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.     

Is non-traditional therapy for multiple sclerosis overwhelming in Saudi Arabia

Objectives:To describe the prevalence, knowledge and attitudes about complementary and alternative medicine (CAM) use and the proportion that seek advice from their physician about CAM use.Methods:This cross-sectional observational study was performed in multiple sclerosis (MS) clinic of King Fahd Hospital of Universityin Alkhobar, Kingdom of Saudi Arabia from January-June 2017. A total of 133 patients have completed the survey.Results:The mean age of patients was 32.3±7.6 years and 84 (63.2 %) were female. Approximately 83.5% of the patients reported the use of CAM. Among all the reported forms of CAM, vitamins were the most prevalent form, followed by cupping, special prayers and meditation. The majority of patients (62%) obtained knowledge of CAM through social media. A significant number of patients (75.6%) did not disclose the use of CAM to their physician. There was a trend for using CAM more in highly educated, older age, and female patients. The most commonly reported rationale to use CAM was overall improvement in health status.Conclusion:The use of CAM among Saudi patients with MS is highly prevalent, without disclosure of its use to physicians. These factors should be taken into account in the doctor-patient consultation to avoid adverse events.

Multiple sclerosis (MS) is a chronic neurological disorder, typified by a relapsing and progressive course of symptoms, resulting in long-term severe disability. Multiple sclerosis was thought to be uncommon in Kingdom of Saudi Arabia, but the prevalence of MS is increasing in the Gulf region, particularly in Kingdom of Saudi Arabia, and the latest prevalence estimates are 40/100,000 in 2008.1,2 These increasing numbers of MS patients represent a challenge to provide treatment, health promotion, employment, and rehabilitation for severely disabled patients.3 The etiology of MS is still unknown. Multiple sclerosis patients face many challenges in their daily routine life, like other patients suffering from chronic diseases. Treatment for MS is not curative, though many disease modifying drugs (DMDs) are available with United States of America’s Food and Drug Administration (FDA) approval; the available treatment options for MS often have several adverse side effects and a very high cost. Therefore, MS patients turn to CAM with the hope to cure their MS, minimizing the relapses and treating their symptoms, even though the efficacy may not be established. Complementary and alternative medicine is defined as “a group of diverse medical and health-care systems, practices and products that are not presently considered to be part of conventional modern medicine”.1There is a worldwide interest in CAM. Its use ranges from 9-70% of the total population, despite insufficient scientific evidence for its use.4 Complementary and alternative medicine is popular among patients as well as healthy individuals.4 There are variations in CAM practices between countries, which depend on their traditions and the prevalence of diseases. Also, the methods that are used in different studies differ.4,5Patients suffering from MS are significant users of CAM.6 The prevalence of CAM use among MS patients has been reported in several studies, with a wide range of prevalence between 33-70%.6 Knowledge about CAM practices and the prevalence in MS patients in Arab countries is limited. To document the influence of psychosocial, religious and cultural factors on health beliefs and behaviors in Kingdom of Saudi Arabia, having a religious background, studying CAM is of utmost importance.4,7 Health care facilities are free for the nationals in Kingdom of Saudi Arabia and provided by The Ministry of Health, but the ministry does not cover CAM. However, a center for CAM was established by a ministerial decree (No. 236) on 10/8/1429 H (12/8/2008 G). This center, being a reference center for CAM and related issues, has the objectives to monitor the CAM practices among different health care services and to regulate them using evidence-based support.8 In a 2015 publication, Kingdom of Saudi Arabia was ranked very high in scientific research related to CAM among all Arab countries.9 This highlights the importance of CAM-related research in Kingdom of Saudi Arabia to document how their different psychosocial, cultural and religious background can influence the use of CAM and to see the effects on their health beliefs and attitudes.10We aimed to determine the prevalence of CAM use among MS patients in Kingdom of Saudi Arabia, as well as to document their knowledge and behaviors concerning CAM, the used types and the reasons behind them and the frequency of the patients disclosing the use of CAM to their physician. We also wanted to determine any association of demographic characteristics, health behaviors and health status with CAM use and disclosure.     

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.     

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.     

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.     

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.     

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.     

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.     

Frequency,risk factors,and outcomes in patients with significant carotid artery disease admitted to King Abdulaziz Medical City,Riyadh with Ischemic Stroke

Objectives:To determine the frequency, risk factors, and outcomes of significant carotid artery disease (CAD) in patients with ischemic stroke.Methods:The frequency of significant CAD in patients admitted to the Stroke Unit between January 2014 and December 2015 was determined from radiological data. Outcomes were determined clinically and radiologically.Results:Among 435 patients, 273 were men (62.8%), with a mean age of 57.4±12.2 years. Significant CAD was found in 48 vessels in 40 (9.2%) patients, of which 30 patients were symptomatic. Nine of these patients were treated with carotid artery stenting, one underwent carotid endarterectomy, and 3 underwent an urgent thrombectomy, without stenting. Seventeen symptomatic patients were not treated for the following reasons: patient/family refusal (n=2), contraindications (n=5), and complete occlusion (n=10). One (7.7%) of the 13 treated patients had an ipsilateral stroke on follow up, one (7.7%) had contralateral transient ischemic attack (TIA), 9 (69.2%) had no recurrence, and no clinical data were available for 2 patients. Among the 17 untreated patients, one (5.9%) had an ipsilateral stroke, 7 (41.2%) had no recurrence, and 9 (52.9%) were lost to follow up.Conclusion:Significant carotid artery disease is uncommon in our cohort found in less than 10% of patients. Vascular risk factors are more or less similar between patients with or without CAD except obesity which appears to have inverse relation with CAD. A small number of patients received carotid intervention with no recurrence of stroke at limited follow up.

Strokes are the second leading cause of death worldwide.1 According to data from the Institute of Neurological and Communicative Disorders and Stroke, 22% of strokes can be attributed to carotid artery disease (CAD).2 Carotid artery disease is classified as extracranial or intracranial. There appear to be racial variations in the distribution of the 2 types of CAD, with a relatively higher incidence of intracranial disease in black and Hispanic individuals3 and a relatively higher incidence of extracranial atherosclerotic disease among Caucasians.4 Extracranial atherosclerosis has long been identified as a common source of emboli that can travel to the brain and cause a stroke.5 Intracranial atherosclerotic disease accounts for 30-50% of strokes in Asia.6 Carotid artery disease is classified into symptomatic and asymptomatic disease. Symptomatic patients with carotid stenosis experience a focal neurological deficit ipsilateral to stenosis.7 Asymptomatic carotid stenosis is not a life-threatening condition, with a mortality rate of 0.05% and a stroke recurrence rate of 1–2% or less annually.8 However, it is significantly associated with the development of life-threatening cardiovascular events, as it co-exists with coronary artery disease in 40% of cases.8 Symptomatic CAD can be managed by medications alone, or medications with carotid artery stenting or carotid endarterectomy, depending on the individual patient.7 In acute cases, carotid thrombectomy without carotid artery stenting can be performed as part of endovascular treatment of an acute stroke, although this has not been well studied in randomized trials. A study by Al Rajeh et al9 on 500 Saudi stroke patients found that ischemic strokes accounted for 76.2% of the stroke cases. Determining the degree of carotid stenosis and type of CAD (i.e., symptomatic or asymptomatic) is crucial for patients’ management and prognosis.7 Data on significant CAD among stroke patients in the Saudi population are lacking. The scarcity of data is cause for concern. In this study, we determined the frequency, risk factors, management and outcomes of significant CAD in ischemic stroke patients. We also determined the prevalence of symptomatic or asymptomatic disease.     

Demographic characteristics and types of stroke in Southwestern Saudi Arabia,and the potential demand of neuro endovascular specialists

Objectives:To identify demographic characteristics, and types of stroke in Southwestern (Aseer) Region, Saudi Arabia.Methods:This study is a retrospective and hospital-based. The data of all stroke patients (n=562) admitted to the tertiary care hospital in the province, Aseer Central Hospital (ACH) within the period from January 2016 until December 2017 are included.Results:The mean ± SD of stoke patients’ age was 62.6 ± 17.0 years. Male patients were more than female patients (62.6% and 37.4%, respectively). The majority (93.2%) were Saudi, while 91.5% had below university education and 6.4% were smokers. Interestingly, only 2% of patients had a family history of stroke, while 68.1% were diabetic, 80.4% were hypertensive, 91.6% had high serum cholesterol level, and 10.7% had history of transient ischemic attacks (TIA). Despite the lack of awareness, and leading to delay in reaching health care facility, 58.1% of stroke patients, were arriving to emergency department (ED) in less than 24 hours (potential endovascular therapeutic window).Conclusions:In Aseer Region, Saudi Arabia, stroke affects mainly those who are older, less educated, diabetic, hypertensive, with hypercholesterolemia and previous history of TIA. Associated factors for stroke differ significantly according to their nationality.

Across the globe, stroke is now one of the most common leading causes for morbidity and mortality in adult patients after myocardial infarctions. Together with neoplasm, and myocardial infarctions, the 3 are top causes for death in the developed countries. Even when survive, a major portion of affected patients may suffer lifelong consequences in the form of physical or mental disabilities, which may result in social and economic challenges at the personal level and the society level.1 Two types of brain stroke exist, hemorrhagic and ischemic. There has been more than a 100% rise in stroke incidence in limited-resources countries.2 Stroke is one of the top 3 leading causes of death in the United States of America (USA). Approximately, 140,000 fatalities per year are caused by stroke in the USA. In year 2000, stroke resulted in 15,409 deaths (7%) of all deaths in Canada.3 As per statistics of the World Health Organization,4 almost 15 million annual cases of stroke are recorded worldwide. One third of stroke patients dies and another third remains disabled for the rest of their lives. Indonesian Basic Health Research for instance, estimated that the prevalence of stroke in Indonesian population is somewhere around 12.1 per million whereas in China, the prevalence of stroke somewhere around 2.21%.In order to prevent and minimize the catastrophic sequelae of stroke, early detection is the main key as well as, determining the type of stroke, which is an essential element in clinical care of stroke patients. History and physical examination can provide a great help in distinguishing the type of stroke;5,6 however, evolving diagnostic images are the main keys in sorting stroke types.7 The incidence of stroke is known to increase as age increases, more specifically, after the age of 45 years, the incidence gets doubled every decade of life. More than 70% of the strokes are occurring in patients who are 65 years or older.8 Men (1 in 5) tend to have higher lifetime risk of stroke than women (1 in 6). Men tend to have more risk of stroke at younger age than women, where women have higher rates of stroke at older age as they tend to have longer life expectancy than men.9 Stroke is increasing rapidly in the area of the Middle East.10 Some studies done in this part of the world, to look for the stroke associated factors and found that age, hypertension, previous stroke or history of transient ischemic attack (TIA), diabetes mellitus, hypercholesterolemia, smoking, and atrial fibrillation are the major ones.1 Some national studies have found that patients with diabetes mellitus, hypertension, or high cholesterol are more vulnerable for stroke11 and the prevalence of 178 in every 100,000, was reported in the Eastern region of Saudi Arabia.12 Similar to other parts of the world, stroke burden is rapidly evolving and becoming a major cause of illness and deaths in Saudi Arabia. Akbar and Mushtaq13 found that stroke is more frequent in patients at their sixth decade of life with clear male predominance in Saudi Arabia. According to Almekhlafi’s hospital based study,14 stroke burden is increasing in Saudi Arabia. Out of 548 patients in the study, stroke and its consequences contributed to 32% of the mortality.In 2014, Robert and Zamzami1reported that only 8 centers of 350 hospitals all around Saudi Arabia, are providing stroke thrombolytic therapy, and 2 out of these 8 centers have stroke code teams. However, by 2019, 8 more centers developed stoke code teams, and more hospitals-initiated stroke thrombolysis therapy. The present study aimed to identify demographic characteristics, clinical findings, and types of stroke in Aseer Region, Saudi Arabia.     

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.     

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.     

Inflammatory bowel disease and restless leg syndrome

Objectives:Inflammatory bowel disease (IBD) has been associated with restless leg syndrome (RLS). This study aims to explore the prevalence, clinical predictors, and severity of RLS in IBD patients compared to controls.Methods:We conducted a case-control study between January and December of 2019 comparing IBD patients with controls. Assessment of RLS was performed using the previously validated diagnostic restless leg syndrome questionnaire (RLSQ). Logistic regression analyses were applied to investigate associations between patient demographics and clinical features and RLS diagnosis.Results:A total of 218 IBD patients and 211 healthy controls were incorporated after excluding 6 patients with positional discomfort and 4 patients with habitual foot tapping. The mean age was 30.2±11.7 and 64% were females. The prevalence of RLS was 16/218 (7.34%) and 17/211 (8.06%) among cases and controls, respectively. Based on the RLSQ severity score, 6/16 (37.5%), 4/16 (25%) and 1/16 (6.3%) of the IBD patients with RLS had mild, moderate and severe RLS; respectively. The odds of IBD were lower among patients with confirmed RLS (OR=0.90, 95% CI=0.44-1.84, p = 0.78). In the logistic regression analysis, only vitamin B12 deficiency (OR=10.20, 95% CI=1.40-74.10, p = 0.022) was associated with RLS diagnosis among IBD patients.Conclusion:No difference was found in the prevalence of RLS between IBD patients and non-IBD controls. Vitamin B12 deficiency was associated with RLS diagnosis among patients with IBD.

Inflammatory bowel disease (IBD) is a family of chronic inflammatory disorders that cause inflammation of the gastrointestinal tract. It comprises two main conditions: ulcerative colitis (UC) and Crohn’s disease (CD). Approximately 30% of IBD patients suffer from extra-intestinal manifestations (EIMs), which can involve the rheumatologic, musculo-cutaneous, and hepato-biliary systems.1,2 Anemia is a common manifestation of IBD that can be attributed to iron, folate (folic acid), or vitamin B12 deficiencies.3Patients with IBD may develop neurological symptoms as part of the disease itself or through secondary complications, such as anemia. Perhaps one of its most distressing neurological manifestations is restless leg syndrome (RLS), which is a movement disorder characterized by an uncomfortable sensation in the legs which engenders restlessness temporarily relieved by movement. This discomfort takes place most commonly during night and when resting, and often disturbs sleep.4 Iron deficiency anemia (IDA) has been strongly associated with RLS.5,6 The RLS can be primary, i.e., idiopathic, or secondary, and is believed to be caused by both genetic and environmental factors.7 The most common secondary causes of RLS include iron deficiency and kidney disease; other causes include cardiovascular disease, arterial hypertension, diabetes, liver cirrhosis, migraine, Parkinson’s disease, and pregnancy.7-9 In a previous study conducted in Saudi Arabia, the prevalence of RLS among IBD patients was estimated to be 21.5%, compared to 9.7% in controls.10 Another study reported a 10% prevalence rate of RLS in North America and Europe, which is much higher than the prevalence rate reported by studies from Asian countries (0.6-1.8%).9 In contrast to many findings in Asian countries, the prevalence of RLS has been reported to increase with age in Europe, North America, and Saudi Arabia,10,11 and women have a higher prevalence of RLS compared to men.11,12 Moreover, it has been suggested that patients with RLS have poorer health and quality of life.11 This study describes the prevalence, clinical predictors, and severity of RLS in IBD patients compared with healthy controls.     

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.     

The role of the family in early intervention of preterm infants with abnormal general movements

Objectives:To determine the effect of family-based intervention on motor function in preterm infants.Methods:This study was designed as a randomized controlled trial between August 2015 and September 2016. Forty-two preterm infants were randomized and split equally between the family-based intervention group, composed of a physiotherapeutic and a familial component (8 males, 8 females; mean age 91±3.09 days), and the traditional early intervention group (8 females, 8 males, mean age: 91.06±2.4 days). Both groups received a treatment program based on a neurodevelopmental approach during 3- to 12-months-old. The groups were evaluated at corrected ages of the third, sixth, ninth, twelfth, and 24th months using the Bayley Scale of Infant and Toddler Development, Third Edition (Bayley-III).Results:Within-group changes over time were statistically significant using multivariate tests of fine motor (Multivariate analysis of variance (MANOVA); F=1515.27, p<0.001) and gross motor (MANOVA; F=1950.59, p=0.001) development. However, there was no interaction between groups in fine (MANOVA; F=0.027, p=0.872) and gross motor development (MANOVA; F=0.022, p=0.883).Conclusion:The early intervention approaches might support fine and gross motor function development in preterm infants in the first year of life.

There is growing evidence that the first year of life is critical for brain development.1,2 The neuronal differentiation process, including the formation of dendrites and axons, as well as the production of neurotransmitters and synapses, is especially active during the prenatal period and continues to be active postnatally.2,3 Myelination starts in the second trimester of pregnancy and progresses rapidly in the first year of life.1,4 Recent studies suggest that interventions during infancy, when high plasticity is observed in the brain, might be more effective than interventions during childhood.5,6 Early diagnosis of infants at high-risk for major developmental disorders, such as cerebral palsy (CP) or minor motor and neurological dysfunction,7,8 is therefore important in providing appropriate interventions.9 Even if early interventions cannot change the physical outcome for infants with neurodevelopmental disorders, intervening with these high-risk infants helps to decrease secondary musculoskeletal system disorders and increase their functional abilities.10 However, it is still unclear which interventions are the most successful. The literature shows that early interventions effectively support cognitive development, but do not or only slightly affect motor development.5,11 With the increase in the survival of preterm infants, comprehensive follow-up programs have been developed to determine appropriate interventions to support them1. One of these, entitled Coping with and Caring for Infants with Special Needs (COPCA), was developed by Dierks et al.12 As a new family-based approach aimed to provide active involvement of the family in the intervention. This program’s approaches are based on both family education and neural group selection theory for infants. In a randomized controlled study, Hielkema et al13 demonstrated no difference in outcomes between Traditional Infant Physical Therapy (TIP) and the COPCA program for infants with an abnormal General Movements Assessment (GMA). A recent review by Hielkema et al14 demonstrated a medium level of evidence on early interventions and family education and called for high-quality studies on these subjects. Dirks and Hadders-Algra et al15 indicated that the importance of the role of the family in early intervention for infants with special needs has increased, and high-quality studies are now required to investigate the effect of family-based care.In addition to them, the quality of mother-infant interaction is one of the most important aspects of normal development.16 In comparison with mothers of full-term infants, mothers of preterm infants have a higher risk of postpartum depression after infants’ discharge.17 This might be caused the effect of premature birth and maternal separation (with prolonged stay in the Neonatal Intensive Care Unit) on hormones in both the mother and infant, which are crucial for managing the adaptive maternal behavior and emotional changes.18 In a randomized controlled trial, Hane et al16 investigated the impact of Family Nurture Intervention (FNI) to improve the developmental trajectories via increasing emotional connection between mothers and their premature infants. These authors proved that infants in FNI had increased cognitive and language scores on the Bayley-III at 18-months-old and decreased risk of attention problems, autism spectrum disorders, and postpartum depression of mother.16 In the other valuable study, Myer et al19 showed an improvement in the frontal cortical brain region (which is responsible for attention, behavior adaptation and cognitive development) in preterm infants that received FNI. Also, Welch et al20 demonstrated greater developmental changes and increased brain activity between brain regions in the FNI group. These studies promote the importance of the mother-infant relationship for normal neurodevelopmental processes. Based on these results, integrating the mothers in early intervention programs is essential for physiotherapy approaches.In the literature, many studies investigated the effect of the early intervention approaches by comparing the traditional infant physiotherapy on infants’ motor development.21-23 However, these studies could not prove any significant effects on motor development after early intervention. The possible explanation of the absence of the differences in motor development between the experimental and control group might be the heterogeneity of interventions, less specificity of the assessment tools to present the changes in development, and the impact of the normal growth process of infants.6,13 It is, therefore, difficult to compare interventions based on randomized controlled trials.13 There is a need for high-quality research that investigates the effects of physiotherapy interventions on gross and fine motor development of the high-risk infants to determine more useful, inexpensive, and accessible interventions for mothers, infants, and clinicians. The present study aimed to determine the effects of a family-based COPCA intervention program on fine and gross motor function in preterm infants.     

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.     

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.