Sadalla Amin Ghanem Eye Hospital

Introduction: In the early window, time to treatment with endovascular thrombectomy (EVT) is inversely associated with favorable clinical outcomes but this remains unclear in the extended window. We aimed to assess the impact of time to EVT on clinical outcomes in the DAWN trial. Methods: The association between every 1-hour treatment delay with 90-day functional independence (modified Rankin Scale [mRS] 0-2), symptomatic intracranial hemorrhage (SICH), and 90-day mortality was explored in the overall population and in three modes of onset subgroups (wake-up vs witnessed vs unwitnessed) considering both time from last seen well (TLSW) and time from symptoms first observed (TSFO). Results: Out of the 205 patients, 98 (47.8%) and 107 (52.2%) presented in the 6-12-hour and 12-24-hour time window, respectively. Considering all three modes of onset together, there was no statistically significant association between TLSW to randomization with either functional independence or mortality at 90 days in either the EVT (mRS0-2 OR 1-hour-delay:1.07;95%CI[0.93-1.24]; mRS6 OR:0.84;95%CI[0.65-1.03]) or medical management (mRS0-2 OR1-hour-delay:0.98;95%CI[0.80-1.14]; mRS6 OR 1-hour-delay:0.94;95%CI[0.79-1.09]) groups. Moreover, there was no significant interaction between treatment effect and time (p=0.439 and p=0.421 for mRS 0-2 and 6, respectively). However, within the thrombectomy group, the models that tested the association between TLSW to successful reperfusion (mTICI≥2b) and 90-day functional independence showed a significant interaction with mode of presentation (p=0.013). This appeared to be driven by a nominally positive slope for both witnessed and unwitnessed strokes versus a significantly (p=0.018) negative slope in wake-up patients. There was no association between treatment times and SICH. Comparable analysis using TSFO yielded similar results. Conclusion: In extended window patients, the association between time to treatment and clinical outcomes seems to be primarily driven by successfully perfused patients with wake-up rather than witnessed or unwitnessed strokes suggesting that wake-up strokes do not behave as “slow-progressors”.

<h3>Objective:</h3> To study the differences in risk factors between stroke caused by intracranial atherosclerosis (ICAS) and extracranial atherosclerosis (ECAS) in the Indian population. <h3>Background:</h3> Stroke is a multi-factorial disease occurs due to the combination of risk-factors. Pathogenic mechanism of intracranial atherosclerosis (ICAS) and extracranial atherosclerosis (ECAS) vary, hence exploring the risk factors of these subtypes is essential for targeting preventive therapy and to influence choice of management. <h3>Design/Methods:</h3> 100 patients presenting with acute ischemic stroke with clinically significant atherosclerosis in intra-cranial/extra-cranial arteries were compared with respect to their risk factors, presentation, progression and outcomes. <h3>Results:</h3> There were 35 ICAS, 52 ECAS and 13 with both ICAS &amp; ECAS. Mean age of the patients, gender, body mass index was not associated with their stroke type. Medical history of IHD and CKD was more common in patients with ICAS. Median (IQR) NIHSS of our study cohort was 12.97 (4.23) at 3 months. It was significantly higher in ICAS group (median = 16.26) as compared to that in the ECAS group (median = 10.92). Anterior circulation strokes were observed in 78% of patients, more commonly occurring in ECAS stroke group. Median (IQR) mRS score of the study cohort at 3 months was 1 (1.00), four patients died (mRS = 6) three of ICAS and one patients with both ICAS &amp; ECAS. ECAS group had significantly more proportion of patients with favorable mRS as compared to ICAS group. After adjusting for all possible confounders, only increasing NIHSS at admission was significantly associated with poor outcomes at 3 months. Stroke type did not significantly affect the the clinical outcome at 3 months. <h3>Conclusions:</h3> Although ICAS and ECAS shared similar risk factors, differences still existed between them as far as clinical outcomes are concerned. With higher NIHSS at admission, ICAS patients are at an increased risk for poor clinical outcome. <b>Disclosure:</b> Dr. Patel has nothing to disclose. Dr. Ponda has nothing to disclose.

ABSTRACT Purpose To analyse posterior segment optical coherence tomography (OCT) findings in ocular syphilis. Methods Medical records of 54 patients presenting consecutively with syphilitic uveitis were reviewed. Vitreous, retina and choroid (one eye/patient) were assessed by spectral-domain OCT on presentation (54 eyes) and after treatment (31 eyes). Improvement in signs and associations between presenting signs and final best corrected visual acuity (BCVA) were determined by McNemar’s and Fisher’s exact tests. Results Early inner retinal OCT findings included hyperreflective dots (n = 49, 91%), tongue-like projections (n = 44, 81%) and large rounded spots (n = 41, 76%). Common outer retinal findings included thickening, irregularity, elevations and/or detachment of retinal pigment epithelium (n = 46, 85%), and disruption or loss of the ellipsoid zone (n = 33, 61%). Most outer retinal changes resolved with treatment (p < .05), and common presenting signs were not associated with poor final BCVA (p > .05). Conclusion OCT findings have diagnostic value in ocular syphilis, but do not predict prognosis.

BackgroundSyphilitic uveitis is re-emerging alongside the systemic infection. In July 2017, an international group of uveitis-specialised ophthalmologists formed the International Ocular Syphilis Study Group to define current practice patterns.Methods103 Study Group members based in 35 countries completed a 25-item questionnaire focused on case load, clinical presentations, use and interpretation of investigations, treatment and clinical indicators of poor prognosis.ResultsMembers managed a mean of 6.1 patients with syphilitic uveitis in clinics that averaged 707 annual cases of uveitis (0.9%); 53.2% reported increasing numbers over the past decade. Patients presented to more members (40.2%) during secondary syphilis. Uveitis was usually posterior (60.8%) or pan (22.5%); complications included optic neuropathy, macular oedema and posterior synechiae. All members diagnosed syphilitic uveitis using serological tests (simultaneous or sequential testing algorithms), and 97.0% routinely checked for HIV co-infection. Cerebrospinal fluid (CSF) analysis was ordered by 90.2% of members, and 92.7% took uveitis plus Venereal Disease Research Laboratory test (VDRL) or fluorescent treponemal antibody absorption test (FTA-ABS) to indicate neurosyphilis. Patients were commonly co-managed with infectious disease physicians, and treated with penicillin for at least 10–14 days, plus corticosteroid. Features predicting poor outcome included optic neuropathy (86.3%) and initial misdiagnosis (63.7%). Reasons for delayed diagnosis were often practitioner-related. 82.5% of members tested every patient they managed with uveitis for syphilis.ConclusionThis comprehensive report by an international group of uveitis-specialised ophthalmologists provides a current approach for the management of syphilitic uveitis.

Introduction: Symptomatic internal carotid artery occlusion (ICAO) can lead to subsequent neurologic decline, recurrent stroke, and mortality. We sought to evaluate safety and feasibility of endovascular revascularization for ICAO without tandem intracranial large vessel occlusion (LVO). Methods: This is a retrospective cohort analysis of all patients presenting to a single academic center with ischemic stroke and ipsilateral, cervical ICAO from November 2003 through April 2016. Patients were excluded if pre-procedural angiography demonstrated tandem LVO or if patients were known to have chronic ICAO. Study endpoints included discharge neurologic exam, post-procedural infarct burden, 3-month functional outcomes, and treatment durability. Results: A total of 107 patients with symptomatic, angiographically confirmed cervical ICAO without tandem LVO were identified. Median admission NIHSS was 8 (IQR 11). Baseline radiographic stroke severity was assessed by ASPECT score (median 9; IQR 2), perfusion mismatch (present in 93%), and clinical-diffusion mismatch (42%). Median time from symptom onset to treatment was 25 hours (IQR 61). Successful revascularization was achieved in 92% of patients. At discharge, 83% had stable or improved NIHSS, while at 3-months 65% achieved functional independence (mRS ≤2). The most common complication was distal embolization (22%) of which 16% required intra-arterial treatment. Rate of significant restenosis (≥70%) was 15% at 1-year. Conclusions: Stenting in selected patients at risk of neurological deterioration due to symptomatic ICAO can be performed with high rates of technical success and good clinical outcomes. Because of significant peri-procedural risks and high rates of restenosis, randomized studies are necessary to understand the benefit of this approach.

To evaluate the anatomical and functional outcomes of surgical treatment of retinal detachment secondary to ocular toxoplasmosis. A retrospective analysis of data from patients who had undergone vitreoretinal surgery for retinal detachment secondary to ocular toxoplasmosis was conducted. The parameters that were analyzed include surgical procedures, anatomical outcomes, visual acuity, and postoperative complications. This study included 22 patients, of which 13 were female (59.1%). The mean age was 28.5 years (SD ± 14.5, range 12-78 years) and the follow-up period varied from 1 to 163 months (mean 64 months). The mean baseline best-corrected visual acuity (BCVA) was 2.0 logMAR (SD ± 1.0). A total of 31 surgeries were performed, and the retina was reattached in 15 patients (68.2%) immediately after the first surgery and in 20 patients (90.9%) at a later point. The mean postoperative BCVA improved to 1.3 logMAR (SD ± 0.9) (p<0.05). Nineteen patients (86.4%) underwent cataract surgery with intraocular lens implant, and 12 patients (60.0%) underwent silicone oil removal. Five patients (22.7%) exhibited elevated intraocular pressure, and 1 patient (4.5%) developed hypotonia. Surgical treatment of retinal detachment secondary to ocular toxoplasmosis resulted in considerable anatomical and functional improvement. Although PPV with silicone oil injection demonstrated the best outcomes, it is not reasonable to conclude that this is the best surgical approach given the small number of patients included in this study.

Background: Reducing time to treatment is important for acute stroke therapy including intravenous tPA and endovascular therapy. Remote evaluation of acute stroke patients by telemedicine may help triage patients for endovascular therapy and facilitate earlier treatment. Purpose: We aimed to evaluate efficiency and clinical outcome using telemedicine as a screening tool prior to transfer of stroke patients to comprehensive stroke centers for endovascular therapy. Methods: We retrospective reviewed patients receiving endovascular therapy at the University of Pittsburgh Medical Center from January 2014 through May 2015 who were initially evaluated for acute stroke at an outside facility and transferred to our hospital. We statistically analyzed our data using unpaired T test with equal standard deviation. Results: 116 patients treated with endovascular therapy were identified. 35 (30.1%) had telemedicine (TM) evaluations prior to transfer and 81 (69.8%) were transferred without telemedicine screening (NTM). The average age was 68 years in TM group and 67 years in NTM group. 71% of TM patients received IV TPA compared to 30% of NTM patients. The average NIHSS on arrival was 17 among TM and 16 in NTM. The mean time from door to groin puncture was 54 minutes in TM patients compared to 66 minutes in NTM group (p=0.37). Good outcomes (mRS &lt; 2) occurred in 54% of TM cases and 36% of the NTM group (p=0.12). Poor outcomes (mRS 5-6) were 21% in TM patients and 40% in the NTM group (p=0.08). TICI 2b/3 revascularization was achieved in 88.5% and 88.9% in TM and NTM groups respectively (p=0.2). Conclusion: Evaluating acute stroke patients using telemedicine prior to transfer to comprehensive stroke centers may reduce time to intervention and improve selection of patients more likely to benefit from endovascular therapy.

Background and Purpose: Craniocervical fibromuscular dysplasia (FMD) has been associated with dissections. Recently, the presence of an S-shaped curve in the ICA has been described as a marker of FMD. We evaluated the occurrence of S-shaped curves in acute ischemic stroke (AIS) patients presenting with ICA steno-occlusive dissections. Methods: This was a retrospective review of the interventional database of two academic tertiary care institutions. Cases of carotid dissections were compared with a control group (consecutive non-tandem anterior circulation strokes). The presence of ICA S-shaped curves, C-shaped curves, 360° loops, as well as, FMD changes and atherosclerotic changes at the ICA bulb and curve/loop was determined by evaluation of conventional-angiogram and CTA. Results: Twenty-four patients with carotid dissections were identified and compared to 92 controls. The baseline characteristics were similar, with the exception of expected younger age and less prevalent history of hypertension, diabetes and atrial fibrillation in the dissection group. Procedural variables were also similar, with the exception of a large percentage of the use of stentretrievers in the control group. The occurrence of parenchymal hemorrhages, good outcomes and mortality were similar amongst the two groups. The frequency of S-shaped curves on either side was 29% in the dissection group vs. 7% in the control group (p&lt;0.01). The S-shaped ICA curves were typically mirror images within the dissection group (85% of the patients with an S-shaped curves had bilaterally occurrence). The frequency of C-shaped and 360 degree curves was statistically similar between groups. FMD changes within the craniocervical arteries were statistically more common in the patients with dissections. Ten patients of the dissection group had either FMD changes or an S-Shaped curve (41%). Multivariate analysis indicated that S-shaped curves were independently associated with the presence of dissections. Conclusion: S-shaped ICA curves are predictably bilateral, independently associated with carotid dissections in patients undergoing thrombectomy for acute ischemic stroke, and may indicate the underlying presence of FMD.

Objective: The study aim was to compare major bleeding risk and health care costs after initiating oral anticoagulants (OACs) for treatment-naïve non-valvular atrial fibrillation (NVAF) patients. Methods: Patients in the Medicare advantage population prescribed apixaban, rivaroxaban, dabigatran or warfarin were selected from the Optum Research Database 01JAN2013-31DEC2014. The first OAC prescription date was designated as the index date. Patients were required to have a NVAF diagnosis, continuous health plan enrollment for 6 months and no OAC claims before the index date. Patients were classified into four cohorts based on their index OAC prescription. Major bleeding events, identified by the Cunningham algorithm plus additional bleeding sites, were compared using a Cox proportional hazards model. Health care costs were calculated per patient per month and compared using generalized linear models. Results: The study included 36,260 patients: 3,762 apixaban, 2,677 dabigatran, 8,740 rivaroxaban, and 21,081 warfarin patients. CHA2DS2-VASc score was higher in apixaban patients (4.2) compared to dabigatran and rivaroxaban (both 4.0; p&lt;0.001), but lower than in warfarin patients (4.3; p&lt;0.001). After adjusting for baseline characteristics, apixaban patients were significantly less likely to have a major-bleeding event within one year of treatment initiation compared to rivaroxaban (HR=0.69; 95% CI=0.59-0.81) and warfarin (HR=0.71; 95% CI=0.61-0.82) patients and trended towards numerically lower major bleeding compared to dabigatran patients (HR=0.87; 95% CI=0.72-1.06). Major bleeding-related medical costs were lower in apixaban patients ($53) compared to rivaroxaban ($111) and warfarin ($138) patients (p&lt;0.001) and similar to dabigatran patients ($44, p=0.370). Furthermore, apixaban patients incurred lower all-cause medical costs ($1,646) compared to dabigatran ($1,974, p=0.02), rivaroxaban ($1,909, p=0.002) and warfarin ($2,162, p&lt;0.001) patients. Conclusion: In a large national Medicare advantage population, treatment-naïve NVAF patients treated with apixaban were significantly less likely to have a major-bleeding event compared to those prescribed rivaroxaban or warfarin and had significantly lower medical costs.

Observe whether there are differences in visual functions among premature infants with treated retinopathy of prematurity (ROP) in relation to preterm infants with ROP and spontaneous regression; and among these two groups with ROP and the control group without ROP. Cross-sectional observational no blind study. Premature infants were born between 06/199206/2006 and were exam between 06/200912/2010; registered in data of Hospital de Olhos Sandalla Amin Ghanem; with gestational age less than or equal to 32 weeks and 1,599 g born weigh; without ROP and ROP stages II or III, in one of the eyes, with spontaneous regression or with treatment; at least three visits during the selection period at maximum 6 months in the first exam and minimum 4 years of age in reassessment (chronological age) were include. Premature that did not respond or were not located for reassessment and those that did not have conditions to do the exams were exclude. Study's groups: G1 ROP posttreatment; G2ROP post-spontaneous regression; G3 without ROP (control). Visual function evaluated with visual acuity (VA), contrast sensitivity test (CST), color test (CT), eye movement, stereopsis. Overall, there were 24 premature infants and 48 eyes. Normal VA: 64.28% (G1), 87.5% (G2) and 100% (G3); Normal CST: 66.67% (G1), 100% (G2) and 55.56% (G3); Normal Ishihara CT: 100% (G1 and G2) and 86% (G3); Normal Farnsworth CT: 20% (G1), 75% (G2) and 50% (G3). Normal stereoacuity: 0.00% (G1); 25% (G2) and 3.5% (G3). Strabismus: 37% (G2), 0.00% (G1 and G3). The prevalent tendency for lower response in CST and CT between the premature children in group G3 and Farnsworth color test in G1 is a curious result of this work and more study is necessary about these visual functions in older premature children. The visual functions showed no statistically significant difference among the groups studied.