Complementary and alternative medicine use among ischemic stroke survivors in Jeddah,Saudi Arabia

Objectives:To determine the prevalence and pattern of complementary and alternative medicine (CAM) use and the CAM types used by stroke patients in Jeddah, Kingdom of Saudi Arabia.Methods:This cross-sectional study included 152 ischemic stroke survivors who visited King Fahad Hospital, Jeddah, Kingdom of Saudi Arabia, between January 2018 and December 2019. Phone-based and face-to-face surveys were conducted. Data on the patients’ demographic characteristics, their use of CAM, and their pattern of CAM use were gatheredResults:Ninety (59.2%) stroke patients used CAM, mainly cauterization (29.61%) and Quran recitation by a religious sheik (28.95%). Most of the patients (72.22%) used CAM post-hospitalization and within less than one month from stroke onset (62.22%). A minority (6.67%) of the patients stopped their medication while on CAM. Some patients (25.56% to 31.11%) discussed with their physician their use of CAM. The CAM users reported a subjective improvement in their physical weakness (45.6%) and psychological wellbeing (62.2%). The patients learned about CAM mainly from their relatives and friends (96.7%), and the most common reason for their CAM use was their belief in this intervention (42.22%).Conclusion:The CAM use was prevalent among our cohort of Saudi ischemic stroke patients, and cauterization and Quran recitation were the most commonly used CAM interventions. An effective communication was lacking between the medical professionals and the stroke patients as regards CAM use despite the interest of the patients in this intervention.

Over the past 2 decades, the burden of stroke has increased globally.1 Stroke is the second leading cause of morbidity and mortality; the annual incidence of stroke is approximately 15 million, and over 5.5 million stroke-related deaths occur annually.2–4 Also, the prevalence of the modifiable risk factors of stroke is increasing, and the burden of stroke increases with the aging of the population.5 Adults aged >25 years have an estimated lifetime stroke risk of 24.9%.6 Despite the advancements in acute stroke care, highly effective treatments for the later phases of stroke are lacking. This shortcoming in the stroke care leads patients and their relatives to seek other treatment options, such as complementary and alternative medicine (CAM).7 The CAM is defined by the United State of America National Institutes of Health as “a group of diverse medical and health care systems, practices, and products that are not generally considered conventional medicine.”8 The CAM has been used for a long time now,9 and people widely practice CAM for various health conditions, such as cancer, epilepsy, multiple sclerosis, infertility, surgical procedure, dermatological conditions, hypertension, pain, and other types of illnesses.1,9–11 The prevalence of CAM use varies by country. For example, the prevalence of CAM use is 82% in the United States,12 61% in Australia,13 51% in Malaysia,14 and 61% in Turkey.15 Religion, cultures, and values influence the types and patterns of its use.16 People in Western countries practice herbal medicine, reflexology, aromatherapy, massage, osteopathy, meditation, and spiritual healing;10,17–19 by contrast, those in Asian countries such as China, India, and Taiwan commonly use therapies such as traditional Chinese medicine, Ayurvedic medicine, physical exercises, acupuncture, Tai Chi, yoga, and homeopathy.20–23 In Saudi Arabia, different types of CAM are used including the Quran recitation therapy, honey consumption, plant-based traditional medicine (e.g., Murrah and black seed consumption), cupping (“Hojamah”), and cauterization (“skin ironing”)9,24–27Research highlighted that aside from their potential benefits, some types of CAM have many side effects and potential toxicities, and patients are commonly unaware of these possible dangers.28 One study reported 2 cases wherein the cauterization led to severe complications, such as skin burn.29 Another study that investigated the components of herbal medicines in Saudi Arabia indicated that 15.7% of the tested samples contain toxic amounts of heavy metals, including arsenic and mercury.30 Despite the potential risk of many CAM interventions, it has been noted that many patients do not inform their physicians about their practice of CAM.31Stroke patients in many countries, including the United States (30.6%–46%)32,33 and South Korea (54%), use CAM.34 In Riyadh, Saudi Arabia, 67% of patients with neurological problems use CAM,9 and most of them use cupping (Hojamah) (45.4%), herbal medicine (42.3%), cauterization (33.7%), and Quran recitation (20.4%).9 However, no available study has analyzed the use of CAM particularly by stroke patients in Saudi Arabia. Thus, this study aimed to determine the prevalence and pattern of CAM use and the types of CAM being practiced by ischemic stroke patients relation to their demographic data.     

Patterns and prognosis of Ventriculoperitoneal shunt malfunction among pediatrics in Saudi Arabia

Objectives:To examine the predictors of pediatric ventriculoperitoneal (VP) shunt malfunction in a university hospital.Methods:A retrospective cohort was conducted. Patients under 18 years old who underwent VP shunt revision at least once between 2016 and 2019 were included. Data were stratified based on age, gender, diagnosis, type of valve, valve position, cause of revision, and part revised.Results:A total of 45 patients (64% males and 36% females) were included in this study. Eighty-two revision surgeries were identified. The most common revised part was the entire shunt system. The most common type of valve which required revision was the low-pressure valve (15.5%). Since a p-value of less than 0.05 was considered significant, no significant differences among the 4 groups for different points.Conclusions:Younger age at initial VP shunt insertion is associated with a higher rate of shunt malfunction. Valve mechanical failures followed by infections are the most common causes for the first 3 revisions. A prospective multi-center study to confirm the current findings is recommended.

Ventriculoperitoneal (VP) shunt insertion is one of the most common procedures in pediatric neurosurgery for treating hydrocephalus.1 Among pediatric age group hydrocephalus is considered a common, surgically correctable condition in which there is an increase in the volume cerebrospinal fluid (CSF), leading to cerebral ventricles dilatation, thinning of the cerebral mantle, and elevation of intracranial pressure.2 Patients with VP shunts represent more than 30,000 hospital admissions per year.2 Although VP shunting has decreased the morbidity and mortality of hydrocephalus, it is still associated with multiple complications, many of which require surgical revision.1–4 Recent studies have reported the rate of complications following VP shunting to be between 30% and 50%.3–6 Shunt malfunctions causes can be categorized into infectious, mechanical, or functional.2–4 Shunt failure definition is revision or replacement of the original shunt between 30-days and 1-year.2 Mechanical failure can happen at the proximal end, valve, or distal end, and it includes obstruction, disconnection, fracture, distal end migration, or inflammation. Functional failure happens when there is overdrainage or underdrainage of cerebrospinal fluid while the whole shunt system is properly functioning. Infection happens when the patients demonstrate clinical findings and positive fluid sampling results.3 The most common complication necessitating revision are obstruction, infection, and displacement.2,3,6,7 Shunt failure is most common within the first 2 years postoperatively.3 Many important predictors of VP shunt failure have been reported in the literature, including etiologies of the hydrocephalus, prematurity, and age at the initial placement of the shunt.1,8,9 Clinical factors that may increase the risk of shunt revision include time from the first surgery, surgical procedure duration, prior treatments, number of surgeons, surgical expertise, surgical technique, anatomic site of the shunt, and diagnosis.1,7–10 Proximal catheter tip location is another predictor, as tip positions in the Foramen of Monro, lateral ventricles, or the third ventricle all were associated with lower rates of surgical revision.11 Other predictors of shunt failure were reported to be poor catheter placement and use of a non-programmable valve.12Previous studies have emphasized the need to identify children at risk, and for prospective cohorts to to investigate the relationship of risk factors and incidence of shunt revisions.1,9,10 Risk factors for VP shunt complications vary across institutions and populations, and a very limited number of studies addressing VP shunt malfunction have been conducted in Saudi Arabia, and only one in the last 10 years was published.13The goal of this study was to determine patterns and predictors of pediatric VP shunt malfunction, causes of the hydrocephalus and VP shunt revision and type of valve malfunction and define the best preventive measures. This knowledge will contribute to lowering the incidence of shunt malfunction, decreasing the number of surgeries, and increasing complication-free intervals between surgeries in hydrocephalic pediatric patients.     

The role of ketogenic diet in controlling epileptic seizures

Objectives:To study the role of the ketogenic diet (KD) in controlling seizures in children with medically resistant epilepsy in Saudi Arabia.Methods:This retrospective study was conducted in the Pediatric Neurology Clinic at a tertiary care epilepsy center. Thirty-one patients with medically resistant epilepsy were enrolled from 2013 to 2018. The seizure reduction variables were evaluated at 6, 12, 18 and 24 months after enrollment.Results:Of the 31 patients, 14 (45.2%) were males and 17 (54.8%) were females. The most common types of seizures were myoclonic seizures and mixed seizures, both of which occurred in 9 (29%) of the participants. Of the participants, 15 (48.4%) had seizures one to 5 times per day. Six months after starting a KD, 2 (6.45%) of participants were seizure-free; 6 (19.35%) were seizure-free after 12 months of treatment.Conclusion:The present study highlighted the effectiveness of KD in medically resistant epilepsy children to local population. A larger cohort is warrant to confirm these findings.

Epilepsy is a common neurological disorder. It is characterized by seizures and affects approximately 65–70 million people worldwide.1 Children and the elderly are most commonly affected by seizures; the condition is rarer in adults.2 Epilepsy remains a challenging neurological disorder despite effective pharmacological therapies.3 More than 30% of epileptic patients do not achieve complete control of seizures with available anti-epileptic drugs (AEDs).1,4 Around 20-40% of patients with epilepsy have refractory epilepsy “failure of, adequate trials of 2 tolerated, appropriately chosen and used AED schedules (whether as monotherapies or in combination) to achieve the sustained seizure freedom” and who are not candidates for surgery, non-pharmacological interventions should be considered for ketogenic diet (KD) treatment.5,6The KD has been proposed for first time in 1920s as a non-pharmacologic treatment to control refractory childhood epilepsy.1 The KD is a high-fat, low-protein, low-carbohydrate diet, with ketogenic ratio of 4:1 or 3:1 in grams which is the most commonly administered ratio.7,8 The KD increases the production of ketone bodies, which brain uses these ketone bodies as an energy source instead of glucose.2 Some hypotheses have been proposed regarding the KD’s anti-seizure effects, suggesting that changes in the nature and degree of energy metabolism in the brain, changes in neurotransmitter function, changes in synaptic transmission, and changes in neuronal cellular properties may explain the diet’s effectiveness.9 Higher ketone levels correlate with better seizure control.9 Ten to 15% of children with epilepsy become completely seizure free on a KD.3 Furthermore, the KD has a prolonged beneficial effect even after it is discontinued.9The International Ketogenic Diet Study Group strongly recommends that the KD be considered as a treatment for children with epilepsy who fail to respond to two or three anticonvulsant medications, regardless of age or gender.9 Our objective was to study the efficacy of the KD in children with medically resistant epilepsy in Saudi Arabia.     

Predicting future handedness and hemispheric dominance during infancy by analyzing sleep spindles

Objectives:To investigate whether sleep spindles asynchrony (SSA) using scalp sleep electroencephalogram (EEG) among children below 2 years of age can predict future handedness.Methods:This is a retrospective study conducted from October 2016 until June 2017 at the King Fahad Medical City (KFMC), Riyadh, Kingdom of Saudi Arabia. We retrospectively reviewed 300 EEGs recorded at our neurophysiology laboratory.We included EEGs performed during sleep for infants aged 2 months to 2 years who have already attained their handedness or those aged above 2 years. We excluded records of children younger than 2 months or above 2 years of age (at the time of the EEG) or those aged below 2 years (at the time of the interview), and severely abnormal tracings and those without sleep or enough SSA .Results:The lateralization of Sleep Spindles (SS) was mostly right-hemispheric (52%) compared to left-hemispheric (36.4%). The overall SS laterality did not correlate with handedness (p=0.81). In the majority of right-handed (64%) and left-handed (60%) children, the SSA was contralateral to the side of hand preference; however, it did not correlate statistically (p=0.377).Conclusion:We were unable to prove a statistically significant correlation between SSA and future hand preference. Further research involving larger cohorts is still needed.

Sleep architecture is an essential part of evaluating any electroencephalogram (EEG). Despite being recognized and described as early as the discovery of EEG, sleep features remain understudied. In most children, Sleep Spindles (SS) do not synchronize over the 2 hemispheres until the child develops Handedness, usually at 2 years of age. This coincidence of the establishment of Handedness and synchrony of SS makes the connection between the 2 maturational developments important. We planned to investigate the possibility of anticipating future hemispheric dominance and future Handedness using the concept of Sleep Spindles Asynchrony (SSA). The SS consist of bilaterally symmetric low to medium voltage bicentral synchronous rhythmic spindle-like waves, with frequency ranging from 12 to 16 Hz, which often appear along K-complexes lasting approximately 2-3 seconds.1 The identification of SS is easy in any sleep EEG due to their abundance in infants and children. Their typical location in adults is a synchronous burst of waves around the vertex; in children, it varies according to age.2–7 It is thought that the origin of sleep spindles is the thalamocortical network. However, there is no functional meaning definitively established for this mechanism so far, which makes our study relevant to this area.3 The SS are not seen in the first 2 months of life and start to appear afterward.8 The absence of sleep spindles during mid-infancy is considered a significant abnormality. However, their independent occurrence (asynchrony) below 2 years of age is common and a normal finding.9–12 These sleep milestones are consistent between subjects, and therefore they are an essential indication of functional maturation.13 Chatburn et al14 found that sleep spindle activity was associated with various aspects of maturation and is an integral part of brain development. It is suggested that sleep EEG may be a marker for intellectual ability.15 Specifically, SS are associated with the intelligence quotient (IQ).16 The SS are also found to be involved in procedural memory.17 There are a few speculations about how Handedness is created in individuals. Although antenatal mechanisms might be essential, analysis considering in utero development verified that Handedness was an extremely accurate indicator of hemispheric dominance after birth.18 Early hand preference does not develop before one-year of age, and the usual age at which Handedness appears is 2 years, coinciding electrographically with SS synchrony, making a causal relationship or mechanism between the 2 markers highly likely.19–20 There is no previously published research to date to have studied this area.21     

Association between craniovertebral junction abnormalities and syringomyelia in patients with chiari malformation type-1

Objectives:To assess the correlation between craniovertebral junction (CVJ) abnormalities and syringomyelia in patients with Chiari malformation type-1 (CM1).Methods:This was a retrospective study including patients with CM1. Identification of cases was done by searching a radiology database at a university hospital from 2012 to 2017. Patients were divided into 2 groups based on whether CVJ abnormalities were present (CVJ+) or absent (CVJ-). The patients’ demographic and clinical data were reviewed. All magnetic resonance imaging studies were examined by a certified neuroradiologist.Results:Sixty-four consecutive patients with CM1 were included. The mean age was 24±17 years; 59% were females. The CVJ+ group had more female patients (p = 0.012). The most frequent CVJ abnormality was platybasia (71%), followed by short clivus (44%) and cervical kyphosis (33%). The CVJ abnormalities were more in Syringomyelia cases (p = 0.045). However, the results were not significant when hydrocephalus cases were excluded.Conclusion:Among CM1 patients, CVJ abnormalities were found more in patients with syringomyelia. Future studies with larger sample size are required to further study the correlation between CVJ abnormalities and both syringomyelia and hydrocephalus in CM1 patients.

Chiari malformation type-1 (CM1) was first described in 1891 by Austrian pathologist Hans Chiari.1,2 The CM1 is defined as caudal displacement of the cerebellar tonsils below the foramen magnum by 5 mm or more.3,4 This definition is merely a radiological definition. In the literature, the degree of cerebellar tonsil displacement varies from 3 mm to 5 mm.4 CM1 affects approximately 1% of the population and may involve a spectrum of neurologic involvement.2 Syringomyelia is reported in 25% of CM1 cases and may cause irreversible damage to the spinal cord with subsequent neurological deficits.5The pathophysiology of syringomyelia development in patients with CM1 has been extensively studied.6-9 Majority of publications indicated a block to the cerebrospinal fluid (CSF) circulation at the level of the craniovertebral junction (CVJ).8,9 Subsequently, the cerebrospinal fluid (CSF) accumulates and forms syringomyelia.8,9 The source of the CSF forming the syringomyelia can be from the fourth ventricle, the subarachnoid space (SAS), or from an extracellular source.8,9 From the 1950s to the 1970s, syringomyelia was believed to result from a difference in CSF pressure between the fourth ventricle and the central canal of the spinal canal.7 Theories to explain this mechanism include James Gardner’s water-hammer theory, Bernard Williams’ cranio-spinal pressure dissociation theory, and Ball and Dayan’s theory of tonsillar obstruction to the CSF pathway.10-12 In the 1990s, Oldfield believed that the mechanism of the development of syringomyelia involved abnormal CSF flow at the level of the foramen magnum.6,7 The descent of the cerebellar tonsils with each cardiac cycle produces a pressure wave in the spinal SAS, and thereby compresses the spinal cord from the outside and propagates a syrinx.7,9Several intradural and extradural factors have been implicated in the pathophysiology of CM1. Among the intradural factors identified during surgery for CM1, the presence of an arachnoid membrane obstructing the foramen of Magendie (i.e., an arachnoid veil) was significantly more frequent in patients with an associated syringomyelia.6 Other studies have examined whether the degree of tonsillar descent below foramen magnum in the CM1 patients is a contributing factor to the development of syringomyelia; however, the impact of tonsillar descent is controversial.6,9,13 Some studies have reported that the rate of syringomyelia increases as the degree of tonsillar herniation increases.6,9 As a possible explanation for syringomyelia development, other studies14,15 have addressed crowding of the SAS at the foramen magnum caused by tonsillar decent. In a study by Doruk et al15, the measured cervicomedullary compression ratio, defined as the ratio of the area occupied by the cerebellar tonsils to the area of the foramen magnum, was significantly correlated with the development of syringomyelia. This ratio could reflect the severity of blockage of the SAS at the CVJ and further supports the previously described mechanisms of syringomyelia development.9Extradural abnormalities at the CVJ are associated with CM1.15 Such pathologies include a small posterior cranial fossa, platybasia, basilar invagination, and short clivus.3,6,8,9 Several studies have examined the presence of CVJ abnormities in CM1 patients with and without syringomyelia.13,16-21 However, the presence of associated syringomyelia within the context of CM1 with and without CVJ abnormalities was inadequately highlighted. For instance, in one study,13 syringomyelia existed in 64% of CM1 patients with a short clivus, compared to 36% of CM1 patients without a short clivus. In order to further understand the relationship between the presence of one or more CVJ abnormalities and syringomyelia in CM1, the current study was conducted. Such knowledge will likely enhance the understanding of CVJ relationship with CM1 and may aid in the management of syringomyelia in such patients.     

Prevalence and risk factors of myasthenia gravis recurrence post-thymectomy

Objectives:To evaluate the prevalence and the factors associated with recurrence of myasthenia gravis following thymectomy.Methods:Six electronic databases which reported on recurrence of myasthenia gravis following thymectomy and/or its risk factors from 1985 to 2018 were searched. Summary prevalence and risk values obtained based on the random effect models were reported.Results:Seventy (70) papers containing 7,287 individuals with myasthenia gravis who received thymectomy as part of their management were retrieved. The patients had a mean follow-up of 4.65 years post-thymectomy. The prevalence of myasthenia gravis recurrence post-thymectomy was 18.0% (95% CI 14.7–22.0%; 1865/7287). Evident heterogeneity was observed (I²=93.6%; p<0.001). Recurrence rate was insignificantly higher in male compared with female patients (31.3 vs. 23.8%; p=0.104). Pooled recurrence rates for thymomatous (33.3%) was higher than the rate among non-thymomatous (20.8%) myasthenia gravis patients (Q=4.19, p=0.041). Risk factors for recurrence include older age, male sex, disease severity, having thymomatous myasthenia gravis, longer duration of the myasthenia gravis before surgery, and having an ectopic thymic tissue.Conclusion:A fifth of individuals with myasthenia gravis experience recurrence after thymectomy. Closer monitoring should be given to at-risk patients and further studies are needed to understand interventions to address these risks.

Myasthenia gravis (MG) a rare clinical condition characterized by autoimmune abnormalities is also the commonest neuromuscular junction (NMJ) disorder.1 Its pathophysiology involves the production of abnormal antibodies which binds to nicotinic acetylcholine receptors at the NMJ of skeletal muscles leading to alteration and damage of the NMJ.1-2 The disease is common in young women, however, another peak in incidence may occur at the 6th or 7th decade of life mainly in men in some population; and it may exhibits no sex preference in others.2 Clinically, patients with MG develop varying levels of skeletal muscle weakness affecting the ocular, bulbar, oculo-bulbar system, respiratory system, and the extremities.1 The pattern and course of MG is complex, varying from early remission to acute exacerbation and even death.3Previous research has revealed a strong relation between MG and disorders affecting the thymus. About 40 to 70% of individuals with MG have thymic follicular hyperplasia, and 10 to 21% of them have thymoma.4-6 Also, 20-47% of individuals having a thymoma have already developed or will develop MG.6-7 Findings from the literature indicate that 40 to 90% of individuals with MG attained remission following thymectomy compared with 10 to 20% among individuals with MG treated with medications without any surgery.6,8 Also, a recent randomised controlled trial demonstrated that thymectomy for individuals with nonthymomatous MG demonstrated better treatment outcomes during a three-year period compared with pharmacological therapy alone.9 Thus, guidelines now recommend thymectomy as a key treatment approach for MG.10A number of systematic reviews and/or meta-analyses among individuals with MG have been carried out. Some of these reviews explored the differences in outcomes between thymectomy and conservative management of MG,11,12 others compared surgical approaches of thymectomy,13-15 or potential prognostic factors for remission among individuals with MG irrespective of histological type following thymectomy.3,16 None assessed recurrence of MG following thymectomy or its risk factors. The identification of patient factors which are associated with recurrence of MG following thymectomy is crucial for the development of targeted interventions to address challenges associated with the care of individuals with MG. This systematic review and meta-analysis aimed to estimate the post-thymectomy recurrence rates and to investigate the factors associated with recurrence of MG following thymectomy in individuals with MG.     

Incidence,risk factors,clinical presentation,and outcomes of hemorrhagic transformation in patients with ischemic stroke admitted to a tertiary hospital in Kingdom of Saudi Arabia

Objectives:To describe the incidence rate, clinical presentation, relevant risk factors, and outcome of hemorrhagic transformation (HT) among ischemic stroke patients.Methods:This retrospective study analyzed HT in patients with ischemic stroke admitted to King Abdullah Medical City from August 2011 to April 2019. Data were analyzed using SPSS. Patients characteristics, procedures, treatments, and outcomes were reported.Results:There were 504 ischemic stroke patients. The HT was detected in 38 patients (8%). The median age was 66.5 (54.3 -77.5) years, and 24 (63%) were males. HT was classified as hemorrhagic infarction (HI) in 22 patients (58%) while 16 patients (42%) were parenchymal hematoma (PH). The most common risk factors noted were: hypertension (74%), diabetes mellitus (DM) (66%), hyperlipidemia (63%) and ischemic heart disease (IHD) (61%). Nine patients (23.6%) developed HT after receiving thrombolytic therapy. Only one patient (3%) died of HT patients.Conclusion:HT accounted for (8%) of all ischemic stroke patients. Old age, DM, hypertension, and hyperlipidemia are frequently encountered with stroke patients who developed HT. Follow up CT brain could be of value and could identify HT early to get better outcomes.

Hemorrhagic transformation (HT) which is a spectrum of hemorrhage related to brain ischemia.1 The HT is a primary complications of acute ischemic stroke (AIS).2 Ischemia makes the cerebral vasculature fragile and more reliable to cause HT after AIS.3–5 HT increases both morbidity and mortality rate in the ischemic stroke patients.2 The HT affects the outcomes with potential severe short- and long-term effects.6 The incidence of HT is between 10–40% and depends on many factors.1,7,8 Most of HT occurs within 2 weeks of an ischemic stroke.5 Previous studies considered old age, hypertension (HTN), diabetes mellitus (DM), large infarct (>2 cm), reperfusion time, lower platelet count and treatment with thrombotic- or anticoagulant-therapies as risk factors.9–12 The most effective treatment for AIS according to previous studies is recombinant tissue plasminogen activator (r-tPA),13 however, it appears to increase the risk of symptomatic or asymptomatic HT.1 Previous studies also suggest that the outcome of HT patients be strongly associated with HT type hemorrhagic infarction (HI) (Petechiae) or parenchymal hematoma (PH) (a space-occupying lesion), PH was a significant predictor of both mortality and neurological deterioration.14 Thus, it is critical to understand HT and its characteristics especially in our population. This retrospective study was designed to describe the incidence rate, clinical presentation, and relevant risk factors of HT among ischemic stroke patients. Identifying such knowledge could improve the outcome and decrease the risk of HT in AIS patients.     

Effectiveness of an early mobility protocol for stroke patients in Intensive Care Unit

Objectives:To evaluate the effectiveness of an early mobility protocol for stroke patients in the intensive care unit.Methods:Participants were patients with first or recurrent stroke (n=60, age=49.02±6.36 years, body mass index=32.95±5.67 kg/m²) admitted to the intensive care stroke unit in general hospitals, Riyadh during October and December 2016. Single group pretest-posttest design involving an early mobility protocol was started within first 24 hours admission. Pre and post measurements of muscle strength, pulmonary function and quality of life were carried out.Results:There were significant improvements in muscle strength of upper and lower extremities´ muscles after treatment (p<0.05), pulmonary functions including Forced Vital Capacity, Forced Expiratory Volume 1 (p<0.05) and quality of life, namely, Barthel Index and modified Rankin Scale (p<0.01).Conclusion:This study demonstrates that initiating an early mobility protocol is safe and effective for intensive care unit stroke patients and supports introducing the current protocol as a standard protocol in neurogenic Intensive Care Units.

Stroke is a life-threatening condition caused by interruption of the blood supply to any part of the brain. Stroke causes acute neurological disorders and long-term disabilities and imposes economic, social and health impacts on individuals and their families.1 Survivors of stroke are left with mental and physical disabilities that cause social and economic burdens and impair quality of life (QOL). In Saudi Arabia stroke is becoming a rapidly increasing problem and a primary cause of morbidity and mortality.2 Worldwide the incidence of first-time stroke was 17 million during 1990-2000.3 Cerebrovascular diseases including stroke is a leading cause of mortality,4 and stroke is the fifth leading cause of death, but it remains the first cause of disability in the USA.5 By 2030 there will be almost 12 million stroke deaths and 70 million stroke survivors globally.6 Stroke has an adverse influence on the QOL of patients. The onset of stroke is sudden, and unlike other disabling conditions, it leaves patients and their family’s ill prepared for its sequelae.7 Stroke may create unique conditions that affect the patients’ QOL, involving dysfunctions in physical, emotional, memory, thinking, and social interactions.8Stroke is an urgent health care issue. It is a common cause of the hospital admissions. Immediate admission to the neuro-intensive care unit can facilitate early stroke treatment strategies.9 Stroke patients in the intensive care unit (ICU) experience a decrease in physical activity that represents a significant stress on the body and leads to a considerable decrease in functional status, increases morbidity, mortality rate, and duration of hospital stay and cost of care.10 In addition to comorbid diseases, patients on mechanical ventilation have many barriers to mobility because they are surrounded by tubes, catheters, life support and monitoring equipment. Additionally, other factors besides weakness, such as sleep loss, lack of social communication, nutritional status, sedation, and an ICU culture that encourages bed rest further contribute to functional deterioration.11 There is considerable loss of the muscle mass during the initial weeks of immobility in the ICU, therefore its management is inherently related to QOL after discharge.12 Considerable published evidence indicates that patients in ICUs have high morbidity and mortality, high costs of care and a marked decline in functional status.13,14Early and progressive mobilization program has been described as a key component for patients in the ICU. It may decrease post stroke complications such as infections, deep venous thrombosis, pneumonia, pressure ulcers, falls and de-conditioning with bed rest.15 It has been recognized that mobilization of post stroke patients is essential to prevent hospital-associated complications, functional decline and facilitate recovery.16 Moreover, the benefits of early mobilization include decreased ICU-acquired weakness, improved functional recovery within hospital,17 Effective stroke intervention begins the day the patient has a stroke.18 It has a positive effect on patient functional ability, promotes positive psychological effects and improves walking at hospital discharge and reduces hospital length of stay.19 While on the other hand, long term inactivity may affect the patients’ physical, social, emotional, behavioral, and psychological pattern.20 In addition, secondary changes associated with stroke-related inactivity include muscle atrophy, a shift in muscle fiber type to a greater predominance of fast-fatigable, insulin-resistant fibers, loss of cardiovascular fitness, and increased intramuscular fat.21 Therefore, early mobilization program which is a complex intervention that needs crucial patient assessment and management, as well as interdisciplinary team collaboration and training.22,23 The early mobilization may improve patient outcomes and recovery.24 Few studies have investigated the role of increased mobility in ICU patients. Therefore, this prospective intervention trial evaluated the effectiveness of an early mobility program administered by physical therapists and nursing personnel for stroke patients admitted in ICU.     

Corpus callosum index correlates with brain volumetry and disability in multiple sclerosis patients

Objectives:To analyze the correlation between corpus callosum index (CCI), brain volumetry, and disability in multiple sclerosis (MS) patients. The brain volumetry consists of the corpus callosum, cortical gray matter, subcortical gray matter, and white matter volumes.Methods:This was a retrospective cross-sectional study from October 2018 to February 2019 of 30 patients with MS aged 20 to 61 years old. Brain volumetry was performed using FreeSurfer© software. The CCI were measured manually using conventional best mid-sagittal T1W brain MRI. The anterior, posterior, and medium segments were measured and divided to its greatest anteroposterior diameter. Higher CCI values indicated greater corpus callosum volumes. Clinical evaluation was comprised of MS subtype, age of onset, relapse frequency and Expanded Disability Status Scale (EDSS).Results:Thirty MS patients with median of age 22 years were included. Relapsing-remitting (RRMS) subtype were 73.3%. Very significant correlations were shown between the CCI and corpus callosum volume (CCV) (r=0.79; p<0.0001) and cerebral white matter volume (r=0.81; p<0.0001). Significant correlations were shown between the CCI and cortical gray matter volume (r=0.64; p<0.0001) and subcortical gray matter volume (r=0.69; p<0.0001). The CCI was positively correlated with age of onset and inversely with EDSS. The CCV and CCI were smaller in secondary progressive MS (SPMS).Conclusion:The CCI is easy and fast to obtain in conventional MRI and significantly correlated with brain volumetry, age of onset and disability in MS patients.

Multiple sclerosis (MS) is one of the most common neurological diseases of the central nervous system and has various clinical manifestations, affecting the sensory, motor, cerebellar, brainstem, and autonomic systems.1–4 The MS progression will lead to disability that can affect the quality of life. In 2013, the prevalence of MS was 33 per 100,000 globally, an increase from approximately 30 per 100,000 in 2008.5 Regarding the cognitive impairment, it has been found in a study by Rao et al6 a 45% frequency of cognitive impairment in MS patients. Furthermore, it has been found in several studies that the decline in visual and verbal episodic memory as well as decelerated cognitive processing speed are the most frequent cognitive domains impaired in multiple sclerosis.7 Between these 2 domains, it has been shown that memory impairment were slightly more common than those with memory impairment and processing speed impairment in 128 patients with relapsing-remitting MS (RRMS).8 In our previous study, we found impairments in the Symbol Digit Modality test (up to 50%), California Verbal Learning test-II (27.5%), and Brief Visuospatial Memory test-revised (32.5%) in MS patients.9Brain volume in MS patients were found to be significantly smaller compared to healthy subjects and associated with the progression of disability.10 Brain atrophy in MS can occur by 3 mechanisms: volume loss within the lesion itself, retrograde degeneration, and Wallerian degeneration in the remote area of the fiber pathway.4,11,12 Brain atrophy can be seen in earliest stages of MS (clinically isolated syndrome).13 Gray matter atrophy begins early in the course of the disease and is correlated with the progression of disability, especially motor and cognitive disability.14–16 Measuring brain atrophy has been proposed as one of several treatment monitoring parameters for MS.17The corpus callosum is one of the main white matter pathways and affected by the progress of chronic diseases, including MS.1,3,4 Corpus callosum damage is correlated with cognitive impairment and motor disability in MS patients. Corpus callosum atrophy could be a clinically relevant marker of cognitive impairment.18–20Brain volumetry using magnetic resonance imaging (MRI) is a useful, noninvasive tool in assessing subcortical morphometric changes as well as evaluating the regional neurological impact of psychopathology, such as dementia, psychiatric disorders, and normal aging.21 Some software packages have been developed for measuring brain tissue volume using MRI with semi-automatic segmentation, such as FreeSurfer© (The General Hospital Corporation, Boston MA, USA), FIRST (FMRIB’s Integrated Registration and Segmentation Tool), FSL (FMRIB’s Software Library), and SPM (Statistical Parametric Mapping).22With this background, the objective of this study was to determine the correlation between the corpus callosum index (CCI) measurements and the corpus callosum, cortical gray matter, subcortical gray, and cerebral white matter volumes determined through brain MRI volumetry and clinical characteristics in MS patients.     

Neurodevelopmental and epilepsy outcomes of patients with infantile spasms treated in a tertiary care center

Objectives:To assess the neurodevelopmental and epilepsy outcomes in children with infantile spasms (IS).Methods:A retrospective chart review of all patients with infantile spasms admitted to King Khalid University Hospital (KKUH), Riyadh, Saudi Arabia between January 2000 and December 2017. Infants who were diagnosed to have IS as per the International League Against Epilepsy (ILAE) definition were included in this study. Patients who lost follow-up and those who did not receive treatment at KKUH were excluded.Results:Total of 53 patients were included and categorized into unknown, cryptogenic and symptomatic type of IS. The majority had symptomatic etiology (71.7%). Type of etiology and delay in initiation of treatment were significant predictors of motor and cognitive outcomes, but not seizure control. Patients with unknown IS, who were diagnosed earlier (0.72-month), had better neurodevelopmental outcomes. Vigabatrin in combination with either Adrenocorticotropic hormone (ACTH) or Prednisolone showed better seizure control in comparison to monotherapy and other combination modalities.Conclusion:Neurodevelopmental outcomes of IS are strongly associated with the underlying etiology. Early initiation of treatments had a favorable cognitive and motor outcome. Early response to combination therapy with resolution of spasms and hypsarrhythmia had better seizure outcomes. However, motor and cognitive outcomes were not affected by the response to the combination therapy.

Infantile spasms (IS) is a rare form of epileptic encephalopathy characterized by spasms and hypsarrhythmia on the electroencephalogram (EEG).1 IS is diagnosed at 6 months of age on average.2 There are no reports on the incidence of IS in Saudi Arabia. International estimates put the figure at 1:6,000 – 1:4,000 live births. Studies suggest that IS constitutes 2% of childhood epilepsies, and a quarter of epilepsy cases are seen during the first year of life.3 The etiology of IS is divided into prenatal, perinatal, or postnatal disorders.3 Genetic defects associated with IS are increasingly being understood. Tuberous sclerosis is the most common disorder associated with IS and constitutes 10-30% of symptomatic IS. It is an autosomal dominant disorder caused by mutations in TSC1 and TSC2 genes, with variable manifestations, including cardiac and renal tumors, cutaneous malformations, and seizures.4 Mutations in the ARX gene and cyclin-dependent kinase-like protein 5 (CDKL5), 14q12 duplications harboring FOXG1, STXBP1, and PLCB1 have been also implicated in IS.5-8 Other prenatal causes include hydrocephalus, hydranencephaly, Trisomy 21, Hypoxic-ischemic encephalopathy, congenital infections, and trauma. IS can also occur secondary to a perinatal or postnatal disorders, including meningitis, trauma, encephalitis, intracranial hemorrhage, and inborn errors of metabolism.9When there is no clear cause of IS identified, IS can be labeled as unknown or cryptogenic. Uunknown IS is characterized by normal development prior to the onset of IS. Cryptogenic IS, on the other hand, is diagnosed when no known etiology is determined, but prior developmental delay has occurred.10Neurodevelopmental regression is characteristic of IS, and children with history of IS often have poor neurodevelopmental outcomes.11 In a cohort of 180 patient, 53% of infants with symptomatic IS have normal seizure status and cognitive development compared to 21.9% of infants with unknown IS.12The long-term survival of patients with IS thought to be poor and was related to the underlying condition, where unknown IS generally has a better prognosis than symptomatic IS.11 The aim of this study was to identify those patients and treatment factors that correlate with favorable neurodevelopmental and epilepsy outcomes in a tertiary hospital in Saudi Arabia.     

Hypsarrhythmia and spasms resolution after Valproic acid discontinuation in an infantile spasm patient

Several studies have reported a variable benefit of valproic acid for the treatment of infantile spasm. However, valproic acid can also worsen spasms, as occurred with this child who presented with post-traumatic seizure which evolved to spasms. The child was started on antiepileptic medications, including valproic acid, despite that spasms persisting. For this reason, she was admitted for adrenocorticotropic hormone therapy. The baseline electroencephalogram showed modified hypsarrhythmia, and the laboratory workup showed thrombocytopenia, which was attributed to the valproic acid. After the valproic acid cessation, the spasms and the hypsarrhythmic pattern resolved dramatically next day, and the intended adrenocorticotropic hormone therapy was not started. Eight months later, she was still free of spasms. In conclusion, though valproic acid might have a beneficial effect in some patients with infantile spasm, it might have a negative impact on spasms in some patients which warrants its discontinuation sooner than later during spasms treatment.

Infantile spasm was first described in 1841 by James West in his own son.1 It is an age-specific epileptic disorder that mostly affects infants aged between 4 to 8 months, and the majority present before the age of 24 months. Classically, the spasms are characterized by bilateral, symmetric contraction of the axial muscles lasting for less than 2 seconds followed by less intense tonic contraction lasting between 2-10 seconds. The spasms occur in clusters separated by intervals of 5-30 second.2 As they are mostly occurring in infants with developmental delay, infants with infantile spasms are inevitably experience regression in their development and demonstrate a characteristic pattern of hypsarrhythmia on electroencephalogram (EEG).3The spasms are usually refractory to most of the conventional antiepileptic medications, and are usually associated with poor long-term prognosis.3,4 Although the treatment guidelines for infantile spasm are limited, hormonal therapy and vigabatrin have higher evidence of effectiveness in the treatment of infantile spasms.5 Other medications including topiramate, zonisamide, valproic acid, pyridoxine and ketogenic diet might help to reduce spasms frequency and are often used after ACTH and vigabatrin.2,3 Although the valproic acid produced benefits in spasms reduction,6 I am reporting this interesting case in which the valproic acid resulted in the perpetuation of the clinical spasms and electrographic hypsarrhythmia in a child with refractory epilepsy secondary to post-traumatic injury. Immediately after discontinuation of the drug, spasms and hypsarrhythmia resolved completely.     

Guillain–Barre syndrome: demographics,clinical features,and outcome in a single tertiary care hospital,Oman

Objectives:Guillain–Barre syndrome (GBS) is an acute autoimmune-mediated peripheral nervous system disease. Different studies from various geographical regions have reported considerable variability regarding its epidemiology, clinical features, and outcome. Our study aimed to document demographics, clinical features, and outcomes among GBS patients admitted to a single tertiary care hospital in Muscat, Oman.Methods:A retrospective data analysis of 44 GBS patients, who were admitted during a two-year period from January 2016 to December 2018 at Khoula hospital, was carried out. Demographics, antecedent illness, duration of symptoms, muscle power graded by the Medical Research Council scale (MRCs), sensory & autonomic involvements, nerve conduction study results, CSF study, need for ventilation, condition at discharge and subsequent follow-up status were obtained.Results:Ninety-one percent of the patients were Omanis, with male predominant 63.6% and the average age was 42.69 years. Quadriparesis was the predominant presenting complaint (61.3%) and AIDP was the commonest variant (52%). All patients received a single cycle of IVIg and (13.6%) patients admitted to the ICU for mechanical ventilation. The study showed good outcome and recovery in 18 months follow up.Conclusion:The clinical presentation of GBS in the majority of patients in Oman is similar to those reported in previous studies, and most patients had favorable prognoses. Our results can be used as baseline data for understanding the characteristics of GBS in Oman and, consequently, for better management.

Guillain–Barre syndrome (GBS), also known as Landry’s paralysis, is an acute immune-mediated polyradiculoneuropathy;1,2,3 with males are about 1.5 times more affected than females, and an overall incidence rate of 1–2 per 100,000 population per year worldwide.4,5 The syndrome is characterized by an acute or subacute progressive generalized muscle weakness of upper and lower limbs with relative or complete areflexia, and limb paraesthesia.1 The typical pattern starts with typically ascending flaccid paralysis, which progresses over a few days to a few weeks. Patients may also develop cranial nerves involvement, usually as a facial or pharyngeal weakness. In addition, autonomic dysfunction is common in the disease, which manifests as postural hypotension, loss of vasomotor control (causing wide fluctuation in blood pressure), and a variety of cardiac arrhythmias. Ventilator assistance is required when respiratory failure and oropharyngeal weakness develop in the course of the disease, which has been reported to be required in approximately one-third of hospitalized patients; these data indicate that early management is vitally important for GBS.1,3Proceeding infections (such as infections with Campylobacter jejuni, Cytomegalovirus, Epstein–Barr virus, Mycoplasma pneumonia, and HIV)2,4,5,6,7 may activate the immune response, owing to molecular mimicry, to cross-react with the peripheral nerve’s components (the myelin and/or the axon) resulting in the endoneural inflammation of spinal nerve roots, nerve’s distal segments, and at potential nerve entrapments sites.2 Some triggering factors (e.g., immunization, trauma, bone marrow transplantation, and surgery) may also affect the pathogenesis of GBS .6–8Seasonal variability is reported for GBS, which can reflect seasonal changes in the peaks of the predisposing factors, such as infections, although GBS may occur during any season.9,10 Seasonal occurrence has been reported to peak during the summer season in Asian countries.11,12The GBS is believed to include a variety of acute neuropathies with underlying immune-mediated pathogenic mechanisms rather than a single disease; therefore, GBS recognized variants are considered as syndromes [including acute inflammatory demyelinating polyneuropathy (AIDP), acute motor axonal neuropathy (AMAN), acute motor-sensory axonal neuropathy (AMSAN), and Miller–Fisher syndrome]. The most prevalent form of GBS reported is AIDP which is responsible for 70–90% of cases.5,6 In addition to history and clinical examination, confirming the diagnosis of GBS may include cerebrospinal fluid (CSF) analysis and electroneurodiagnostic testing, both of which can be normal in the early phase of the disease.3,4Therapeutic plasma exchange (TPE) and intravenous immunoglobulin (IVIg) are used effectively for adult and pediatric patients with GBS; and if these treatments are administered during the first few weeks of the disease along with a efficient supportive care, they can minimize mortality and improve the outcome of the disease.13,14 Physical therapy is considered as an essential part of the supportive management for decreasing complications’ incidence, such as respiratory complications and deep venous thrombosis (DVT), as well as for pain management and to enhance early mobilization.15The understanding of clinical presentation and epidemiology of GBS in each population can help us better understand the pathogenesis of the disease, its risk factors, and prognosis.16 Moreover, the evaluation of GBS outcome may be effective for planning an appropriate therapeutic strategy and for determining disease-related morbidity and mortality. The results of different studies from various geographical regions have reported considerable variability regarding the epidemiology, clinical features, and outcomes of GBS.17,18 Therefore, our study aims to assess the presentation, clinical findings, demographics, seasonal variations, and outcomes among patients with GBS in a tertiary care institute in Muscat, Oman.     

Knowledge of and attitudes toward epilepsy surgery among neurologists in Saudi Arabia

Objectives:To investigate the levels of knowledge and attitudes toward epilepsy surgery among neurologists in Saudi Arabia and evaluate the factors that affect the physicians’ knowledge and attitudes.Methods:A quantitative observational cross-sectional study conducted at King Saud University Medical City, Riyadh. The data were collected using a newly developed, self-administered online questionnaire. The questionnaire contained 3 sections: demographic information, knowledge, and attitudes which then sent to neurologist in Saudi Arabia from December 2016 to March 2017.Results:A total of 106 neurologists met our inclusion criteria. Eighty percent of the participants had at least one epilepsy center in their city, and 78% indicated that they had access to adequate expertise and resources to enable the appropriate selection of epilepsy surgical candidates. Only 57.5% of the neurologists had a sufficient level of knowledge regarding epilepsy surgery. Neurologists with higher level of knowledge referred more patients to EMU and discussed epilepsy surgery more often with their patients. Overall, more than half of the neurologists (52.8%) had a positive attitude toward epilepsy surgery. There was a significantly positive correlation between the scores of knowledge and attitude (p<0.001).Conclusion:Neurologists in Saudi Arabia appear to have moderate knowledge of and positive attitudes toward epilepsy surgery. The place of the last neurology certificate, type of practicing hospital, and access to expertise and resources, affected their knowledge. Adequate knowledge was positively correlated with attitude.

Epilepsy is one of the most common neurological disorders in Saudi Arabia, with an estimated prevalence of 6.54 per 1000 individuals.1 It is estimated that 20-40% of newly diagnosed patients are expected to fail seizure control with medical treatment.2 Refractory epilepsy is commonly defined as the failure to achieve freedom from seizures despite two or more antiepileptic drugs (AEDs).3 Patients with drug-resistant epilepsy (DRE) have a lower quality of life and face more social difficulties than patients with controlled epilepsy.4-6 More than half of the economic burden of epilepsy is accounted for by patients with refractory epilepsy.7 Epilepsy surgery is the best evidence-based treatment option for these patients with drug resistant focal epilepsy.8,9 The current guidelines for patient referral to epilepsy surgery were published in 2003 by the American Academy of Neurology.9 The benefits of epilepsy surgery may not only reduce the frequency of seizures but might also lower mortality and improve the quality of life.10 Despite its proven efficacy and favorable outcome, the average referral delay of an epilepsy surgery candidate is more than 20 years.11 This delay is predominately attributed to non-adherence to referral guidelines, which results from a lack of awareness and familiarity with them.12 Another factor that contributes to the delay is patients’ misbeliefs regarding the surgery’s risks and benefits, which are highly influenced by physicians’ lack of knowledge.13 Epilepsy surgery was introduced to Saudi Arabia in 1998.14 Several epilepsy surgery centers have subsequently been established across the country. A survey in 2013 showed that 56% of health-care professionals in Saudi Arabia were not aware that surgery was a treatment option for patients with epilepsy.15 Our aims in this study were to investigate the levels of knowledge and attitudes toward epilepsy surgery among neurologists in Saudi Arabia and evaluate the factors that affect the physicians’ knowledge and attitudes.     

Stroke mimics: Clinical characteristics and outcome

Objectives:To study the prevalence and nature of stroke mimics (SM) among Saudi patients who came to the emergency department with a sudden neurological deficit and suspected stroke.Methods:The electronic health records from February 2016 to July 2018 of patients who were admitted to the Stroke Unit at King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, Kingdom of Saudi Arabia (KAMC-RD) with a suspected stroke were all reviewed. A comparison between SM and stroke was established. Our study identified the predictors of SM by using logistic regression analysis. This study was approved by the local institutional review board.Results:Out of 1, 063 patients, 131 (12.3%) had SM. The most common causes were a peripheral vestibular disorder (27.4%) followed by psychogenic causes (24.4%). Stroke mimics were more common among younger individuals and women. Arterial hypertension, diabetes, and smoking were less likely to be found in SMs. At discharge, individuals with SM were more likely to be independent, had milder deficits, and shorter hospital stays. Predictors of SM were young age, female gender, mild deficit at presentation, and good functional status before the stroke.Conclusion:The incidence of stroke mimics is common among suspected stroke patients. Practicing physicians should consider potential diagnostic errors, particularly in the hyperacute phase of the stroke.

Stroke is one of the most common leading causes of mortality worldwide.1 Annually, the diagnosis of stroke in about 25 million people. Moreover, 6.5 million people die from stroke each year.2 Stroke is a life-threatening condition and requires immediate assessment so that patients can receive time-critical interventions such as tissue plasminogen activator (tPA). Therefore, accurate diagnosis is crucial. Sudden onset of neurological symptoms, or signs localized to brain arterial territories, are cause for suspicion of stroke. In most of these cases, a clinical assessment supported by brain computed tomography (CT) and basic laboratory tests are typically enough to make an accurate diagnosis in an emergency department. However, the misdiagnosis of stroke is relatively common. Stroke mimics (SM) are defined as acute onset of focal neurological symptoms, which later diagnosed with a non-vascular origin.3 In some patients with SM may erroneously receive intravenous thrombolysis therapy.4,5Stroke mimics are common in patients with suspected stroke.3-7 Conditions that mimic stroke include metabolic disorders such as hypoglycemia, hyperglycemia, hypernatremia, hyponatremia, uremia, metabolic encephalopathy, and hyperthyroidism.4,6,7,8 Moreover, migraine, seizure, psychological disorders, demyelinating diseases, and brain tumors may also mimic stroke.4,6-8 The characteristics and statistics about SMs among suspected cases of stroke in Saudi Arabia have not been reported. Yahia et al. reported that 15.9% of patients with suspected stroke were SMs, psychiatric etiology was the commonest.9 In this study, we estimated the prevalence, types, and predictors of SM among Saudi patients.     

The potential role of nutritional components in improving brain function among patients with Alzheimer’s disease: a meta-analysis of RCT studies

Objectives:To find out the potential role of nutritional components in improving brain function among patients with Alzheimer’s disease (AD).Methods:The correlation between nutrition and cerebral function in cases of AD has been the focus of 19 prospective randomised controlled trials (RCTs) with a combined research sample of 2297 patients. These RCTs are subject to systematic review and meta-analysis in the current paper.Results:Findings showed that chain-free secondary saturated fatty acids (SFA) and trans fatty acids (TFA) occurred in higher concentrations in AD patients’ brains than in controls. Furthermore, neuroinflammation was caused by remodelling of the lipid membrane and AD patients’ cognitive function was impacted by alterations in tyrosine, tryptophan, purine, and tocopherol pathway metabolomics. Moreover, in cases of mild-to-moderate AD, reduction in functionality was induced by administration of alpha-tocopherol for more than 12 months. Consumption of Souvenaid helps in synaptic synthesis, which enhances functional connectivity. Furthermore, consumption of the B vitamins folate, cobalamin and pyridoxine at dosages of 0.8 mg, 0.5 mg and 20 mg per day, respectively, over a period of one year resulted in lower plasma tHcy levels and brain atrophy.Conclusion:Chain-free SFA and TFA occur in greater amounts in the brains of individuals with AD than in those without AD.

Life expectancy has recently increased enormously throughout the world, owing to development in medical sciences. As a result, the ageing population has expanded quickly, causing a phenomenal rise in the prevalence of late-life cognitive diseases like AD and vascular dementia (VaD).1-3 Besides impacting cognition in ageing individuals, causing the brain to become atrophied and disrupting learning, cognitive, reasoning and communication capabilities, such conditions are also a significant burden from a social and economic perspective.4 Dementia occurs in 5-8% of people older than 65, 15-20% of those older than 75 and 25-50% of those older than 85 years of age.5 Age, gender, head trauma and CVD risk factors (e. g. cardiac disease, diabetes, high blood pressure, depression, high cholesterol, sedentarism, smoking, alcohol drinking) are among the known sporadic AD risk factors that are not of genetic origin.6-8The creation of medication capable of deferring AD onset by disrupting and mitigating Aβ synthesis has been the aim of a number of clinical research trials and empirical work and has attracted ample annual investment from pharmaceutical companies. Even though such medication is yet to be formulated, drugs for symptom management do exist.9 Thus, the approach toward drug development for AD, as well as the therapeutic role of nutrition in preventing AD, need to be reconsidered.Evidence has been produced that AD risk and progression are diminished by diet-related components like antioxidants,10,11 vitamins,12-14 polyphenols,15,16 and omega-3 fatty acids.17,18 By contrast, saturated fatty acids19 and simple carbohydrates20 are considered to increase likelihood of AD development.21 The RCTs carried out in the period 2010-2018 were reviewed in this paper to investigate whether AD patients’ cognitive function can be enhanced based on nutritional constituents. To this end, a meta-analysis was conducted to establish the extent to which cerebral function in AD cases was influenced by nutrition-based treatments. Furthermore, subgroup meta-analyses were also carried out to determine conformance to nutrition plans, proportion of deaths due to general causes and AD, respectively, body weight (BW), lean body mass (LBW), life expectancy, quality of life (QoL), and development of additional neurodegenerative diseases.     

The comorbidity of headaches in pediatric epilepsy patients: How common and what types?

Objectives:To estimate the prevalence and characteristics of headache in pediatric epileptic patients.Methods:This cross-sectional study was performed over 6 months period from January 2018 to June 2018 at King Abdullah Specialist Children Hospital, King Abdulaziz Medical City, Riyadh, Kingdom of Saudi Arabia using a structured questionnaire in pediatric patients with epilepsy.Results:There were 142 patients enrolled (males, 57.7%; average age, 10.7±3.1 years) with idiopathic epilepsy (n=115, 81%) or symptomatic epilepsy (n=27, 19%). Additionally, patients had focal epilepsy (n=102, 72%) or generalized epilepsy (n=40, 28%), and among them, 11 had absence epilepsy. Overall, 65 (45.7%) patients had headaches compared with 3/153 (2%) in the control group (p < 0.0001). Among the 65 patients with headaches, 29 (44.6%) had migraine-type, 12 (18.4%) had tension-type, and 24 (36.9%) had unclassified headache. There was no significant difference in age, gender, type of epilepsy syndrome, and antiepileptic used except in patients with or without headache. For migraine patients, there was a lower headache prevalence in the subgroup treated with valproic acid compared with other treatments.Conclusion:Headache, predominantly migraine, is a common problem in pediatric epileptic patients and choosing valproic acid when possible can be important in preventing migraine in these patients.

Epilepsy and headache are chronic paroxysmal disorders that affect adult and pediatric patients1 with episodic manifestations. Headache or (cephalalgia) is defined as a feeling of pain in the region of the head or neck. Primary headaches include migraines, tension-type headache, and cluster headache. Epileptic seizure is a brief episode of signs or symptoms caused by abnormal excessive synchronized neuronal activity.2 Epilepsy is defined as a condition where the patient has an enduring tendency to have recurrent unprovoked seizures.2 These two disorders coexist in some patients.3 There are few studies on the comorbidity of headaches in children with epilepsy.4-6 Other studies reported a significant association between migraine and epilepsy.1,7-9 Additionally, the genetic predisposition for both entities was reported in some forms of channelopathy,10 and others found more prevalence of migraine headache in specific diseases in pediatric like benign epilepsy with centrotemporal spikes and juvenile myoclonic epilepsy.11 Seizure-associated headache is common, with an incidence of 42–51% in adult epileptic patients.12 However, for pediatric patients, it is often neglected by parents and physicians because of other neurological manifestations of the seizure such as loss of consciousness and motor components,13 and approximately 36% of the parents were reported to be unaware that their children experienced headache.14 It is our experience that headache is a common problem in up to 50% of epilepsy patients but we do not know exactly the prevalence, in addition to what type of headache is most commonly found in epileptic pediatric patients. Because of few reports on this topic have conflicting results, the objective of this study was to evaluate the prevalence and characteristics of headache in children with epilepsy who were seen at one center in Saudi Arabia.     

Acute hemiparesis: A rare presentation of spontaneous spinal epidural hematoma mimicking acute stroke

Acute hemiparesis is an extremely rare presentation of spontaneous spinal epidural hematoma, which may be misdiagnosed as acute ischemic stroke and improperly treated with an intravenous thrombolytic agent. Here, we report a case of a 54-year-old woman who presented with acute neck pain and right-sided weakness. She was initially suspected of having ischemic stroke and therefore treated with an intravenous thrombolytic agent. However, she developed progressive tetraparesis, and subsequent magnetic resonance images confirmed cervical spontaneous spinal epidural hematoma.

Stroke is a leading cause of mortality and morbidity in Taiwan.1 Acute hemiparesis is one of the most indicative manifestations of acute stroke. Administration of recombinant tissue plasminogen activator (rtPA), a thrombolytic agent, within 3 to 4.5 hours of symptom onset is the standard treatment for acute ischemic stroke.2 However, various diseases such as slipped cervical discs, epilepsy, and spinal epidural hematoma may present along with acute hemiparesis, mimicking acute stroke, and thus be inappropriately treated with rtPA.3 Spontaneous spinal epidural hematoma (SSEH) is a rare condition of unknown etiology and requires urgent surgical intervention.3-5 The characteristic manifestation of SSEH is sudden-onset neck pain following by motor paralysis or tetraparesis.4 However, SSEH presenting with acute hemiparesis has been rarely reported in the literature. Therefore, we reported a case of SSEH with acute hemiparesis wrongly treated with rtPA in the emergency department (ED).     

Proprioceptive neuromuscular facilitation to improve motor outcomes in older adults with chronic stroke

This case series described changes in motor outcomes across 4 cases of older adults (mean age – 64.75) with chronic stroke (>6 months) after implementation of a 6-week proprioceptive neuromuscular facilitation-based program. Findings of this study were compared with a previously reported case. At baseline, all cases presented with motor impairments that increased their fall risk such as impaired balance, lower extremity strength, and mobility. Outcomes were measured using the Mini-BESTest, posturography, 5 times sit-to-stand test, upright motor control test, and 10-meter walk test. All cases completed 1 hour of therapy 3 times a week for 6 consecutive weeks at a university-based outpatient rehabilitation clinic. Positive outcomes in balance, strength, and mobility were seen in all cases. Proprioceptive neuromuscular facilitation can modify motor outcomes to decrease fall risk in older people with chronic stroke. Chronicity of stroke, age, and co-morbidities may influence the degree of improvements expected in these motor outcomes.

Stroke is a prevalent condition associated with high global burden of disease. In 2010, an estimated 33 million people live with chronic stroke, an 84% increase in the past 2 decades.1 Individuals living with stroke have multiple long-term motor impairments with strength, balance and mobility that negatively impact participation and quality of life.2 These motor impairments increase risk for falls and may compound the multiple-system physiologic decline associated with aging.3 While several studies have reported that most gains from rehabilitation occur with the first 6 months after stroke, improvements have still been noted following well-targeted exercise therapy programs in more chronic presentations.4 Interventions grounded in modern theories of neuromuscular re-education and neuroplasticity are needed to improve rehabilitation efforts and optimize functional outcomes.5Proprioceptive neuromuscular facilitation is a form of neuromuscular re-education that has been used in improving the function of patients with stroke.6,7 Preliminary empirical evidence describes how a proprioceptive neuromuscular facilitation-based program coupled with the principles of neuroplasticity has the potential to generate positive outcomes in an older adult with chronic stroke.6 However, despite the increase in published literature on the effects of proprioceptive neuromuscular facilitation, there is still limited evidence that explores how a proprioceptive neuromuscular facilitation using modern principles of neuroplasticity can improve motor outcomes. There is also a need to explore the characteristics of patients that would likely benefit from this type of program.This study aimed to compare the changes in motor outcomes after a proprioceptive neuromuscular facilitation program across 4 new cases of older people with chronic stroke with different chronicity and disability severity. Further, this study aimed to relate the findings with those from a previously published case report that demonstrated the potential usefulness of the proprioceptive neuromuscular facilitation program.6 Each case described in this study showed chronic stroke with varying clinical presentations including differences in strength, balance, and mobility. The variations in each case may allow generation of hypotheses related to the potential benefits of a proprioceptive neuromuscular facilitation-based program, and which patients are likely to benefit from this intervention.     

Angiocentric glioma of brainstem

Angiocentric glioma is a rare brain tumor commonly found in frontal or temporal lobes. It has a benign course, and surgical resection can be curative. Brainstem location is extremely rare, with only six cases reported so far in the literature. In the present study, the seventh case of brainstem angiocentric glioma has been reported, and its course in comparison with supratentorial location and the role of molecular diagnosis has been discussed.

Angiocentric glioma is a rare brain tumor, which was initially reported in 2005.1 It is classified as a grade I distinct clinicopathological entity by WHO CNS-2016 classification.2 Less than 100 cases have been reported in literature, with common locations being in the cerebral cortex of frontal or temporal/ lobe or hippocampus.1 In these series, patients are typically presented with seizures at 14-17 years of age. Brainstem location is extremely rare, with only six cases ever reported in the literature studies.3–6 Here, we are reporting a rare case of brainstem angiocentric glioma with myxoid features with 7 years follow up.