostic guidelines of Alzheimer's disease
- Dr. Musa Atazadeh, Neurologist, Yadman center of cognitive disorders, Tehran
New findings in Alzheimer's disease (AD) pathophysiology encouraged the National Institute on Aging
and Alzheimer’s Association (NIA-AA) to update and unify the 2011 guidelines for the diagnosis of AD. In
the 2018 research framework, AD has a pathophysiologic definition, so sign and symptoms of AD will no
longer be required for the diagnosis. This update is a “research framework”, because it is designed for
observational and interventional research studies, not routine clinical care. This pathophysiologic
background includes three types of biomarkers: those of β-amyloid deposition, tau pathology, and
neurodegeneration. Three cognitive staging schemes are described: a scheme employing 3 traditional
syndromal categories, a 6 stage numeric scheme and staging using continuous cognitive measures.
Defining AD as a pathophysiological construct enable a more precise approach to therapeutic
intervention trials.in this paper we will review the 2018 research framework for the diagnosis of AD,
which is based on biomarkers and pathologic findings, as categorized in the ATN mnemonic, in which A
stands for amyloid, T for tau, and N for neuronal injury.
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Headache Cognitive processing styles and mindfulness on pain intensity prediction in people with a
primary headache
- Farhad Assarzadegan, Associate Professor, Department of Neurology, Shahid Beheshti University of
Medical Sciences
- Sarah Namjoo, Ph.D. in Health Psychology, Department of Psychology, Islamic Azad University
Background: Primary headaches are the most common cause of absence from work and school and one
of the most common reasons for referring to the neurologist. Objectives: The present study has been
designed to investigate the relationship of cognitive processing style and mindfulness with pain
intensity, and ultimate aim was to provide the role of Pain-Related Cognitive Processes and Mindfulness
in the prediction of headache intensity.
Methods: The study has been conducted descriptively by using the correlation method. The statistical
population of this study was composed of 85 patients (56 females and 29 male) with one type of
primary headaches and selected through purposive sampling after the diagnosis of a headache by a
neurologist in Emam Hossein hospital in Tehran Province. To measure the variables of the study, we
have used the Numeric pain rating scale (NRS) and The Pain-Related Cognitive Processes Questionnaire
(PCPQ). All data were analyzed using descriptive statistics (frequency and percentages). Bivariate
correlation matrix and hierarchical stepwise linear regression statistics were used.
Results: The results showed that there was a significant and negative association between pain
intensity (NRS) and mindfulness (p<0.01) and all Pain-Related Cognitive Processes, except pain focus
(p<0.01). The results of stepwise linear regression indicate that mindfulness explains just 39 percent of
total score changes in pain intensity (p<0.05 and ΔF (1 and 83) =53.63, ΔR=0.385). Adding cognitive
processing styles to the model led to an 18% increase of the explained variance (R2Change= 0.179). In
total the present research model justifies 54% of the severity of headache variance (p<0.01, ΔR=0.54).
Conclusion: The results suggest that Pain-Related Cognitive Processes and Mindfulness are effective in
pain intensity prediction. In other words, this result can explain the role of mindfulness and adaptive
cognitive processing in primary headache pain management.
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Headache
The Role of Dietary Supplements in Migraine Headache Prophylaxis
- Zeinab Ghorbani, Headache Department, Iranian Center of Neurological Research, Tehran University of
Medical Sciences
- Soodeh Razeghi Jahromi, Faculty of Nutrition and Food Technology, Shahid Beheshti University of
Medical Sciences
- Mansoureh Togha, Headache Department, Iranian Center of Neurological Research, Tehran University
of Medical Sciences
Background: Migraine is ranked as the 3rd highest cause of disability under the 50s and affects 11%of
adults worldwide. Migraine prevalence of females is 3times more than in males. Migraine attacks in
most of the patients occur about 1or2 times/month; however, about 1.4%to2.2% of the US population
suffers from its chronic type which is more disabling. It has been indicated that>20%of chronic
migraineurs are disabled and disability risk increases with the higher prevalence of comorbidities. In the
current review, we aimed at summarizing the results of studies assessed the effects of dietary
supplements on migraine.
Methods: We searched MEDLINE, ScienceDirect, Scopus and google scholar from 1990 to 2018 and
reviewed all published articles, guidelines, textbooks and reference lists of the selected studies.
Results: Four hundred to 600mg.d magnesium citrate might be effective in reducing frequency and
intensity of attacks through suppressing neuroinflammation, calcium channels, NO and serotonin
release. Riboflavin 400mg.d of seems to reduce frequency of attacks due to its effects in regulating
mitochondrial function. Similarly, coenzymeQ10 can regulate energy metabolism, mitochondrial
function and endothelial health and 100 to 300mg/d CoQ10 could reduce the frequency, duration, and
severity of migraine attacks. Moreover, concurrent supplementation with 80mg.d curcumin and omega3
fatty acids (600 mgEPA and 300m gDHA) might decrease migraine frequency by suppressing
inflammation. Also, a combination of 2mg vitamin B9, 25mg B6, and 400Mg B12 might improve migraine
features by reducing homocysteine levels. Besides, 1000 to 2000IU.d vitamin D for 8-12wks might be
effective in improving headache severity and frequency especially in those with lower serum 25OHD
levels and more frequent headache attacks per month.
Conclusion: In conclusion, till now, it is highlighted that supplementation with appropriate amounts of
magnesium, riboflavin, CoQ10, and vitamin D might help attenuate migraine progression. It should be
noted that similarly to pharmaceutical constituents, long term and/or high-dosage ingestion of dietary
supplements may result in adverse effects that should be considered when prescribing them.
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Headache
Relationship of dental maltreatments and headaches, referral and non-referral pain
- Omid Tavakkol, Associate Professor, Head of prosthodontics and TMJ Department, Shiraz
Background: Although it is known today that there is a relationship between chronic TMJ disease and
orofacial pain and headaches , even as a result of chronic inflammation or as a referral pain , but it is a
new window to look that tooth malpositioning, and wrong dental treatments can induce some pains like
orofacial pain, headaches and even classic migraines with aura
Methods: Reviewing relating dental articles, investigating patients with migraine and other orofacial
pains before and after correcting iatrogenic dental maltreatments, explaining the differential diagnosis
and ways to diagnosis , and finally describing the mechanism
Results: There is a positive relationship between headaches and dental maltreatments and after
correcting the wrong position of teeth and jaw so that muscles can rest and the symptoms disappear
entirely even without drug therapy
Conclusion: Because of there is a great gap between dentists and physicians as teamwork sometimes
there is a great missing in diagnosis and treatments.an example is headaches induced by dental
maltreatments that can be solved easily by correcting the position of the jaw.
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Headache
Clinical manifestations of Migraine in Children
- Mahmoud Reza Ashrafi, Professor of Pediatric Neurology, Division of Pediatric Neurology Children’s
Medical Center, Tehran University of Medical Sciences
Migraine headache and their variants are the most common episodic disorder of childhood. Migraine
without Aura (Common Migraine) is the most common form of Migraine in childhood (60-85 %). HA is
bifrontal or bitemporal and occasionally unilateral. HA is associated with loss of appetite, abdominal
pain, nausea and vomiting that are often the most disabling features. Parents will often recognize early
Prodromal features hours or days in advance including mood changes, irritability, euphoria, increased
thirst, fluid retention, food craving for high carbohydrate foods, yawning and sighing. Autonomic
Migraine associated symptoms consisted of nausea, vomiting, anorexia, periumblical abdominal pain,
diarrhea, pallor, cool extremity, goose flesh, photophobia, phonophobia, desire to sleep, Increased or
decreased BP, Syncope and periorbital discoloration. Irritability, head banging, head holding, pallor,
sensitivity to light, sound or smell, sleep disorders, acute behavioral change, unexplained vomiting and
abdominal pain are clinical manifestations of Infantile or early Childhood migraine. In Migraine with aura
(Classic Migraine). The patient presents with one or more fully reversible neurologic symptoms (aura)
including visual, motor or sensory symptoms. The aura should develop gradually over at least 4 Min and
usually lasts 20-30 Min but may last as long as 60 Min. Pain is severe and throbbing lasting 2 – 72 Hours.
Pain may be unilateral but more commonly is bilateral. Migraine Variants are episodic recurrent or
transient neurologic dysfunction in a known Migraine patient or in a patient who later develop Migraine
and consisted of Paroxysmal vertigo, Paroxysmal Torticollis and cyclic vomiting.
20
Headache
keypoints of neuroimaging in trigeminal autonomic cephalalgias
- Dr. Elham Jafari, Iranian headache Association
Background: Trigeminal autonomic cephalgias (TACs) are characterized by unilateral severe, short-lasting, headache attacks with ipsilateral autonomic features. These include cluster headache (CH), paroxysmal hemicrania (PH), short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT) and short-lasting unilateral headache attacks with autonomic features (SUNA), and hemicrania continua (HC). The majority of the cases of TACs are idiopathic or primary, but TACs can be associated with a wide range of intracranial and extracranial neurovascular and structural disorders. Neuroimaging should be considered in all patients with TAC or TAC-like syndromes, especially in those with atypical presentation. Certain red flags have been identified which include older age at onset, abnormal general or neurological examination, attack-related features not fulfilling ICHD criteria for duration, frequency, and localization, and unresponsiveness to treatment. Additional imaging may be considered to assess the pituitary gland, intranasal and infraorbital structures, and both intracranial and cervical blood vessels. Early detection of cranial or cervical lesions may prevent worsening of the disease and development of potentially serious neurological symptoms Methods: In this review, we summarize the main findings of recent case descriptions. Results: Most of the reported pathologies are of vascular (38 %), tumoral (25.7 %), inflammatory/infectious (13.5 %) origin, or related to a trauma (8.8 %). Conclusion: Even clinically typical TACs can be caused by structural lesions. Neuroimaging should be considered in all patients with TAC, notably in those with atypical presentation.
21
Headache
Social and economic burden of migraine
- Samaneh Haghighi, Sina Hospital, Headache Department, Iranian Center of Neurological Research, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran - Mansoureh Togha, Sina Hospital, Headache Department, Iranian Center of Neurological Research, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
Background: Migraine and tension-type headache (TTH) are the most prevalent subtypes of primary
headaches which affect approximately 11% and 42% of the adult population globally, respectively.
Methods: We searched MEDLINE, Science Direct, Scopus and google scholar from 1990 to 2018 using
the words “migraine”, “headache”, “global burden of disease (GBD)”, “prevalence”, and “financial”,
“economic”, “social” and “individual burden”. Also we have included the unpublished results of the
studies conducted by Prof. Togha on economic burden of migraine.
Results: Migraine (958·8 million), and medication overuse headache (MOH) (58·5 million), were among
the most prevalent neurological disorders worldwide. Based on the reports of GBD 2016, migraine has
been ranked as the leading cause of disability in those aged less than 50s. Moreover, MOH affects about
1.5–3% and is highly disabling that characterised by headache on 15 or more days in a month was 18th
cause of YLDs according to GBD 2015. According to a recently published systematic review article on 30
studies comprising 33,873 participants that aimed to evaluate the prevalence of migraine in Iran, it was
estimated that about 14% of Iranians had this type of headache. This estimation was similar or even
more than that reported globally. Furthermore, several studies have linked migraine with a wide range
of diseases including psychological disorders (especially depression and anxiety). If migraine is not
treated properly it will progress to chronic type and be more disabling over time which can lead to a
complicated condition. Financial cost of headache in adults in Iran (2018) Interesting findings were
reported in a study that conducted by Prof. Togha in the last year in order to determine the economic
burden of MOH and migraine in Iran. It was observed that with considering about 14% migraineures in
Iran and about 85 million total populations, we will have approximately 11.9 million migraine subjects in
our country. Thus total financial cost of migraine in Iran is estimated as $ 18.954 million.
Conclusion: Migraine diagnosis and treatment has attracted great attention through the last decade,
though the disease continues to be misdiagnosed and mistreated. The causes of this care gap are
multifactorial and need improvements in several aspects. It seems that the role of education in
headache management is under-recognized. On the other hand, the high prevalence and high economic
burden of headache disorders call for urgent actions. Thus there would be a need for developing and
implementing educational programs to improve headache-related primary health care in our country
which may ultimately lead to immediate cost savings.
22
Headache
Hypertension and headache
- Abbas Ghorbani, MD Associate Professor, Esfahan University of Medical Sciences, Neurology
Department
Some people can experience a headache when their blood pressure is elevated. Blood pressure normally
decreases during the night. Absence of this phenomenon (non-dipping) is associated with increased
cardiovascular risk and headache. Altered autonomic and endocrine circadian rhythms are suspected to
play a role. treatment of non- dipper patients can improve headache.
Background: Circadian rhythms typically originate in “master oscillators” located in the suprachiasmatic
nuclei (SCN) of the anterior hypothalamus. Absence of this circadian rhythm in blood pressure (“non-
dipping”) is more commonly seen in hypertensives, and is a risk factor for the development of end-organ
damage and poor cardiovascular outcomes.
Methods: This constraint required us to define the “daytime” (baseline) period from 8PM to 10PM, and
“nighttime” (sleeping) period from 12AM to 6AM. The latter approach has been shown to provide an
accurate estimate of blood pressure during sleep, whereas wider intervals may overestimate the true
sleeping BP. Future studies would benefit from careful 24 hr monitoring in these patients, to include
periods of supine rest at intervals during the day, with strict control of physical activities, meals, water
ingestion and other confounding factors. This would test the validity of our ad hoc definition of dipping.
Nonetheless, the clear separation in blood pressure between our “dipping” and “non-dipping” groups
supports the adequacy of our definition. Furthermore, careful examination of individual data from
previous studies shows that in some of those patients’ blood pressure peaked early in the evening and
decreased thereafter
Results: The non-dipping pattern of blood pressure (defined as a nocturnal fall of less than 10%) occurs in
about 25% of hypertensives. Treatment of non-dipping patients can reduce frequent and severity of migraine
and non-migraine sufferer. Angiotensin II receptor antagonists appear to be effective in preventing
headaches, but the mechanism of this benefit and the types of headaches that are prevented are not
known. Randomized trials are warranted.
Conclusion: separation in blood pressure between our “dipping” and “non-dipping” groups supports the
adequacy of our definition. Until the present day, there are still no specific therapeutic
recommendations based on dipping status. As discussed, there is limited evidence that with certain
antihypertensive agents, for instance diuretics, or changing the timing of drug administration, a non-
dipping BP pattern can be reversed into a dipping pattern.
23
Headache
Short lasting headaches without autonomic features :
- Fariborz Khorvash, Associate professor of neurology, Alzahra hospital, Isfahan university of Medical
sciences
Background: Unlike trigeminal autonomic cephalgias short lasting headaches without autonomic
features are not a homogenous Group and often the only common feature of these Group is a headache
that lasts from a fraction of second to two minutes. It seems ICHD3 and its criteria is the best tool for
clarifying these headaches. The most important types of this Group are trigeminal, occipital,
glossopharyngeal, nervous intermedicus neuralgias. Neck-tongue syndrome and primary stabbing
headache are other headaches with this feature. Recurrent paroxysms of unilateral pain in the
distribution(s) of one or more divisions of the related nerves, with no radiation beyond, and lasting from
a fraction of a second to 2 minutes, severe intensity, electric shock-like, shooting, stabbing or sharp in
quality and Precipitated by innocuous stimuli within the affected territory are some important
characterstics of pain. Neuralgic headaches are divided according to their syndromology (neuralgia or
neuropathy), location (central or peripheral pain) and etiology (classical, idiopathic or secondary). The
cause of a neuropathic pain maybe clears such as infection by varicella-zoster or a structural abnormality
(multiple sclerosis plaque) demonstrated by imaging and such term is called secondary. For cases where
imaging or surgery has revealed vascular compression of nerve, the term classical is reserved. Medical
treatment of choice are antiepileptic drugs (carbamazepine, oxcabazepine, gabapentine, lamotrigine,...)
. Other treatments such as botulinum toxin injection , gama knife and microvascular surgery
decompression are reserved for refractory patients.
Conclusion : Short lasting headache without autonomic features are an important and nonhomogenous
Group tht unlike TACs is less considered. ICHD3 is an excellent scale for discussing symptoms and signs
of these headaches.
24
Movement Disorders Is there any relationship between Parkinson diseases and H.Pylori?
- Payam Saadat, Associate Professor of Neurology, Mobility Impairment Research Center, Babol
University
Background: Conflicting results have been reported about the association between Helicobacter pylori
infection and Parkinson's disease. To evaluate the relation between H. pylori infection and Parkinson's
disease in patients living in northern Iran.
Methods: In this case-control study, we included 99 consecutive patients with Parkinson's disease
visiting a Neurology Clinic. Also, 297 controls were chosen from the participants of the Amirkola Health
and Ageing Project, who were matched to the patients with Parkinson's disease for sex, age, and
educational level. H. pylori infection was assessed by IgG Enzyme-Linked Immunosorbent Assay. The
severity of Parkinson's disease was assessed by using the Unified Parkinson's Disease Rating Scale
(UPDRS) and the Hoehn and Yahr Scale (HYS).
Results: A rate of 66.7% (n=33) of the patients with Parkinson's disease were positive for H. pylori
infection, while it was 79.5% (n=236) in the controls {Odds Ratio (OR) =0.52, 95% Confidence Interval
(CI)=0.31-0.86, p=0.01}. Scores of UPDRS and HYS were less in H. pylori-positive Parkinson's disease
patients than in those who were not infected; however, the differences were not significant.
Conclusion: The results of this study suggest that H. pylori infection may protect people from
Parkinson's disease. More definitive studies are necessary to confirm this finding
25
Movement Disorders
Could Cannabinoids help Parkinson’s disease?
- Mirmohsen Sharifi-Bonab, MD, Neurologist, Movement Disorders Fellowship
- Bastiaan R Bloem, MD, Ph.D., Neurologist, Movement Disorders Fellowship
- Jasper Visser, MD, Neurologist
Background: Parkinson’s disease (PD) is the most common neurodegenerative movement disorders.
Currently available pharmacological treatment includes mainly Dopamine replacement. Although this
medication significantly improves motor symptoms in early stages of the disease, but its effectiveness
decreases and its complications increase progressively over time. Furthermore, it has no effects on
disease progression.
Methods: An extensive literature search was performed using Pubmed covering published papers up to
January 2019. Complementary searches were done in Google Scholar and Web of Science, and
additional relevant papers were obtained from the reference lists of identified articles. We first
reviewed most recently updated evidences regarding to PD pathogenesis with more focus on role of
microglia and neuroinflammation. Subsequently, we reviewed pharmacological properties of different
derivatives of Cannabinoids (CBs) and their potential mechanisms which could be relevant to alleviate
PD symptoms and/or modulate the immune system in the central nervous system. Finally, we searched
comprehensively for any clinical evidences regarding to effects of CBs on PD symptomatically and/or
therapeutically.
Results: Multiple sources of evidence indicate that microglia-induced neuroinflammation plays a crucial
role in the pathogenesis of PD. Combination of genetic susceptibility and environmental factors produce
mutated α-Synuclein that spreads inside of CNS via neurons, like prion diseases, and meanwhile
activates microglia. In terms of symptomatic management of PD, presence of Endo-cannabinoids (ECBs)
system in different basal ganglia neural structures and its interaction with dopaminergic, glutamatergic,
and GABAergic neurotransmitter signaling systems, makes the components of ECBs suitable targets for a
novel non-dopaminergic symptomatic treatment of PD. Regarding to modulating the progression of PD,
modulation of both Cannabinoids receptors (CBRs) and other accessory receptors have been promising.
It seems that with proper combination of CBs, we could not only potentiate their beneficial effects, but
also we could alleviate their psychological drawbacks.
Conclusion: Altogether, on one hand regarding to burden of PD and scarcity of modality in even
symptomatic management of PD and absence of any therapeutic option to this disease and on the other
hand, existence of promising potentials for symptomatic and even therapeutic modulation of PD with
CBs, well designed RCTs with appropriate derivatives of these components are needed.
26
Movement Disorders
Progress in the treatment of Parkinson-Plus syndromes
- Ali Shoeibi, Neurology Department, Qaem Hospital, Mashhad University of Medical Sciences
Background: Neurodegenerative atypical parkinsonian (APD) or parkinson-plus syndromes is the term
applied to four proteinopathic disorders including progressive supranuclear palsy (PSP) and corticobasal
degeneration (CBD) among tauopathies and multiple system atrophy (MSA) and dementia with Lewy
bodies (DLB) among synucleinopathies. Compared to the typical parkinsonism, i.e. Parkinson’s disease,
these are atypical in terms of parkinsonian features they present, which is more symmetrical and axial-
dominant, and/or the additional non-parkinsonian clinical features such as early dementia, early
postural instability, supranuclear gaze palsy, asymmetrical apraxia, and autonomic dysfunction. APDs
are rapidly progressive disorders for which no disease-modifying treatment is available yet. Treatment
has traditionally been based on neurotransmitter replacement and symptomatic measures. However, in
the last two decades new advances occurred in our understanding of APDs’ etiopathogenesis.
Translation of these findings into the clinic was the resulting next step and many disease-modifying
agents entered clinical trials in the recent years. Main disease-modifying approaches focus on the
pathologic modification, seeding, aggregation, and transcellular spread of the proteins that aggregate
(i.e. tau and α-synuclein), neuroprotection and reduction of inflammation, and modification of
expression of the related genes. However, despite all efforts, none of the completed trails showed
positive effect on disease progression. There are still challenges in defining APDs based on clinical
features and biomarkers, designing clinical trials and finding robust outcome measures, and laboratory
technics and models that can best recapitulate these disorders in preclinical studies.
27
Movement Disorders
Update in therapeutic strategies for Parkinson’s disease
- Mehri Salari, Functional Neurosurgery Research Center (M. Salari), Shohada Tajrish Neurosurgical
Center of Excellence, Shahid Beheshti University of Medical Sciences
Background: To update evidence‐based medicine recommendations for treating motor symptoms of
Parkinson's disease (PD).
Methods: Level I studies of interventions for motor symptoms were reviewed. Criteria for inclusion and
quality scoring were as previously reported. Five clinical indications were considered, and conclusions
regarding the implications for clinical practice are reported.
Results: A total of 143 new studies qualified. There are no clinically useful interventions to
prevent/delay disease progression. For monotherapy of early PD, nonergot dopamine agonists, oral
levodopa preparations, selegiline, and rasagiline are clinically useful. For adjunct therapy in early/stable
PD, nonergot dopamine agonists, rasagiline, and zonisamide are clinically useful. For adjunct therapy in
optimized PD for general or specific motor symptoms including gait, rivastigmine is possibly useful and
physiotherapy is clinically useful; exercise‐based movement strategy training and formalized patterned
exercises are possibly useful. There are no new studies and no changes in the conclusions for the
prevention/delay of motor complications. For treating motor fluctuations, most nonergot dopamine
agonists, pergolide, levodopa ER, levodopa intestinal infusion, entacapone, opicapone, rasagiline,
zonisamide, safinamide, and bilateral STN and GPi DBS are clinically useful. For dyskinesia, amantadine,
clozapine, and bilateral STN DBS and GPi DBS are clinically useful.
Conclusion: The options for treating PD symptoms continues to expand. These recommendations allow
the treating physician to determine which intervention to recommend to an individual patient. © 2018
International Parkinson and Movement Disorder Society.
28
Multiple Sclerosis Pregnancy and NMOSD
- Nastaran Majdinasab, Associate Professor of Neurology of Ahvaz Jundishapour University of Medical
Sciences
Background: MS is a chronic demyelinating disease of the CNS Historically, women with MS were
advised against pregnancy but more recently, it appears that pregnancy is a benign event in the course
of MS Within the past 2 decades, consistent attempts have been made to study this issue via
retrospective and prospective analyses additionally, new data on safety and efficacy of
immunomodulating MS treatments for pregnant and lactating women are continually emerging NMOSD
is also affected women during their childbearing years, but the course of disease during pregnancy
differs from MS
Methods: PRIMS enrolled 254 women (246 with relapsing MS), and 269 pregnancies, and patients were
followed for at least 12 months postpartum. Compared with prepregnancy, annualized relapse rate fell
by 70% during the third trimester. However, during the first 3 months postpartum, the relapse rate
increased to 70% above the prepregnancy level and eventually returned to the prepregnancy rate after
those initial 3 months. The annualized relapse rate from postpartum months 3 to 12 was not
significantly different from that of the prepregnancy year. In a follow-up study, clinical predictors of a
likelihood of postpartum relapse in PRIMS were evaluated. Three variables correlated significantly with
the occurrence of a postpartum relapse increased relapse rate in the year before pregnancy, increased
relapse rate during pregnancy and higher EDSS score at the onset of pregnancy. Epidural anesthesia and
breastfeeding were not predictive of a post-partum relapse or disability progression
Results: The precise effects of childbearing on long-term disability progression in MS are unclear, but
overall, it appears that pregnancy does not seem to worsen disease and disability. The rates of disability
increased most rapidly in nulliparous women. The timing of pregnancy relative to disease onset, or
either onset or worsening of MS about a pregnancy
Conclusion: Importantly, the results of such studies may be confounded by patient choice; women with
a worse disability may be more likely to choose not to become pregnant. Further prospective studies are
needed to clarify the long-term effects of pregnancy on MS disease course.
29
Multiple Sclerosis
B cell MS? Borderline MS? MS/NMOSD overlap Sx?
- Mohammad Ali Nahayati, MS Fellowship Assistant Professor of Mashhad University of Medical
Sciences
Background: In this review our aim is suggesting some indication for considering MS patients with
prominent B-cell pathology and treatment
Methods: Monophasic or relapsing acute optic neuritis, myelitis, brainstem encephalitis, encephalitis,
or any combination thereof, and 2. radiological or in patients with a history of optic neuritis,
electrophysiological (VEP) findings compatible with CNS demyelination, and at least one of the following
findings:
• • • • Clinical findings
• n. Simultaneous bilateral acute ON
• o. Unusually high ON frequency or disease mainly characterized by recurrent ON
• p. Particularly severe visual deficit/blindness in one or both eyes during or after acute ON
• q. Particularly severe or frequent episodes of acute myelitis or brainstem encephalitis
• r. Permanent sphincter and/or erectile disorder after myelitis
• s. Patients diagnosed with “ADEM”, “recurrent ADEM”, “multiphasic ADEM” or “ADEM-ON”
• t. Acute respiratory insufficiency, disturbance of consciousness, behavioral changes, or epileptic
seizures
Results: In the above indication we must consider B-cell predominant pathology and consider the best
treatment.
Conclusion: with considering these indications we must avoid to use drugs with T-cell predominant
mechanism and prescribe B-cell type drugs.
30
Multiple Sclerosis
Approach to mog-antibody disease as a new entity disease and updates about it and their
distinguishing features from MS
- Farhad Golipoor Maemodan, MS Fellowship
Background: Inflammatory demyelinating CNS diseases include a broad spectrum of different diseases.
For disease stratification, prognostic evaluation, treatment decisions, and patient counseling an early
diagnosis are important. However, due to overlapping clinical and paraclinical features diagnosis at the
first demyelinating event is not always possible. Antibodies seem to be valuable diagnostic tools
(diagnostic biomarker). However, for most inflammatory demyelinating CNS syndromes, a potential
antigen target is still not known.
Methods: MOG (myelin oligodendrocyte glycoprotein) antibodies have been extensively studied over
the last 30 years, with some early experimental studies hypothesizing a pathogenic role in CNS
inflammatory diseases. The more recent development of highly sensitive and specific methods for MOG
antibody detection using cell-based assays, along with the new diagnostic classification of similar
neuroinflammatory conditions, has made it possible to identify a subset of patients with antibodies to
MOG who express a clinical phenotype distinct from MS or neuromyelitis optica (NMO). Therefore,
MOG antibody disease (MOG-AD) is now recognised as a distinct nosological entity with specific
management and therapeutic requirements.
Results: MOG antibody disease is an autoimmune disease of the central nervous system (CNS)
characterized by the presence of a serological antibody against myelin oligodendrocyte glycoprotein
(MOG). In addition to distinct immunological target, MOG antibody disease is different from related
autoimmune CNS diseases in its clinical course, radiological presentation and treatment responsiveness.
Apparent differences in this spectrum have not only been found with MS but also, to a lesser degree,
with AQP-4 associated disorders. In particular, in MOG antibody-associated NMOSD a different
immunopathogenesis, with an oligodendrogliopathy rather than a classical astrocytopathy, is suggested.
Conclusion: We present an overview of cases and the updates, clinical features with emphasis on their
distinguishing features of MOG antibody-associated disorders (clinical and paraclinical) from MS and
NMOSD, proposed international diagnostic consensus criteria, approach and investigations (and
indications of MOG-Ab assay), and challenges of managing patients with MOG-AD and proposed
therapeutic algorithm.
31
Multiple Sclerosis
Clinical characteristics, course, and prognosis in early-onset MS and late-onset MS:
Comparison with adult-onset forms
- Mahdi Barzegar, Isfahan Neurosciences Research Center, Alzahra Research Institute, Isfahan, Iran
- Vahid Shaygannejad, Isfahan Neurosciences Research Center, Alzahra Research Institute, Isfahan, Iran
- Nasim Nehzat, Isfahan Neurosciences Research Center, Alzahra Research Institute, Isfahan, Iran
- Omid Mirmosayeeb, Isfahan Neurosciences Research Center, Alzahra Research Institute, Isfahan, Iran
Background: Multiple sclerosis is the common neurological diseasthe e in the adult population (AOMS);
however, the first symptoms can occur before age 16 or after age 50 and is classified as early-onset MS
(EOMS) and late-onset MS (LOMS), respectively.
Methods: In this study, we assessment 2188 MS patients from 2008 to 2018. Fifty-nine patients with
MS had a clinical onset of the disease in childhood, 1915 in adult and 66 patients diagnosed after the
age of 50 years. We compared clinical and demographic in each type of MS. Also, the severity of disease
was evaluated in the onset of symptoms (first EDSS) and in the last clinical examination (last EDSS). The
mean time between first and last examination and EDSS evaluated for all patients were 7.01±1.23 years.
Results: In patients with EOMS, AOMS and LOMS, mean age at onset was 12.43±3.55, 29.17±7.61 and
54.13±3.80; Female to male ratio was 4.81:1, 4.10:1 and 2.66:1, respectively. Mean of disease duration
was 7.01±1.23 years Vision and brainstem symptoms in EOMS, sensory and vision symptoms in AOMS
and motor symptoms in LOMS were more common first symptoms. In LOMS, the first and last EDSS was
higher than in AOMS and EOMS. Also, the last EDSS in LOMS was higher than first EDSS, but this
difference was not statically significant. In EOMS and AOMS, last EDSS were lower than first EDSS. LOMS
with progressive was predominant in the onset of diseases (21.2% VS 9.3 and 3.4 % in AOMS and EOMS).
There was a similar pattern in immune and non-immune comorbidities in each type of MS, but
Hypothyroidism, Diabetes Mellitus, Hypertension and Hyperlipidemia were more common in LOMS
patients. MRI pattern in patients was similar, except supratentorial lesions were less common in EOMS
in compare to other MS.
Conclusion: Our results showed the first symptoms of MS based on the age of onset is different. The
severity of diseases and frequency of progressive course in LOMS was higher than other MS patients,
and in these patients prognosis was poor. On the other hand, clinical characteristics and progression in
EOMS were similar to other MS patients.
32
Multiple Sclerosis
Intelligent computer systems for multiple sclerosis diagnosis. A systematic review of
reasoning techniques and methods
- Seyed Ali Masoud, Professor of Neurology, Kashan University of Medical Science
- Leila Akramian, Health Information Technology and Management Department, Shahid Beheshti ,
Tehran
- Azamossadat Hosaini, Health Information Technology and Management Department, Shahid Beheshti ,
Tehran
- Farkhondeh Asadi, Health Information Technology and Management Department, Shahid Beheshti ,
Tehran
- Eslam Nazemi, Computer Science and Engineering Department, Shahid Beheshti, Tehran
Background: Intelligent computer systems are used in diagnosing multiple sclerosis and help physicians
in the accurate and timely diagnosis of the disease. This study focuses on a review of different reasoning
techniques and methods used in intelligent systems to diagnosis MS and analyzes the application and
efficiency of different reasoning methods in order to find the most efficient and applicable methods and
techniques for MS diagnosis.
Methods: Complete research was carried out an article in various electronic databases based on Mesh
vocabulary.85 article out of 614 articles in English between 2000 to2018 were analyzed.30of which have
been selected based on inclusion criteria such as system scope and domain, a full description of
reasoning method and system evaluation.
Results: The result indicates that different reasoning methods are used as an unintelligent system of MS
diagnosis.In27% of the studies, the rule-based method was used, in 20 % the fuzzy logic, in 18%the
artificial neural network method, and in 35% other reasoning methods were used. The average
sensitivity, specificity, and accuracy of reasoning methods were 0.91, 0.77, and 0.86 respectively.
Conclusion: Conclusions: Rule-based, fuzzy-logic and artificial neural network methods have had more
application in intelligent systems for the diagnosis of MS, respectively. The highest rate of sensitivity and
accuracy indexes is associated with the neural network reasoning method at 0.97 and 0.99, respectively.
In the fuzzy logic method, the Kappa rate has been reported as one, which shows full conformity
between software diagnosis and the physician's decision.In some article, in order to remove the
limitation of the methods and enhance their efficiency, combinations of different methods are used.
33
Multiple Sclerosis
The risks of long term immunosuppression in MS
- Hamidreza Ghalyanchi Langroodi, MD. Neurologist. MS fellowship, Research and Development Center
of Ghaem Int. Hospital, Rasht
Background: Because treatment of multiple sclerosis (MS) needs life-long management with
disease-modifying drugs, any hazards associated with long-term use should be considered when
evaluating therapeutic options. The innate and adaptive immune systems play various roles in the
pathogenesis of MS. Each MS therapies affect the immune system with a unique mode of action, and
consequently possess different long-term safety profiles. Interferons and GA and probably
Teriflunomide are immunomodulators and the others (DMF, Fingolimod, Natalizumab, Ocrelizumab and
Alemtuzumab and Cladribine and Azathioprine and ...) are mainly immunosuppressor. Long term use of
immunosuppressor drugs induces serious safety concerns, including an increased risk of infection and
cancer. Because the duration of clinical trials is relatively short and post-marketing experience is limited,
the risks associated with newer immunosuppressive agents, which target specific elements of MS
disease pathophysiology, are not yet fully established. But some important safety concerns of these
drugs will be reviewed in this short lecture.
Conclusion: A successful therapeutic strategy for any serious, chronic disease such as MS should weigh
effectiveness versus long-term safety of available treatments. When considering the long-term use of
disease-modifying agents for treating MS, classification as immunosuppressants or non-
immunosuppressants could be useful when evaluating potential risks associated with chronic use.
34
Multiple Sclerosis
How to manage patients with progressive MS?
- Mohammad Hossein Harirchian, Neurology Department, Emam Khomeini Hospital, Tehran University
of Medical Sciences, Iranian Center of neurological disorders
Primary progressive MS (PPMS) is a variant of disease which has been considered previously as a degenerative disease with no or minimal inflammatory component since the beginning of its course. Accordingly, there was no approved disease modifying treatment (DMT) for it until recently. During recent years there has been some clinical trials showing the efficacy of some drugs at least in some of PPMS patients. Anti CD20 monoclonal antibodies i.e. Rituximab and its newer humanized version-Ocrelizumab-are used nowadays for PPMS. High dose Biotin (Progio), a neuroprotective agent, has been shown to delay the confirmed disability progression as well. Because of these beneficial and approved drugs of PPMS, some follow up plans to monitor and optimize treatment should be considered for this variant of disease such as its relapsing remitting type. Symptomatic treatment has its own position in this variant of disease as last years.
35
Neuroimaging The Correlation between Serum level of 25-hydroxyvitamin D and Subclinical Atherosclerosis
- Abdoreza Ghoreishi, Department of Neurology, Vali-e-asr-Hospital, Zanjan University of Medical
Sciences
- Vida Mohamadzadeh, Department of Neurology, Vali-e-asr-Hospital, Zanjan University of Medical
Sciences
Background: We investigated the relationship between serum vitamin D level and carotid artery
intima-media thickness(C-IMT) on 100 people of Iranian society. The relationship between serum
vitamin D level and carotid artery intima-media thickness had inconsistent results with previous studies.
Methods: One hundred individual without a history of cardiovascular risk factor were selected for
Analysis between ages of 20-50 years old. Measurements of serum 25(OH) D3 concentration and
Carotid intima-media thickness was made by electrochemiluminescence immunoassay and Bmode
Ultrasound techniques, respectively. Confounding variables such as diabetes, hypertension,
smoking, alcohol, tobacco, dyslipidemia, Body Mass Index(BMI), Serum uric acid, duration of
sunlight exposure, history of drug intake especially statins and anti-hypertensive or fracture and
Serum calcium was considered and have been excluded from our study. Questionnaires were used
fa or participant’s data collection.
Results: The mean serum level of vitamin D was 15.55±0.42 SD ng/mL, and the average IMT was
0.74±0.12 SD mm. Correlation analysis found an inverse relationship between serthe um 25 (OH)D3
level and C-IMT(p value=0.002).
Conclusion: Serum level of 25(OH) D3 was inversely correlated with C-IMT in our investigated Iranian
people.
36
Neuromuscular
A study of the correlation between MUNIX and MUS value changes and clinical outcome in
ALS patients as novel biomarkers.
- Sahebeh Rajabkhah, Iranian Center of Neurological Research, Neurology Department, Shariati Hospital
- Shahriar Nafissi, Iranian Center of Neurological Research, Neurology Department, Shariati Hospital
- Davood Fathi, Iranian Center of Neurological Research, Neurology Department, Shariati Hospital
- Farzad Fatehi, Iranian Center of Neurological Research, Neurology Department, Shariati Hospital
Background: Previous literature has evaluated the prognostic role of muscle ultrasonography (MUS)
and the motor unit number index (MUNIX) for people with Amyotrophic lateral sclerosis (ALS). There are
limited data to assess their correlation with clinical variables. This study aims to detect the relation
between clinical disease progression variables and paraclinical findings (ultrasonographic and MUNIX
parameter changes).
Methods: A retrospective study was performed; it included 20 definite or probable ALS patients based
on revised El-Escorial criteria with at least ALSFRS-R of 30 and 30 control age-matched subjects.
Demographic data such as age, weight, gender, disease duration and clinical scores including MMT
(MMT sum-score), ALSFRS-R, 9 Peg Hole test, Dynamometry were registered. Muscle ultrasound
parameters include structural muscle changes: thickness, echo-intensity, and fasciculation in 3 distal
muscle groups bilaterally. MUNIX protocol was assessed in the same muscles. Results were compared
with 20 healthy control subjects.
Results: We found decreased muscle thickness, increased echo-intensity and declined MUNIX
measurements in the ALS group compared to normal control subjects. Moreover, our study showed a
powerful correlation between the echo-intensity and MUNIX values in tested upper limb muscles (r=0.8,
p=0.001). There was moderate correlation between ALSFRS-R and upper limb muscles MUNIX and echo-
intensity (r=0.5, p=0.05, r=0.6, p=0.002, respectively).
Conclusion: MUS can detect lower motor neuron (LMN) involvement such as a decrease in muscle
thickness, increased echo-intensity and fasciculation as prognostic biomarkers and MUNIX is a technique
for assessment of motor unit loss and could be as a reliable and sensitive marker for monitoring disease
progression and follow up in treatment trials.
37
Neuromuscular
Muscle MRI in inherited Muscle Diseases, 35 cases
- Omid Aryani, Department of Neuroscience, Iran University of Medical Sciences, Tehran, Iran
- Alireza Khosravi, Department of Neurology, Zahedan University of Medical Sciences
- Musa Atazadeh, Department of Neurology, Najmiyeh Hospital
Background: In the diagnosis of inherited muscle diseases, neuromuscular imaging in general and
magnetic resonance imaging (MRI) in particular are increasingly being used to characterize the severity
and pattern of muscle involvement. Although muscle biopsy is still the gold standard for the
establishment of the definitive diagnosis, MRI is frequently used to describe muscle involvement
patterns, which aids in narrowing of the differential diagnosis and distinguishing between dystrophic
and non-dystrophic diseases.
Methods: This review and study aim to give a comprehensive overview of current methods and
applications as well as future perspectives in the field of neuromuscular imaging in inherited muscle
diseases. We also provide diagnostic algorithms that might guide us through the differential diagnosis in
hereditary myopathies. So we studied 35 cases of inherited muscle disease by Muscle MRI in Tehran.
Results: Imaging findings, when combined with clinical findings, aim to decrease the number of
differential diagnosis in patients with inherited neuromuscular disease. As such, genetic testing can be
more efficiently used to identify a specific condition.
Conclusion: MRI is becoming the technique of choice in the diagnostic workup of patients with
suspected hereditary muscle diseases. The role of MRI goes far beyond the pure detection of
inflammatory and/or dystrophic changes.
38
Neuromuscular
Dysphagia in neurological disease
- Mojtaba Shahidi, Erfan Hospital, Neurology Department
- Moayed Salmani, Erfan Hospital, Rehabilitation Department
Background: It is estimated that dysphagia affects between 6 and 15 million adults and an unknown
number of children in the US. Dysphagia is very common after stroke and is common in various
neurological diseases such as myasthenia gravis, motor neuron diseases, some types of acute and
chronic peripheral and cranial neuropathies, head and neck cancers, as well as aging. In the United
States, more than 50% of head and neck cancer patients develop some degrees of dysphagia due to the
disease process itself or its treatment methods such as radiation therapy (XRT), chemoradiation (CRT),
and surgery.
Methods: Narrative review article
Results: Despite its common prevalence, few patients receive a formal diagnosis of dysphagia, many of
whom develop serious complications. Pneumonia, malnutrition and dehydration may be symptoms of
dysphagia. In fact, they are also complication of dysphagia, which result from either unsafe swallowing,
which causes aspiration and the risk of pneumonia, or inefficient swallowing, which results in an
insufficient amount of food or liquid reaching the stomach.
Conclusion: The approach to management of swallowing disorders represents a multidisciplinary model
for the safe evaluation and treatment of patients with a swallowing problem that makes oral feeding
difficult or impossible. In addition to the swallowing therapist, dysphagia team typically includes the
patient’s physician(s), nursing staff, dietitian, speech therapist, physical therapist, pharmacist, and
radiologist.
39
Neuromuscular
Brachial and Lumbosacral Plexus Imaging: clinical implication
- Dr. Bahram Haghi Ashtiani, Neurologist, and Neuromuscular Fellowship, Assistant Professor of
neurology, Iran University of Medical Sciences, Firoozgar hospital
Role of imaging in neuromuscular field is increasing during last decade. in this lecture, we hope to understand; When we need to use imaging in evaluation of peripheral nerves? Which modalities are preferable in different disorders? Which findings are abnormal, and need intervention? How we can use these technics for follow up od patients?
The exploration of peripheral nerves (especially plexuses) pathology has been limited to clinical exam and electrodiagnostic tools until very recently. Imaging technics currently, not only allows exploring the abnormalities, but also let us having a good view on anatomy.
In this presentation, first I’ll talk about different imaging modalities and then about normal and pathologic nerves images in different modalities, and finally principle pathologies imaging findings in different disorder will be discussed.
And at the end, as a summary we conclude that; Imaging is a useful supplement in the exploration of
plexopathy and after EMG result consult with a radiologist and then allows positive diagnosis with
directs surgical procedure biopsy or excision. Different modalities which is useful in different disorder
will be as below;
Entrapment syndrome: standard radiography + ultrasound (Doppler), CT-angio, dynamic maneuvers, MRI
Trauma: MR-Myelography, CT-Myelography
Tumor process research: ultrasound screening, MRI, PET
Radiation / recurrence: MRI, PET
Inflammatory: MRI
40
Neuromuscular
Phenotype-genotype correlations in Congenital Myasthenic Syndromes
- Davood Fathi, Brain and Spinal Cord Injury Research Center, Neuroscience Institute, Tehran University of
Medical Sciences, Tehran, Iran. Neurology Department, Shariati Hospital, Tehran University of Medical
Sciences, Tehran, Iran
Background: Phenotype-genotype correlation is going to be a need in neuromuscular field as finding and
report of new mutations in genetic neuromuscular diseases is very common and increasingly expands
the number of subtypes of any disorder and complicates the diagnostic and management process.
Phenotype-genotype correlation in Congenital Myasthenic Syndromes (CMS) clinical practice could be
very helpful in narrowing genetic tests, determining treatment strategies, and prediction of disease
prognosis.
Methods: by searching in PubMed , there were some articles discussing about phenotype-genotype
correlations in different types of CMS. Here, it is tried to categorize different clinical aspects in relation
with different genetic characteristics.
Results: There are some clinical findings which could categorize different groups of CMS mutations.
Ophthalmoplegia suggests AChR- deficiency, slow channel, fast Channel, and COLQ subtypes as the
genetic etiologies. Presence of limb-girdle type muscular weakness proposes Agrin, LRP4, MUSK, DOK7,
and glycosylation defects mutations. Fast channel, Rapsyn, and CHAT subtypes could present with
respiratory crisis.
Conclusion: considering the complexity of clinical presentations and genetic defects in CMS, phenotype-
genotype correlation studies could simplify the diagnostic and management process of CMS.
41
Neuromuscular
New Classification of histopathological findings in inflammatory myopathies
- Reza Boostani, MD, Associate Professor of Neurology, Mashhad University of Medical Sciences,
Mashhad, Iran
- Masoumeh Gharib, Assistant Professor of Pathology, Mashhad University of Medical Sciences,
Mashhad, Iran
The major forms of rare acquired muscle disorders known as idiopathic inflammatory myopathies (IIMs)
including polymyositis (PM), dermatomyositis (DM) and sporadic inclusion body myositis (sIBM) as well as
myositis associated with antisynthetase syndrome (ASS), and immune-mediated necrotizing myopathy
(IMNM) have unique clinical and histopathological features, and share an immune-mediated component.
Although it has been proposed that in sIBM an interplay between inflammatory and degenerative
pathways should be taken into account. These conditions can occur in isolation or can be associated with
systemic malignancies or connective tissue disorders (overlap syndromes). Newer classifications are now
utilizing clinical and histopathological phenotypes as well as autoantibodies to further classify these
lesions and determine prognostic groups. Here, we discuss the update in histopathological diagnosis of
IIM, especially IBM and IMNM, considering morphology, immunohistochemistry, immunofluorescence,
and other ancillary studies that help in the diagnosis process and better understanding of these diseases.
42
Neuromuscular
Role of electrodiagnostic findings in classification and prognosis of Polyneuropathies
Dr. Gholam Reza Shamsaei, Ahvaz jundishapour university of medical sciences
Nerve conduction studies and electromyography (EMG) play key roles in the evaluation of patients with suspected polyneuropathy. Electrophysiologic studies can be used (1) to confirm the presence of a polyneuropathy, (2) to assess its severity and pattern, (3) to determine whether motor, sensory, or a of fibers are involved, and, most importantly, (4) to assess whether the underlying pathophysiology is axonal loss or demyelination. In cases in which a demyelinating polyneuropathy is found, further differentiation between an acquired and inherited condition can often be made. The information obtained from electrophysiologic testing, in conjunction with key pieces of clinical information, usually allows the differential diagnosis to be narrowed considerably so that further laboratory testing can be more appropriately applied and a final diagnosis reached.
43
Neuromuscular
Stem cell therapy in Amyotrophic Lateral Sclerosis
- Dr. Keivan Basiri, MD, Neurology department, medical school, Isfahan University of medical Sciences
Background: Amyotrophic lateral sclerosis (ALS) is a neurodegenerative disorder of upper and lower
motor neurons, characterized by progressive muscular atrophy and weakness. Despite various
hypotheses, the etiology of ALS remains incompletely understood. However, it has been postulated that
stem cell therapy could potentially target several mechanisms responsible for the etiology of ALS, and
could be regarded as one of the most promising therapeutic strategies for ALS treatment.
Methods: We present a brief review of different methods of stem cell therapy in ALS patients and
discuss the results with various cell types and routes of administration.
Results: Intravenous delivery as a recognized systemic route represents the less invasive approach, but
it is uncertain whether the infused stem cells can successfully cross the blood–brain barrier. Injecting
stem cells locally to the anterior horn of the spinal cord is direct with precise migration of grafted cells
to their desired destination. Intrathecal injection at lumbar levels is a very effective, minimally invasive,
low cost strategy which would permit multiple injections at preferred intervals. Stem cells can be
injected into the subarachnoid space or the lateral ventricles – this type of administration allows them
to bypass the blood–brain barrier and reduces the risk of CNS injury.
Conclusion: Different cell sources and different routes of transplantation have been used in several
clinical trials and demonstrated possible safety and good tolerability of stem cell therapy in ALS patients,
but sufficient data about long term transplantation complications are lacking and only a few studies
showed clinical efficacy.
44
Neuromuscular
Disease severity and response to treatment in Iranian patients with Myasthenia Gravis
- Farnaz Sinaei, Iranian Center of Neurological Research, Shariati Hospital, Tehran University of Medical
Sciences, Tehran, Iran
- Shahriar Nafissi, Iranian Center of Neurological Research, Shariati Hospital, Tehran University of
Medical Sciences, Tehran, Iran
- Farzad Fatehi, Iranian Center of Neurological Research, Shariati Hospital, Tehran University of Medical
Sciences, Tehran, Iran
- Koorosh Kamali, Department of Public Health, School of Public Health, Zanjan University of Medical
Sciences, Zanjan, Iran
- Soroush Ehsan, Iranian Center of Neurological Research, Shariati Hospital, Tehran University of Medical
Sciences, Tehran, Iran
- Shahram Oveisgharan, Iranian Center of Neurological Research, Shariati Hospital, Tehran University of
Medical Sciences, Tehran, Iran
Background: MG is an autoimmune neuromuscular junction disorder characterized by fluctuating
muscle weakness ending fatally if left untreated. The course of the disease specifically its maximal
severity and response to treatment cannot be fully predicted in all cases. In this study we investigated
different diagnostic and therapeutic factors affecting disease severity and response to treatment over a
follow up period of more than 5 years.
Methods: Patients with the diagnosis of Myasthenia Gravis, referred to the neuromuscular clinic of
Shariati Hospital were enrolled. Relationships between different factors (most importantly age of onset,
antibody status, thymus pathology, duration of the disease and the diagnostic delay) and maximal
disease severity and post-treatment status were assessed according to the recommendations of the task
force of Myasthenia Gravis Foundation of America. The study was approved by the research committee
of Tehran University of Medical Sciences.
Results: In our series of 146 patients, MG was more severe in older, anti-Musk positive, and
thymomatous cases (Table 1). Despite differences in the course of the disease and treatment options
(Figure 1), the overall outcome was favorable in the majority of patients. Seropositivity to Musk
antibody and the presence of thymoma determined the need to immunosuppressive drugs.
Nevertheless, these patients did not show further resistance to the conventional immunosuppressive
therapies.
45
Conclusion: We presented a comprehensive report of Iranian patients with MG over the whole course of
their disease. In contrary to the previous reports, anti-Musk positive patients did not need a more
vigorous treatment comparing anti-acetylcholine receptor positive or seronegative patients.
46
Neurosciences Safety and Efficacy of Mesenchymal Stem Cells Transplantation in Patients with Amyotrophic
Lateral Sclerosis
- Amir Reza Boroumand, Neuroscience Department, Mashhad University of Medical Sciences
- Sajad Sahab, Neuroscience Department, Mashhad University of Medical Sciences
- Jalil Tavakolafshari, Immunology Department, Mashhad University of Medical Sciences
- Ali Gorji, Neuroscience Department, Mashhad University of Medical
Background: Recently, stem cell-based therapies, as potentially effective treatments of Amyotrophic
lateral sclerosis (ALS), have emerged employing intraspinal, intrathecal, intramuscular, intracerebral, or
intravenous autologous stem cell administration routes.
Methods: The study was designed as a single-center, prospective, open-label study, without a placebo
control group, to assess the safety and efficacy of intrathecal and intravenous administration of ex vivo-
expanded autologous Bone marrow-derived mesenchymal stem/stromal cells (BM-MSCs) in 12 patients
with ALS disease. Autologous BM-MSCs were isolated and expanded under GMP conditions. Patients
received 1×10 6 cells/kg of BM-MSCs through intrathecal and intravenous simultaneously. The patients
were neurologically examined one time before BM-MSCs transplantation to evaluate the stage of the
disease before treatment through ALSFRS-C. Simultaneously, spirometries have done to evaluate FVCs.
The follow-up period was 6 months, with regular intervals between examinations at 1, 2, 3 and 6
months, to assess the safety and efficacy of the treatment. Potential adverse reactions were assessed,
and the clinical outcome was evaluated by the ALS functional rating scale (ALSFRS-c) and spirometry.
Results: We present the results of a 3-month interim analysis of the ongoing study. Simultaneous
intrathecal and intravenous administration of BM-MSCs into ALS patients was feasible and safe. The
mean ALSFRS score and spirometry results remained stable during the first 3 months of observation.
Conclusion: To summarize, our study showed that the intrathecal and intravenous application of BM-
MSCs in ALS patients is a safe procedure and may represent a new approach to slowing down the
progression of ALS.
47
Neurosciences
Chorionic Mesenchymal Stromal Cells (hCMSCs) Transplantation Ameliorates Motor Function
and Prevents Cerebellar Atrophy
- Hossein Toreyhi, Shahid Beheshti University of Medical Sciences
- Abbas Aliaghaie, Shahid Beheshti University of Medical Sciences
Background: Cerebellar ataxias include a range of neurodegenerative disorders hallmarked by
deterioration of cerebellum. Cell replacement therapy (CRT) offers a potential remedy for the diseases
associated with the central nervous system (CNS). This study was designed to assess the neuro-
restorative/protective effects of hCMSCs implantation on a rat model of cerebellar ataxia induced by 3-
acetylpyridine (3-AP) as a neurotoxin.
Methods: To begin, Chorionic Mesenchymal Stromal Cells (hCMSCs) were extracted, cultured and their
mesenchymal abilities proofed. Then, experimental ataxia was induced in twenty-four male adult rats by
single injection of 3-AP, and bilateral hCMSCs transplantation in the cerebellum was performed 7 days
after 3-AP administration in seven of them. After assessment of their motor coordination by Rotarod
test and electromyography (EMG) changes by its device their cerebellum was sampled. Their Purkinje
neuron degeneration was analyzed by Fluoro-Jade staining, then the transcription status of
inflammatory, neurotrophic and apoptotic genes assessed by RT-PCR test. We also analyzed the
expression level of VEGF and immunohistochemically changes in calbindin.
Results: The findings showed that transplantation of hCMSCs in a 3-AP model of ataxia ameliorated
motor coordination and muscle activity, increased cerebellar volumes of molecular and granular layers
plus white matter, decrease degeneration of Purkinje cells, increase transcription of neurotrophic
factors and reduce the inflammatory changes and apoptosis. We also observed the increase in
expression of VEGF and calbindin.
Conclusion: Taken together, human CMSCs could be considered as a suitable candidate for CRT-based
therapies with a specific focus on cerebellar ataxia.
48
Seizure Practical Approach in Autoimmune Epilepsy: the systematic review
- Soheila Rezakhani, Kerman Neuroscience Research center
Background: A systematic literature review of Pubmed and Embase was performed from inception to
10 December 2018. We included randomized clinical trials (RCTs), quasi-RCTs, and case-control studies.
The literature search results screening, data abstraction, and risk of bias appraisal will be performed by
two individuals, independently. We reviewed autoimmune epilepsy in diagnostic and therapeutic
methods.
Methods: A systematic literature review of Pubmed and Embase was performed from inception to 10
December 2018. We included randomized clinical trials (RCTs), quasi-RCTs, cohort, registry, and case-
control studies. The literature search results screening, data abstraction, and risk of bias appraisal will be
performed by two individuals, independently. We reviewed autoimmune epilepsy in diagnostic and
therapeutic methods.
Results: Forty-seven publications detailing 2823 subjects matched our inclusion criteria. There was
considerable heterogeneity in methodology, patient profile, investigation results and clinical outcome
measures. Findings were often discrepant for cases of anti-NMDAR encephalitis when compared with
other causes of autoimmune encephalitis. Delay in immunotherapy contributed to a variety of worse
outcomes for patients with different subsets of autoimmune encephalitis. Altered consciousness, ICU
admission and no use of immunotherapy were variables associated with poor prognosis in anti-NMDAR
encephalitis. Older age, sex, the presence of status epilepticus, CSF abnormalities and MRI changes were
unlikely to have significant prognostic value. The influence of antibody titers, autonomic dysfunction and
underlying malignancy was unclear.
Conclusion: The detection of anti-neuronal antibodies in patients with the corresponding appropriate
symptoms implies the diagnosis of autoimmune encephalitis. Review of studies has shown that rapidly
initiated immunosuppressive treatment improves these patients’ outcomes.
49
Seizure
The relation between preoperative auras and postoperative outcomes in patients with MTS,
epileptic surgery in Isfahan
- Mohammad Zare, Neurology Department, epilepsy ward of Isfahan University Medical Science
- Ladan Tofangsazi, Neurology Department, epilepsy ward of Isfahan University Medical Science
- Hooshang Moeen, Neurology Department, epilepsy ward of Isfahan University Medical Science
- Magid Barekatain, Neurology Department, epilepsy ward of Isfahan University Medical Science
- Reza Basiratnia, Neurology Department, epilepsy ward of Isfahan University Medical Science
- Jafar Mehvari, Neurology Department, epilepsy ward of Isfahan University Medical Science
Background: Temporal lobe epilepsy (TLE) is the most prevalent type of epilepsy in adults. Mesial
temporal sclerosis (MTS) is the most common pathologic abnormality related to TLE. Medical therapy in
MTS patients had met failure in 30% of cases and surgery is a favorable option. Aura is one the main
feature of TLE special MTLS This study aimed to evaluate the relationship between preoperative auras
and postoperative outcomes in Isfahan.
Methods: This study is a cross-sectional study on MTS-TLE patients who have experienced Temporal
Lobectomy (TL) in Kashani hospital in Isfahan University of Medical Science (IUMS) from 2007 to 2016.
All patients had a Temporal Lobectomy and had a minimum of one year follow up. Post-surgical
outcomes of patients were evaluated based on Engel Epilepsy Surgery Outcome Scale and categorized
into four groups.
Results: In this study, 99 patients with a mean age of 29.45±9.14 years (ranged from 10-56) were
evaluated that 46.5% (n=46) were male. Following patients showed that 73.7% (n=73) of patients were
seizure free after their surgeries. Evaluating Engel criteria showed that most of the patients (n=81) were
in class I of this scale. About 36.3% (n=36) had not experienced any aura before their seizures, and
among those with aura, the most prevalent aura was abdominal aura followed by another type of aura
and affective aura.
Conclusion: This study evaluated the relation between the type of aura in MTS patients and
postoperative outcomes. According to this study type of aura cannot predict postoperative outcomes in
MTS patients.
50
Seizure
The Approach to Epilepsy in MS Patients
- Fardin Faraji, Associate Professor of Neurology, Arak University of Medical Sciences
- Afsoon Talaie, Msc of Nutrition, Ph.D. of Biochemistry, Islamic Azad University, Arak branch, Iran
Background: Multiple sclerosis as a demyelinating inflammatory disease, is the most common immune-
mediated disorder affecting the central nervous system. The disease usually begins between the ages of
20 and 50 and is twice as common in women as in men. Epilepsy is a common disorder. In the developed
world, onset of new cases occurs most frequently in babies and the elderly. In the developing world,
onset is more common in older children and young adults. About 5–10% of people will have an
unprovoked seizure by the age of 80, and the chance of experiencing a second seizure is between 40
and 50%.
Methods: A review of published clinical series of adult patients who had epileptic seizures and multiple
sclerosis (MS) yielded a prevalence of 2.3%, about three to six times that in the general adult population.
The probable anatomic basis for the seizures is areas of inflammation, edema, and demyelination in the
cerebral cortex and the juxtacortical white matter. Epilepsy usually appears late in the course of the
disease, although a single episode or a cluster of seizures can represent the onset symptom or a relapse
of MS.
Results: Prognosis of epilepsy during MS is usually good, but the choice of AEDs remains a matter of
debate. Seizures may take several forms: Generalized tonic-clonic seizures, simple or complex Partial
seizures. Paroxysmal symptoms, such as trigeminal neuralgia, tonic spasms, Lhermitte's sign, in many
appear similar to an epileptic seizure but are of different origin. Seizures are usually diagnosed by clinical
history and an electroencephalogram (EEG). The findings indicate that RRMS/Epilepsy patients have
more extensive cortical inflammation than RRMS patients with no history of epilepsy. In most of the
patients, plaques are localized in the frontal region, associated with severe disability status. MRI shows
numerous subcortical plaques. However, pure intracortical lesions are unlikely to be demonstrated with
conventional MR, in contrast to the DIR sequence. Interferons, Glatiramer acetate, Dalfampridine and
Intrathecal baclofen can increase the occurrence of seizures.
Conclusion: in respect to MS patients with epilepsy, we must consider the form of epilepsy, MRI
findings and appropriate choice of drug.
51
Seizure
The role of antibiotics and probiotics in the treatment of epilepsy
- Nasim Tabrizi, Neurology Department, Mazandaran University of Medical Sciences, Sari, Iran
Background: Epilepsy is one of the most common neurological disorders that could affect the general
population at any age. Despite the development of novel antiepileptic drugs and new treatment
strategies, about 20-30% of epileptic patients fail to show the ideal treatment response. A topic of great
interest which recently has lighted a new way to treat is the role of intestinal microbiota and
consequently probiotics and antibiotics in epilepsy. This article aimed to assess the possible role of this
new treatment approach in experimental models and humans.
Methods: I searched the medical databases within 1990-2017 interval using the following keywords:
epilepsy, seizure, probiotic, antibiotic, intestinal microbiota, and treatment. English clinical studies, case
reports and case series, were included. The articles were reviewed, and relevant data were extracted.
Results: Recent studies have shown that there is a dramatic difference in gut microbiota in drug-
sensitive and drug-resistant epileptic patients and dysbiosis have been introduced as a potential etiology
of epileptogenesis by several mechanisms. On the other hand, transportation of gut microbiota of
ketogenic diet-responder mouse models to non-responders was associated with therapeutic response.
Moreover, there is a report of pediatric patients with refractory epilepsy who showed a significant
decrease in seizure frequency during antibiotic treatment. Also, there is solid evidence that
administration of probiotics in both experimental models and patients with refractory epilepsy have led
to the therapeutic response.
Conclusion: Dysbiosis should be considered as one of the potential mechanism of epileptogenesis, and
the alleviation of it might lead to the treatment of epilepsy. However standard clinical trials using
probiotics and antibiotics are still required to prove this claim.
52
Seizure
New Classification of Epilepsy
- Farzad Sina, MD, Affiliation: Neurology Department, Rasool Akram Hospital, Iran University of Medical
Sciences
Recent revisions in the International League Against Epilepsy (ILAE) classification of seizures and epilepsy
have important implications for the clinical utility of EEGs in pediatric patients. The new classification
system provides both increased rigor and increased flexibility in classifying seizures using clinical and
EEG criteria. The clinical utility for pediatric epilepsy providers of the following six points will be
discussed in this presentation, using case-based examples:
1. Epilepsy is now considered to be two unprovoked (or reflex) seizures, or one unprovoked (or reflex)
seizures and a 10-year recurrence risk of greater than 60%. In clinical practice, recurrence risk is often
assessed via inter-ictal EEG testing and neuro-imaging.
2. Seizures of unknown onset (that is, not clearly focal or generalized in onset) are now officially
recognized in the top tier of seizure classification. Such seizures are common in children and inter-ictal
and ictal EEG plays a valuable role in establishing, when possible, the mechanism of onset.
3. Seizures with traditional "generalized" semiology, such as tonic, atonic, myoclonic seizures and
epileptic spasms are recognized to be potentially of focal, generalized or unknown onset. Inter-ictal and
ictal EEG is important is accurately classifying such seizures, and accurate classification is important for
optimal treatment.
4. Epileptic spasms replaces infantile spasms as a seizure type, recognizing that spasms may persist
beyond infancy.
5. Epilepsy types now include "combined focal and generalized," validating the existence of mixed
epilepsies, especially in children.
6. Epilepsy syndromes remain organized by age of onset, since epilepsy syndromes can include both
focal and generalized seizure types
53
Seizure
Practical use of newer antiepileptic drugs as add on therapy in focal seizures
Dr. Mahmood Motamedi, Professor of Neurology, Sina Hospital, Tehran University of Medical Sciences
Introduction: Some of the epileptic patients will not tolerate or not complaint with a range of treatment
programs but they may still become seizure free with the newer antiepileptic drugs (AEDs) possessing
novel mechanisms of action.
Background: The last four AEDs licensed as add on therapy for focal epilepsies are Lacosomide
,Eslicarbazepine ,Retigabine and Prampanel .All of them are used as adjunctive therapy of focal seizures
with or without secondary generalization but in this setting, Retigabine is used only provided that the all
previous treatment schedules have not adequately controlled seizures or were not tolerated, so, it
should be considered as a last choice in this context. Lacosamide may be indicated in convulsive and
non-convulsive status eilepticus . Moreover, Lacosamide and Prampanel use are also approved for the
treatment of genetic epilepsies. Lacosamide selectively enhances the slow inactivation of voltage-gated
sodium channels. Eslicarbazepine inhibits the sodium channels too, but its effect on these channels may
be more prominent on slow inactivation of them. Its other mechanisms of action are effect on T calcium
channels. Retigabine opens the neuronal voltage- gated potassium channels which are related to cell
excitability. Itmay have moderating effects on GABAa receptors too. Prampanel selectively inhibits
AMPA receptors.
Conclusion: In this presentation pharmacology, tolerability, safety and practical issues regarding the use
of these newer AEDs will be reviewed.
54
Seizure
Indications for prophylactic anti-epileptic therapy
Sanaz Ahmadi Karvigh, MD, Epileptologist, Assistant professor of Neurology, Tehran University of Medical Sciences Anti-epileptic (AED) treatment is indicated when the risk of recurrent seizures is substantially high (more than 60%) or in specific cases when there is a great chance of damage resulting from seizure. There is no clear evidence that anti-seizure drugs can prevent epileptogenicity. On the other hand, long-term risk of epilepsy was not decreased after anti-epileptic administration. Due to current evidence, prophylactic anti-epileptic therapy in patients with brain tumor, traumatic brain injury (including subdural hematoma) or prior to craniotomy is not recommended given the risk- benefit assessment and even if started should be discontinued very soon (1 week). Also patents with various cerebrovascular accidents (ischemic stroke, cerebral venous thrombosis, intra cranial hemorrhage, subarachnoid hemorrhage) do not benefit from AED prophylaxis and the risk if long-term epilepsy development was not decreased after AED prophylaxis. Another population are those with highly epileptogenic lesions such as benign cortical tumors, cavernous angiomas, viral and autoimmune encephalitis. There are few studies addressing this issue and no strong evidence supports the AED prophylaxis in this group. Although most patients will need secondary prophylaxis at some point. There is an emerging argument appraising the aforementioned evidence-based guidelines which claims that the reason for increased risk to benefit ratio of AED administration in older studies was due to high rate adverse effect of old generation drugs. The new generation drugs have lower adverse effect and drug interaction profile. Therefore, individually tailored strategies may justify use if AED in selected cases however, even in these cases early discontinuation of AEDs after resolving the underlying etiology is crucial.
55
Others Prevalence of Carpal Tunnel Syndrome in Diabetic Patients
- Hossein Ali Ebrahimi Meimand, Neurology Research Center, Kerman University of Medical Sciences,
Kerman, Iran
- Narges Khanjani, Neurology Research Center, Kerman University of Medical Sciences, Kerman, Iran
- Abbas Bahrampour, Modeling in Health Research Center, Institute for Futures Studies in Health,
Department
- Hamid Najafipour, Epidemiology, Faculty of Health, Kerman University of Medical Sciences, Kerman,
Iran
- Zohreh Foroozanfar, Epidemiology, Faculty of Health, Kerman University of Medical Sciences, Kerman,
Iran
Background: Carpal tunnel syndrome (CTS) is defined as the impaction of the median nerve in the
carpal tunnel of the wrist. Metabolic disorders are closely associated with CTS, and metabolic syndrome
(MS) is found to be more in patients with CTS. Metabolic syndrome is highly prevalent in patients with
type 2 diabetes. This study was conducted to determine the prevalence of CTS in diabetic patients with
and without metabolic syndrome
Methods: In this cross-sectional study, 439 diabetic patients that participated in the study of risk
factors for coronary artery disease in Kerman (KERCADRS) were enrolled. People with positive clinical
symptoms for CTS and a positive Boston questionnaire were referred to a neurologist for further
diagnosis. For the diagnosis of metabolic syndrome, three criteria (ATPIII, IDF and new criteria in
Kerman) were used. Also, electro-diagnostic tests were used for the diagnosis of CTS. Data were
analyzed by independent t-test and chi-square test in SPSS20.
Results: The prevalence of CTS in diabetic patients was 24.23%. The prevalence of the disorder in male
and female patients was 16.21% and 30.65%, respectively. The results showed that there is no
significant difference in the prevalence of CTS in diabetic people with and without metabolic syndrome,
overall as well as sex subgroups
Conclusion: The higher prevalence of CTS in diabetic patients in this study compared to other studies
shows the lack of prevention and case finding in diabetic patients. Therefore, screening, educating and
informing at-risk people about the disease is necessary.
56
Others
Comparison of regular aerobic and yoga on the quality of life in patients with multiple
sclerosis
- Nahid Jivad, Associate Professor, Department of Neurology, Faculty of Medicine, Shahrekord University
of Medical Sciences
- Ali Hassanpour-Dehkordi, Assistant Professor, Department of Nursing, Faculty of Nursing and
Midwifery
Background: The pathophysiology of multiple sclerosis (MS) is characterized by fatigue, motor
weakness, and spasticity, to name a few. MS symptoms may lead to physical inactivity associated with
the development of secondary diseases. This study was to investigate the effect of regular aerobic and
yoga on the quality of life of patients with MS.
Methods: The present quasi-experimental study was conducted on 90 patients with chronic MS
chosen randomly and divided into two tests and one control groups. Data were analyzed using SPSS
software (version 11.5) through paired t-test, ANOVA, and Tukey’s post hoc.
Results: There were no significant differences among the scores of quality of life in the three groups
before investigation. Although they were significant after the intervention, the mean score of the yoga
group was higher than that of the aerobic group, and the aerobic group showed a higher mean score
compared with the control.
Conclusion: Yoga and aerobic exercises may improve quality of life in patients with MS. It is highly
recommended that the governor along with MS societies and other organizations servicing and
supporting patients start to develop sport-regulated programs to help improve the quality of life for
these patients.
57
Others
Validation of translation of The Liverpool Adverse Event Profile for Measuring Adverse Effects
of Antiepileptic Drugs
- Mohammad Reza Najafi, Professor of Neurology, Isfahan University of Medical Sciences
- Fereshteh Moradi, General physician, Isfahan Neuroscience Research Center
- Narges Motamedi, Assistant Professor, Department of Community and Family Medicine
Background: Liverpool adverse event profile (LAEP) was developed in 1994 and validated among
patients with epilepsy in the UK. As yet, this important instrument has not been validated in the Persian
language. LAEP questionnaire is patient-centered, and is concerned with general questions. Due to the
significance of the questionnaire in both clinical analysis of the patient-reported AEs and in conducting
relevant researches, the researchers decided to have an investigation into its reliability and validity in
Persian language in order to use it with 0ur patients.
Methods: An observational and cross-sectional design was utilized to study patients suffering from
epilepsy and treated with a stable dose of AEDs. The instrument was translated from the English version
into Persian to examine its overall accuracy. To that end, the Persian LAEP (hereafter called p-LAEP) was
administered to 140 patients to examine comprehensibility and transparency of the language and
instructions. Further, the researchers used the patients’ and specialists’ comments to assess its
construct validity. Next, using a qualitative-quantitative approach, the content validity ratio (CVR) and
content validity index (CVI) were calculated to examine the overall validity of this scale. Also, the
reliability of the instrument was assessed through Cronbach’s alpha coefficient.
Results: Bearing in mind the widely used statistical cut off points, we decided the acceptability of
validity of all items with CVI and reliability of Cronbach’s ɑ coefficient to be over 0.79 and 0.7,
respectively. Baseline ratio for CVR varies proportional to the number of participants. On the whole, the
analysis demonstrated a reasonable content validity ratio (as shown in tables in the text), with the
reliability (Cronbach’s ɑ coefficient) being 0.79.
Conclusion: Overall, the results suggest that p-LAEP is an appropriate instrument to measure adverse
effects of antiepileptic drugs among Persian speaking patients with epilepsy.
58
INDEX
A
Ahmadi Karvigh, 54
Akramian, 32
Aliaghaie, 47
Aryani, 37
Asadi, 32
Ashrafi, 19
Assarzadegan, 16
Atazadeh, 15, 37
B
Baghizadeh, 12
Bahrampour, 55
Barekatain, 49
Barzegar, 31
Basiratnia, 49
Basiri, 43
Bloem, 25
Boostani, 41
Boroumand, 46
E
Ebrahimi Meimand, 55
Ehsan, 11, 44
F
Faraji, 50
Fatehi, 36, 44
Fathi, 36, 40
Foroozanfar, 55
G
Ghalyanchi Langroodi, 33
Gharib, 41
Ghasemian Mojarrad, 11
Ghorbani, 17, 22
Ghoreishi, 35
Golipoor Maemodan, 30
Gorji, 46
H
Haghi Ashtiani, 39
Haghighi, 21
Harirchian, 34
Hassanpour-Dehkordi, 56
Hassanzadeh, 11
Hejazi, 8, 11
Hemasian, 7
Hosaini, 32
J
Jafari, 20
Jivad, 56
K
Kamali, 44
Kashipazha, 14
khamseh, 13
Khanjani, 55
Khorvash, 7, 23
Khosravi, 37
M
Majdinasab, 28
Masoud, 32
Mehvari, 49
Mirmosayeeb, 31
Moeen, 49
Mohamadzadeh, 35
59
Moradi, 57
Moshayedi, 6
Motamedi, 53, 57
N
Nafissi, 36, 44
Nahayati, 29
Najafi, 57
Najafipour, 55
Namjoo, 16
Nazemi, 32
Nehzat, 31
O
Oveisgharan, 44
R
Rajabkhah, 36
Razeghi Jahromi, 17
Rezakhani, 48
S
Saadat, 24
Saadatnia, 7
Sahab, 46
Salari, 27
Salmani, 38
Savoj, 9
Shahidi, 38
Shahzamani, 7
Shamsaei, 42
Sharifi-Bonab, 25
Sharifimoghadam, 11
Sharifipour, 11
Shaygannejad, 31
Shoeibi, 26
Sina, 21, 52, 53
Sinaei, 44
T
Tabrizi, 51
Talaie, 50
Tavakkol, 18
Tavakolafshari, 46
Tizro, 10
Tofangsazi, 49
Togha, 17, 21
Toreyhi, 47
V
Visser, 25
Z
Zare, 49