Factors Affecting the Activation and Appearances of Epileptiform Abnormalities in Routine Electroencephalography by Different Provocation Methods.

OBJECTIVE: The objective of this study was to observe the effects of various clinical factors on the activation and appearance of epileptiform abnormalities (EAs) in routine electroencephalography (rEEG) by different provocation methods. METHODS: This observational study involved a review of 136 patients presented for EEG recording due to various indications and their EEG showing EAs during various provocation methods. RESULTS: Generalized spike-wave discharges (GSWDs) were the most frequent activated epileptiform pattern observed in, 81 (59.1%) recordings. This pattern was seen mainly in females 49 (P = 0.00), in patients with generalized seizures 48 (P = 0.00), in prolonged EEG records 3 (P = 0.03), and in both genetic 35 (P = 0.00) and lesional epilepsies 21 (P = 0.00). Focal sharp waves with bilateral synchrony (FSWSBS) were the most activated ictal pattern (P = 0.00). Ictal EAs after hyperventilation (HV) (P = 0.03) and intermittent photic stimulation (IPS) (P = 0.01) were mainly observed in patients with uncontrolled seizures (P = 0.00), and immune-mediated epilepsy (P = 0.02). Females sex (odds ratio [OR]: 1.33, confidence interval [CI]: 0.6-2.6; P = 0.25), bilateral tonic-clonic seizures (OR: 1.17, CI: 0.5-2.4; P = 0.31) and lesional epilepsies (OR: 1.45, CI: 0.7-2.9; P = 0.20) had risk of activation of EAs by provocation methods; however this risk was not statistically significant. While sleep deprivation (SD) (OR: 6.33, CI: 2.2-18.2; P = 0.00), nonrapid eye movement sleep (NREM) (OR: 2.41, CI: 1.0-5.4; P = 0.00), and prolong EEG recording (OR: 1.91, CI: 0.9-3.9; P = 0.04) were leading to a statistically significant risk of activation and appearances of EAs due to provocation. CONCLUSION: Different provocation methods can activate and augment the variety of EEG patterns of diverse clinical significance. Detection of activated ictal EAs is dependent on various patient factors, including seizure control, and the provocation method applied. Further larger prospective cohort studies with adequate sample sizes are warranted.

Résumé Objectif:L'objectif de cette étude était d'observer les effets de différents facteurs cliniques sur l'activation et l'apparition d'épileptiformes. anomalies (EA) dans l'électroencéphalographie (EEG) de routine par différentes méthodes de provocation.Méthodes:Cette étude observationnelle impliquait une examen de 136 patients présentés pour un enregistrement EEG en raison de diverses indications et de leurs EEG montrant des EA au cours de diverses méthodes de provocation.Résultats:Les décharges épileptiformes généralisées étaient le schéma épileptiforme activé le plus fréquemment observé dans 81 enregistrements (59,1 %). Cele schéma a été observé principalement chez les femmes 49 (P = 0,00), chez les patients présentant des crises généralisées 48 (P = 0,00), dans les enregistrements EEG prolongés 3 (P = 0,03), et dans les épilepsies génétiques 35 (P = 0,00) et lésionnelles 21 (P = 0,00). Les ondes aiguës focales avec synchronie bilatérale étaient les ondes critiques les plus activées motif (P = 0,00). Les AE ictales après hyperventilation (P = 0,03) et stimulation photique intermittente (P = 0,01) ont été principalement observées chez les patients avec crises incontrôlées (P = 0,00) et épilepsie à médiation immunitaire (P = 0,02). Sexe féminin (oddsratio [OR] : 1,33, intervalle de confiance [IC] :0,6­2,6; P = 0,25), crises tonico-cloniques bilatérales (OR : 1,17, IC : 0,5­2,4; P = 0,31) et épilepsies lésionnelles (OR : 1,45, IC : 0,7­2,9; P = 0,20) avait un risque d'activation des EA par des méthodes de provocation; cependant, ce risque n'était pas statistiquement significatif. Alors que la privation de sommeil (OR : 6,33, IC : 2,2­18,2; P = 0,00), sommeil à mouvements oculaires non rapides (OR : 2,41, IC : 1,0­5,4; P = 0,00) et prolonger l'enregistrement EEG (OR : 1,91, IC : 0,9­3,9; P = 0,04) entraînaient un risque statistiquement significatif d'activation et d'apparition d'AE par provocation.Conclusion:Différent les méthodes de provocation peuvent activer et augmenter la variété des schémas EEG de signification clinique diverse. La détection des EA ictaux activés est dépend de divers facteurs liés au patient, y compris le contrôle des crises et la méthode de provocation appliquée. D'autres études de cohorte prospectives plus importantes avec des tailles d'échantillons adéquates sont justifiées.

Characteristics of Stroke-related Seizures and their Predictive Factors: A Tertiary Care Center Experience.

BACKGROUND AND PURPOSE: Various risk factors have been described in the literature that increase the risk of seizures associated with stroke. This study was aimed to determine the occurrence rate of poststroke seizures (PSSs) and the associated risk factors in Arab population. MATERIALS AND METHODS: Study included all stroke patients aged >18 years with a minimum follow-up of 24 months following stroke to identify seizure occurrence. Patient's hospital records for all admissions and clinic visits were reviewed. Seizures were classified into early PSS if they occur within 1 week of stroke, and late PSS if they occur after 1 week of stroke. RESULTS: Out of 594 patients, 380 were males. Seizure occurrence was higher in anterior circulation infarctions (94.8%, P < 0.05), cortical location (80.5%, P < 0.05), large artery atherosclerosis (63.8%, P < 0.05), lower activated partial thromboplastin time (APTT) (P = 0.0007), patients with ischemic heart disease (IHD) (P = 0.01), and those who underwent craniotomy (P = 0.001). Nonhigh-density lipoprotein cholesterol was inversely related to PSS (P = 0.01). Higher stroke severity (89%) and confusion (67%) at the time of presentation were independently related to PSS. CONCLUSIONS: Eighty-two (13.8%) patients had PSS. Greater stroke severity at presentation with altered sensorium was independent risk factors for the development of PSS. Patients with underlying IHD, lower APTT, and undergoing neurosurgical intervention require vigilant monitoring for PSS.

Résumé Ontexte et objectif:Divers facteurs de risque ont été décrits dans la littérature qui augmentent le risque de convulsions associées à un AVC. Cette étude visait à déterminer le taux d'occurrence des crises post-AVC (PSS) et les facteurs de risque associés dans la population arabe.Matériels et Méthodes:L'étude a inclus tous les patients victimes d'AVC âgés de plus de 18 ans avec un suivi minimum de 24 mois après l'AVC pour identifier la survenue d'une crise. Les dossiers hospitaliers des patients pour toutes les admissions et visites à la clinique ont été examinés. Les saisies ont été classées en premiers PSS s'ils surviennent dans la semaine suivant l'AVC, et PSS tardif s'ils surviennent après 1 semaine de l'AVC.Résultats:Sur 594 patients, 380 étaient des hommes. Crise d'épilepsie la fréquence était plus élevée dans les infarctus de la circulation antérieure (94,8 %, P < 0,05), la localisation corticale (80,5 %, P < 0,05), l'athérosclérose des grandes artères (63,8 %, P < 0,05), un temps de thromboplastine partielle activé (APTT) inférieur (P = 0,0007), les patients atteints de cardiopathie ischémique (IHD) (P = 0,01) et ceux ayant subi une craniotomie (P = 0,001). Le cholestérol des lipoprotéines non de haute densité était inversement lié au PSS (P = 0,01). Course supérieure la gravité (89 %) et la confusion (67 %) au moment de la présentation étaient indépendamment liées au PSS.Conclusions:Quatre-vingt-deux (13,8 %) patients avait PSS. Une plus grande gravité de l'AVC lors de la présentation avec un sensorium altéré était un facteur de risque indépendant pour le développement du PSS. Les patients avec une IHD sous-jacente, un APTT inférieur et une intervention neurochirurgicale nécessitent une surveillance vigilante du PSS.

Characteristics and outcomes of large artery occlusion-related stroke due to intracranial atherostenosis: An experience from a single center in Saudi Arabia.

BACKGROUND: Literature on the frequency, response to treatment, and outcomes of acute ischemic stroke (AIS) due to intracranial atherostenosis (ICAS)-related intracranial large artery occlusion (ILAO) from Saudi Arabia is scarce. The aim of this study was to identify the percentage, describe the characteristics, and observe the treatment response in patients with AIS attributed to ICAS-related ILAO. MATERIALS AND METHODS: This cross-sectional study included all adult patients from 2017-2021 who fulfilled the inclusion criteria for the diagnosis of ICAS-related AIS. Patients were dichotomized based on ILAO. Mortality and functional outcomes (FOCs) based on 90 days' dependence level were compared between the two groups. The association between ILAO and other variables was assessed using the Chi-squared test, odds ratios (OR), and 95% confidence interval (CI). RESULTS: ILAO was found in 38.7% of patients with ICAS-related AIS. Men comprised three-fourths of the cohort and were more frequent in the ILAO group. Smoking was associated with increased (P = 0.04) likelihood of ILAO. Patients with ILAO had more severe strokes (P ≤ 0.001) than patients without. Middle cerebral artery was the most common occluded vessel (52%). Functional dependence (P = 0.003, OR = 2.87, CI = 1.42-5.77), malignant transformation (P = 0.001, OR = 8.0, CI = 1.82-35.9), and mortality (P ≤ 0.001, OR = 7.67, CI = 2.40-24.5) were significantly higher among ILAO group. Patients with ILAO with unfavorable FOC were older than those who achieved better FOC (P ≤ 0.001). Thrombolysis (P = 0.02, OR = 2.50, CI = 1.15-5.41) and mechanical thrombectomy (MT) improved FOC in patients with ILAO (P = 0.04, OR = 2.33, CI = 1.10-4.92). CONCLUSION: ILAO is common in patients with ICAS-related AIS. Timely hyperacute stroke treatment can help improve the FOC of otherwise disabling stroke due to ILAO. Raising awareness of the community about stroke is needed, so that a higher number of patients can arrive at hospital within the golden hours. Further data from the region are required to recognize the efficacy of MT in ICAS-related ILAO.

Outcomes and predictors of seizure recurrence in post-stroke epilepsy, a retrospective hospital-based study.

BACKGROUND: The occurrence of seizures following a stroke is a well-recognized complication associated with a significant increase in morbidity and mortality. Despite the numerous studies examining outcomes and risk factors related to post-stroke seizures (PSS), there remains a lack of clarity regarding the clinical characteristics, treatment, and PSS recurrence (PSSR) rates in patients experiencing their initial episode of PSS. PURPOSE: This study aimed to determine the risk factors for developing recurrent seizures after first PSS and their effects on functional outcomes and mortality. METHODS: All patients underwent an electroencephalography (EEG) and were monitored for a minimum of 24 months following the first PSS. The primary endpoint was the recurrence of seizures. Predictive factors for PSSR were determined by using the Cox-proportional hazards model, and the cumulative latency of recurrence at 90, 180, 360, and 720 days was estimated using Kaplan-Meier analysis. RESULTS: Seizure recurred in 36.8% (39/106). Significant association of PSSR was noted with female gender, use of older anti-seizure medications (ASMs) (p<0.001), EEG findings as focal slow wave activity (p<0.001), Ictal epileptiform abnormalities (p=0.015), status epilepticus (p=0.015), and with severe disability (p=0.008). However, multivariate cox-proportional hazards model showed significant association of female gender (HR=3.28; 95% CI: 1.42-7.58; p=0.006). Hazard ratio (HR) was increased with older ASMs use, focal aware seizure types, Ictal EAs, and periodic discharges on EEG; though, statistically significant. CONCLUSION: Factors such as the type of ASMs, EEG findings, and seizure type were significantly linked to PSSR. Female gender was the only independent predictor established. Additionally, significant functional decline was reported with recurrence.

Clinical Implications of Various Electroencephalographic Patterns in Post-Stroke Seizures. The Utility of Routine Electroencephalogram.

Objective: Post-stroke seizures (PSS) are one of the major stroke-related complications. Early therapeutic interventions are critical therefore using electroencephalography (EEG) as a predictive tool for future recurrence may be helpful. We aimed to assess frequencies of different EEG patterns in patients with PSS and their association with seizure recurrence and functional outcomes. Methods: All patients admitted with PSS were included and underwent interictal EEG recording during their admission and monitored for seizure recurrence for 24 months. Results: PSS was reported in 106 patients. Generalized slow wave activity (GSWA) was the most frequent EEG pattern observed (n = 62, 58.5%), followed by Focal sharp wave discharges (FSWDs) (n = 57, 55.8%), focal slow wave activity (FSWA) (n = 56, 52.8%), periodic discharges (PDs) (n = 13, 12.3%), and ictal epileptiform abnormalities (n = 6, 5.7%). FSWA and ictal EAs were positively associated with seizure recurrence (p < .001 and p = .015 respectively) and it remained significant even after adjusting for age, sex, stroke severity, stroke subtype, or use of anti-seizure medications (ASMs). Other positive associations were status epilepticus (SE) (p = .015), and use of older ASM (p < .001). FSWA and GSWA in EEG were positively associated with severe functional disability (p = .055, p = .015 respectively). Other associations were; Diabetes Mellitus (p = .034), Chronic Kidney Disease (p = .002), use of older ASMs (p = .037), presence of late PSS (p = .021), and those with Ischemic stroke (p = .010). Conclusions: Recognition and documentation of PSS-related EEG characteristics are important, as certain EEG patterns may help to identify the patients who are at risk of developing recurrence or worse functional outcomes.

Prospective Matched Case-Control Study of Over-Early P100 Wave Latency in Migraine with Aura.

A sizable portion of the world's population suffers from migraines with aura. The purpose of this research is to describe the findings of a case-control study that was carried out to gain a better understanding of how migraine with aura manifests. The research looked at the P100 delay of the visual-evoked potential in both eyes of 92 healthy people and 44 patients who suffered from migraines with visual aura. All of the participants in the study were recruited from King Fahad University Hospital in Saudi Arabia. Both sets of people had the same ancestry and originated from the same location. Patients who suffered from migraines with aura exhibited a significantly shorter P100 delay in both eyes compared to healthy controls (p = 0.001), which is evidence that their early visual processing was distinct. In order to arrive at these findings, we compared people who suffer from migraines with aura to people who do not suffer from migraines and used them as subjects. These findings contribute to the ongoing attempts to bring the disease under control and provide vitally significant new information regarding the functioning of headaches with auras. The primary focus of study in the future should be on determining the nature of the connection between issues with early visual processing and headaches with aura.

Association between glycated hemoglobin and functional outcomes in patients with intracranial large artery atherosclerotic disease-related acute ischemic stroke: identifying the magic number.

Objective: This study aimed to investigate the effect of the glycated hemoglobin A1c (HbA1c) level on the functional outcome (FOC) in patients with intracranial large artery atherosclerotic disease (ICLAD)-related acute ischemic stroke (AIS). Methods: This retrospective study enrolled patients with ICLAD-related AIS who were admitted to King Fahd University Hospital between January 2017 and September 2021. Patients were divided into two groups based on the optimal cutoff HbA1c level determined using receiver operating characteristic curve analysis-those with HbA1c ≤6.9% and those with HbA1c >6.9%. Demographic and other clinical characteristics were compared between the two groups using chi-square tests. The association between HbA1c and 90-day FOC was assessed using the chi-square test and odds ratios (ORs). Multivariate analysis was performed to adjust for confounding factors. Results: A total of 140 patients were included in the analysis. A significant association was observed between the HbA1c level and FOC. Compared to patients with HbA1c ≤6.9%, patients with HbA1c >6.9% were more likely to have an unfavorable FOC [p = <0.001, OR = 2.05, 95% confidence interval (CI) = 1.33-3.14]. The association between HbA1c >6.9% and unfavorable FOC was sustained even after adjusting for confounding factors (p = 0.008) and atherosclerosis risk factors (p = 0.01). HbA1c >6.9% was also associated with higher ORs for in-hospital complications (p = 0.06, OR = 1.34, 95% CI = 1.02-1.77) and mortality (p = 0.07, OR = 1.42, 95% CI = 1.06-1.92) although these associations did not attain significant p-values. Conclusion: HbA1c >6.9% was significantly associated with unfavorable FOC in ICLAD-related AIS. However, further studies with larger sample sizes are required to verify whether HbA1c is an independent predictor of poor FOC. Nevertheless, targeting HbA1c <7% should be the goal of physicians when managing patients at high risk of ICLAD.

Colloidal/Calcified Neurocysticercosis at University Hospital of KSA: A Case Series.

Background: Neurocysticercosis (NCC) is considered the most common central nervous system (CNS) helminthic infection. The prevalence of NCC cases in the Middle East has increased in recent years. Thirty-nine cases of NCC were reported between 2003-2011 in the Arabian Peninsula, among, five cases being from the kingdom Saudi Arabia (KSA). Most of the cases reported from the KSA were presented with seizures, and they belonged to expatriate workers or their related contacts. In this case series, we presented three cases of colloidal/calcified NCC. Cases: Our patients were diagnosed with NCC based on epidemiologic exposure, clinical features, and typical radiological findings. Stool samples for ova and parasites were negative in all three cases. Among these cases, two patients were immigrants and belonged to endemic areas, and third case who is the youngest in this series was a Saudi, without any history of exposure to any source. Results: The first and the third cases were treated with Albendazole and Dexamethasone. We did not offer any medication regarding NCC in the second case as he had asymptomatic NCC and the disease was inactive so did not mandate anti-helminth medication. Conclusion: NCC in KSA, like in non-endemic countries, is not a rare or unusual infection anymore, presenting with seizures or incidental findings in an asymptomatic state. Vigilant diagnostic protocols with efficient diagnostic tools are required for detecting carriers of the adult form of the parasite. Timely detection of these carriers can avoid further spread and its related complications in the Saudi population.

Obesity and metabolic syndrome in patients with epilepsy, their relation with epilepsy control.

Obesity and metabolic syndrome (MetS) are commonly observed in patients with epilepsy (PWE). Obesity and MetS are not only affecting the physical fitness and quality of life of these patients, rather antiepileptic drugs (AEDs) compliance and seizure control have also been affected. The objective of this review is to search the published literature regarding the prevalence of obesity and MetS in PWE and their relation to the response to AEDs. A comprehensive search using PubMed, Cochrane Databases, and Google Scholar was performed. A supplementary citation search was also conducted by analyzing the reference lists of identified sources. The initial search revealed 364 articles of potential relevance. The studies were analyzed in detail to obtain clinical information relevant to the objectives of the review. Many observational, case control studies, randomized control trials and few review articles were included for critical appraisal and review writing. Epilepsy is associated with MetS and obesity in all age groups. AEDs and lack of exercise are the chief causes while metabolic disturbances such as adiponectin, mitochondrial dysfunction, valproic acid (VPA)-associated insulin resistance, leptin deficiency, and endocrine dysfunction are also addressable factors. Although the risk of drug-resistant epilepsy (DRE) is also higher among obese PWE, the interaction between, MetS, and its components with DRE remain to be fully investigated. Further research is required to elucidate their interplay. Appropriate and careful selection of AEDs without compromising therapeutic efficacy supplemented by lifestyle counseling for exercise and diet should be practiced to avoid weight gain and potential DRE.

Résumé L'obésité et le syndrome métabolique (MetS) sont couramment observés chez les patients épileptiques (PWE). L'obésité et le MetS n'affectent pas seulement la condition physique et la qualité de vie de ces patients, mais plutôt l'observance des médicaments antiépileptiques (DEA) et le contrôle des crises ont également été affectés. L'objectif de cette revue est de rechercher la littérature publiée concernant la prévalence de l'obésité et du MetS chez les PWE et leur relation avec la réponse aux DEA. Une recherche exhaustive à l'aide des bases de données PubMed, Cochrane et Google Scholar a été effectuée. Une recherche de citation supplémentaire a également été effectuée en analysant les listes de référence des sources identifiées. La recherche initiale a révélé 364 articles potentiellement pertinents. Les études ont été analysées en détail afin d'obtenir des informations cliniques pertinentes aux objectifs de la revue. De nombreuses études observationnelles, des essais contrôlés randomisés et des articles de synthèse ont été inclus pour l'évaluation critique et la rédaction de la synthèse. L'épilepsie est associée au MetS et à l'obésité dans tous les groupes d'âge. Les antiépileptiques et le manque d'exercice sont les principales causes, tandis que les troubles métaboliques tels que l'adiponectine, le dysfonctionnement mitochondrial, la résistance à l'insuline associée à l'acide valproïque (VPA), la carence en leptine et le dysfonctionnement endocrinien sont également des facteurs adressables. Bien que le risque d'épilepsie résistante aux médicaments (ERD) soit également plus élevé chez les PWE obèses, l'interaction entre le MetS et ses composants avec l'ERD reste à étudier en profondeur. Des recherches supplémentaires sont nécessaires pour élucider leur interaction. Une sélection appropriée et minutieuse des antiépileptiques sans compromettre l'efficacité thérapeutique, complétée par des conseils sur le mode de vie pour l'exercice et le régime alimentaire, doit être pratiquée afin d'éviter la prise de poids et un toucher rectal potentiel. Mots clés: syndrome métabolique ; épilepsie; médicaments antiépileptiques; épilepsie résistante aux médicaments.

Important Factors to Expect the Outcome After Intracerebral Hemorrhage: An Observational Study From a University Hospital in Saudi Arabia.

BACKGROUND: Intracerebral hemorrhage (ICH) has worse clinical outcomes than other stroke types. The risk factors contributing to ICH outcomes are not entirely understood, and published literature from Saudi Arabia on ICH outcomes is limited. Our goal was to study the specific clinical and imaging determinants of ICH outcomes. METHODS: We retrospectively retrieved all patients with spontaneous ICH (SICH) from a prospective King Fahd Hospital University registry between 2017 and 2019. The clinical characteristics of ICH events and data on clinical outcomes (6 to 12 mo) were recorded. Groups of patients with a favorable modified Rankin Scale of 0 to 2 and nonfavorable outcomes of a modified Rankin Scale of 3 to 6 were investigated. The relationship between the clinical characteristics of the SICH event and its outcomes was assessed using linear and logistic regression analyses. RESULTS: A total of 148 patients with a mean age of 60.3 years (±15.2) and a median follow-up of 9 months were included. Unfavorable outcomes were reported in 98 patients (66.2%). The ICH event variables associated with unfavorable outcomes were impaired renal function, Glasgow Coma Score <8, hematoma volume, hematoma expansion, and intraventricular extension (IVE). CONCLUSIONS: Our study demonstrated important clinical and radiologic features in patients with ICH that may affect their clinical long-term functional outcomes. A larger multicenter study is required to validate our results and evaluate the methods to improve health care in patients with SICH.

Prevalence and Clinico-Radiologic Spectrum of Intracranial Atherosclerotic Disease-Related Stroke: An Observation from a Single Center in Saudi Arabia.

BACKGROUND: Intracranial atherosclerotic disease (ICAD) is an important etiologic subtype of acute ischemic stroke (AIS). However, little direct evidence is available regarding ICAD-related stroke in Saudi Arabia (SA). This study aimed to identify the prevalence and describe the clinico-radiological spectrum of ICAD-related AIS in a SA cohort. METHODS: This was a hospital-based retrospective study enrolling patients with ICAD-related AIS between 2017 and 2020. The electronic charts were reviewed. The mechanisms of stroke were identified as artery-to-artery embolization (AAE), in situ thrombotic occlusion, hypoperfusion, or perforator branch occlusion. Pearson's χ 2 test was performed to calculate the P values to establish the statistical significance of factors that could correlate with the mechanisms of stroke and functional outcome. RESULTS: ICAD was found in 133 of AIS comprising 26% of total. Data from all patients were reviewed. Left ICA (25%) was the most frequently affected vessel. Territorial pattern (63.9%) was the most common infarct pattern, and AAE (44.3%) was the most common underlying mechanism. Perforator branch occlusion was more prevalent in women than in men. Malignant and hemorrhagic transformation ( P =0.00) were more prevalent in the AAE group. Left-sided vascular involvement was statistically associated with unfavorable outcomes than the right ( P =0.019). CONCLUSIONS: The prevalence of ICAD in our cohort from Western Asia did not differ from that in Southern Asia. ICA involvement was observed more frequently than previously reported. Further research from SA is required to better understand ICAD-related strokes in this region.

Therapeutic Dilemma of Wake-up Stroke: Clinical and Brain Imaging Characteristics and Reperfusion as a Treatment Option.

Objective: Wake-up stroke (WUS) comprises a significant proportion of ischemic strokes. However, due to unclear onset, these patients are often not considered for reperfusion therapy. The objective of this study was to investigate the clinical and imaging differences between WUS patients and those with clear-onset stroke, documenting any sex, age, or risk factor predilection for WUS.Methods: This prospective observational cohort study used an ongoing stroke registry to identify patients with acute ischemic stroke admitted to a hospital in Saudi Arabia within 5 days of symptom onset from April 2018 to March 2020. Patients were classified into 2 groups: WUS and clear-onset stroke.Results: Among 645 patients, 448 met the criteria for acute ischemic stroke and were included in the study. WUS was identified in 112 (25%) patients. There were no differences in sex or median age between the 2 groups. Diabetes mellitus, hypertension, and dyslipidemia were higher in the WUS group, while atrial fibrillation, history of stroke and epilepsy were higher in the clear-onset stroke group. Bihemispheric stroke was higher in the clear-onset stroke group than in the WUS group (6.0% vs 2.7%).Conclusions: Only minor dissimilarities between clinical and radiologic features of WUS and clear-onset stroke were found. Circadian patterns of stroke onset were observed in both groups. Stroke was more likely to occur during waking than during sleep, and a diurnal pattern of common occurrence during the morning was documented. Recognition of the acceptable timeframe for acute reperfusion therapy in unwitnessed strokes is crucial so that thrombolytic treatment can be started for these patients.

Non-HDL Cholesterol, Obesity, and Metabolic Syndrome in Epileptic Patients.

Objective: To compare cardiovascular risk factors in patients with epilepsy with those of non-epileptic neurologic patients to determine their association with antiepileptic drug therapy.Methods: This observational study with a cross-sectional design was performed in a tertiary care hospital in the Eastern Province of Saudi Arabia from January to December 2018. A total of 110 patients with epilepsy were included in the study, along with 46 age- and sex-matched non-epileptic controls (approximate ratio of 2:1). Blood pressure reading (BP), anthropometric measurements, fasting blood sugar levels, and fasting lipid profiles were performed for all subjects.Results: Raised non-high-density lipid cholesterol (nHDLC) was the most common cardiovascular risk in epileptic patients, with a frequency of 51% compared to 30.4% in controls (P = .019). Epileptic patients who were male (58.3%, 28/48, P = .012) and those aged < 35 years (47.3%, 26/55, P = .036) were more likely to have high nHDLC. Obesity was also common in epileptic patients with frequency of 49.1% (n = 54) versus 30.4% (n = 14) in controls (P = .032). Metabolic syndrome was present in 26.3% of epileptic patients versus 23.9% of controls (P = .749). Among the epileptic patients, of those with high nHDLC, 85.7% had satisfactory seizure control (P = .019).Conclusions: Raised nHDLC and obesity but not metabolic syndrome appear to be highly prevalent in epileptic patients compared to those without epilepsy. Antiepileptic drugs alone may not play a role in developing high lipid levels. More studies are needed to determine the causes of higher risk factor profile in epileptic patients and their relationship with seizure control.

Driving Habits Among Patients With Epilepsy in a Tertiary Care Hospital in Saudi Arabia.

Objective: Patients with epilepsy are instructed to avoid high-risk situations such as certain occupations and driving to prevent harm to themselves and others. There is considerable variation in standards to decide if a patient with epilepsy is fit to drive among various countries worldwide, and these patients often continue to drive despite being advised not to. The objective of this study was to determine if patients with epilepsy and uncontrolled epilepsy are driving, the awareness of epilepsy patients regarding driving, and whether physicians are advising the patients to stop driving.Methods: A clinic-based study was conducted in Saudi Arabia from June 2018 through January 2019 with structured interviews of consecutively recruited male patients with established epilepsy diagnosis. Demographic factors, employment status, control of seizures, and awareness of driving restrictions were documented.Results: The response rate was 80.6%. Of the 121 participants (mean age of 35.97 years), 110 (90.9%) were driving, and 39% of those patients were married. Also, 76.9% of participants were employed. Of the participants, 48.8% had 1 seizure in the last 6 months, and 88% of those patients were driving; 51.2% had not had a seizure in the last 6 months, and 93% of those patients were driving. Additionally, 17.4% reported a seizure attack while driving. Only 38% of respondents were aware they should stop driving, whereas 62% were unaware of driving restrictions.Conclusions: There is a definite need to establish a driving policy for patients with epilepsy and to optimize the standards of care of epilepsy patients in Saudi Arabia to ensure minimization of harm to both patients and the public.

Preventable Etiologies of Epilepsies in Saudi Arabia: A Tertiary Care Experience.

Objective: To determine the etiologies of epilepsy in a cohort of patients using the International League Against Epilepsy 2017 classification system and to determine frequencies of preventable causes and their clinical characteristics.Methods: Epileptic patients in neurology clinics at a tertiary care hospital were prospectively recruited from June 1, 2018, to November 30, 2018. Patients were divided according to their respective etiologic categories. Traumatic brain injury, stroke, hypoxic-ischemic encephalopathy, and central nervous system infections were considered preventable etiologies.Results: A total of 160 patients were included in the study. Of these patients, 61 had epilepsy of unknown etiology, while among the remaining 99 patients in whom etiology could be identified, traumatic brain injury was the most frequent overall cause with 17 (17.2%) cases. Frequencies in other etiologies were genetic (idiopathic generalized epilepsy): n = 14, stroke: n = 13, hypoxic-ischemic encephalopathy: n = 13, cerebral tumors: n = 10, mesial temporal sclerosis: n = 9, cortical malformation: n = 7, and other structural pathologies: n = 5. Other rarer causes (including central nervous system infections) had less than 5 patients each. When the preventable etiologies were grouped, they formed 46 of 99 patients (46.5%) with identifiable etiology. Seizure control was mostly satisfactory in the total sample (126/160 [78.8%]), including patients with preventable etiologies, of whom 50% were on polytherapy.Conclusions: Epilepsies with preventable etiologies are common in our clinics. Studies are needed in other centers to identify epilepsy etiologies and confirm our findings, which may help determine better strategies for primary prevention of epilepsy.

When Brain Biopsy Solves the Dilemma of Diagnosing Atypical Cerebral Amyoild Angiopathy: A Case Report.

BACKGROUND Cerebral amyloid angiopathy-related inflammation (CAA-ri) is an acknowledged syndrome of reversible encephalopathy, also known as cerebral ß-related angiitis. It is characterized by brisk progressive higher mental dysfunctions, headaches, seizures/epilepsy, and behavioral changes, and is highly responsive to immunosuppressive medications. To quickly and properly determine patients' management plans and prognoses, doctors are left with only CAA-ri-associated behavioral changes and seizures, in addition to a high index of suspicion of the correct diagnosis. CASE REPORT A 67-year-old woman was presented to the emergency room (ER) with behavioral changes and seizures. Upon screening, the patient was found to have radiological evidence of asymmetrical cortical-subcortical white-matter lesions accompanied by multiple cerebral microbleeds in the background of the negative screening for infectious/neoplastic and paraneoplastic processes. After undergoing a brain biopsy, the diagnosis was confirmed to be amyloid deposition within the inflammatory vessel walls. The patient showed a dramatic improvement after methylprednisolone pulse therapy, plasma exchange, and rituximab maintenance. CONCLUSIONS We encourage and support brain biopsies to confirm highly suspicious CAA-ri atypical cases to initiate early treatment and achieve the best outcome without any further delays.

An Observational Study Comparing the Safety and Efficacy of Conventional Anticoagulation Versus New Oral Anticoagulants in the Management of Cerebral Venous Sinus Thrombosis.

Objective: To compare the safety and efficacy of conventional anticoagulants with new oral anticoagulants (NOACs) for management of cerebral venous sinus thrombosis (CVST).Methods: This was a retrospective, prospective cohort study of patients who presented with CVST to a tertiary stroke center in the Middle East from January 2012 to October 2019. Patients with a diagnosis of CVST were identified, and data were analyzed for demographic characteristics. Specific consideration was given to compare the efficacy and safety of different anticoagulation treatments.Results: A total of 36 patients were included in the final analysis, with 15 (41%) men and 21 (59%) women and a male to female ratio of 1:1.4. Most of the patients (n = 22, 61%) were Saudi. Their ages ranged between 15 and 82 years (mean ± SD age of 34.22 ± 13.16 years). Headache was the most common feature, present in 22 (61%) of the patients, followed by unilateral weakness in 15 (41%) and cranial nerve palsies in 11 (30%). The most common etiology was prothrombotic state (both hereditary and acquired thrombophilia: n = 16, 45%). Other etiologies were postpartum state/oral contraceptive pill usage in 7 (19%), infections in 7 (19%), and trauma in 3 (8%). Most of the patients (n = 24, 67%) still received conventional anticoagulation (warfarin/low molecular weight heparin), but 9 (25%) of the patients consented to start NOACs. Efficacy (as measured by clinical improvement plus rate of recanalization of previously thrombosed venous sinuses) showed no statistically significant difference, although it proved to be better tolerated, as none of the patients stopped the treatment due to adverse events and risk of major bleeding was significantly low in the NOAC group. Nine patients in the warfarin group stopped medication, while none in the NOAC group did so (P = .034).Conclusion: NOACs were found to be at least as good as conventional anticoagulation for the management of CVST. However, efficacy was almost similar, a finding that is consistent with most of the published case series and the few recently published prospective studies. Larger prospective and population-based studies are needed to clarify our preliminary results.

Migraine Prevalence, Characteristics, Triggers, and Coping Strategies Among Medical Students in Saudi Arabia.

Objective: To determine the prevalence, characteristics, and triggers of migraine and coping strategies used among medical students in Saudi Arabia.Methods: This cross-sectional descriptive study was conducted among undergraduate students in the College of Medicine of Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia. Included students were in their second to sixth academic year of the Bachelor of Medicine or Bachelor of Surgery programs during the 2019-2020 academic year. The diagnosis of migraine was made according to the International Classification of Headache Disorders, Third Edition criteria.Results: A total of 396 students participated in the study; 238 (60.1%) were female and 158 (39.9%) were male. Their age ranged between 18 and 26 years old, with a mean age of 21.32 ± 1.659 years. Only 16 of 396 students fulfilled the criteria for migraine, with a prevalence of 4.04%. Migraine prevalence was higher in females (n = 11, 4.6%) compared to males (n = 5, 3.1%), with a female:male ratio of 1.5:1. The most common triggers associated with migraine were study-related stress (88%) and emotional-related stress (81%).Conclusions: This project was undertaken to evaluate prevalence, triggers, and coping strategies of migraine among medical students. The prevalence of migraine headache in this study was lower compared to other national and international universities, with a higher female to male ratio. Stress was a major trigger among our study population. The findings of this study will add to the growing body of literature on migraine.

Hypertensive Intracerebral Hemorrhage in Young Patients From a Tertiary Care Center in Saudi Arabia: An Observational Study.

Objective: Young patients with intracerebral hemorrhage (ICH) make up a small but important subgroup of patients with ICH. This study investigated the clinical characteristics and outcomes of hypertensive ICH in very young (18-45 years) and young (46-55 years) patients.Methods: This was a retrospective study of patients aged 18-55 years with hypertensive ICH admitted to a hospital from April 2014 to April 2019. Clinical and radiologic features as well as long-term clinical outcomes were compared between 2 age groups: group 1 (18-45 years) and group 2 (46-55 years). Factors affecting the clinical outcome were investigated as well.Results: Of 63 patients with hypertensive ICH, 24 (38.1%) were in group 1 (mean ± SD age of 38 ± 4.6 years), and 39 (61.9%) were in group 2 (50 ± 2.5 years). The risk factor profile was similar except for diabetes, which was more prevalent in group 1 (odds ratio [OR] = 4.65; 95% CI, 1.4-15.2). Patients in group 1 had higher mean ± SD NIH Stroke Scale scores (15.7 ± 4.6, P = .044), had lower Glasgow Coma Scale (GCS) scores (OR = 3.33; 95% CI, 1.0-10.8), were at higher risk of intubation (OR = 2.79; 95% CI, 1.1-9.9), and had higher ICH volume (21 ± 18, P = .034). Worse clinical outcome was higher in group 1 (OR = 5.14; 95% CI, 1.0-26.1). Low GCS score, mean hematoma volume, and intraventricular extension were independently associated with worse outcome.Conclusions: Relatively young patients with hypertensive ICH have higher prevalence of diabetes and worse clinical outcome in comparison to older patients with hypertensive ICH. Such patients should be monitored and treated more aggressively.

Clinical and Radiological Correlates of Different Electroencephalographic Pattern in Hospitalized Patients.

Objective. The present study aimed to determine the clinical and radiological correlates of different electroencephalographic (EEG) patterns in hospitalized patients. Subjects and Methods. In this retrospective study performed at the Neurology Department, King Fahd University Hospital, Kingdom of Saudi Arabia (KSA), data of 374 patients who underwent EEG were reviewed and analyzed. Results. Presence of focal spike and wave or sharp wave (SW) (P = .00), generalized theta activity (P = .00), generalized delta activity (P = .04), persistent focal slow wave activity (SWA) (P = .003) and asymmetric background (P = .01) in the EEG record was significantly associated with abnormal imaging findings. Specifically, generalized theta delta activity (P = .01) and markedly attenuated EEG activity (P = .007) were associated with presence of cortical lesions; whereas, triphasic waves (TWs) (P = .009), and generalized theta activity (P = .001) were found to be related with presence of subcortical lesions. While, generalized delta activity (P = .01) was the only correlate with extra-axial lesions. Conclusion. At present, certain EEG patterns cannot be precisely correlated with imaging findings, suggesting that intercurrent metabolic, infectious, and/or toxic contributors could be the confounding factors. Nonetheless, when EEG patterns are examined alongside magnetic resonance imaging findings and other clinically relevant data, these might be indicative of a group of diseases in some pertinent situations. Thus, further larger prospective clinical studies that incorporate continuous EEG monitoring, advanced radiology techniques, and laboratory analyses would be beneficial to elucidate their interplay for better firm up the correlations.