Early seizures in stroke - frequency, risk factors, and effect on patient outcomes in a tertiary center in Saudi Arabia.

OBJECTIVES: To determine the frequency, risk factors, and outcomes of Early seizure (ES) after stroke in a Saudi cohort. METHODS: A retrospective study was conducted in King Abdulaziz Medical City, Riyadh, KSA. All stroke patients whether they had first or recurrent stroke were included from February 2016 to December 2017. Data were analyzed using the SAS software version 9.4. RESULTS: Out of 665 patients, 456 (68.6%) were males and 564 (85.2%) were Saudis; the cohort's mean age was 60.6±12.6 years. Fifty-one (7.7%) patients had ES, which were more common in women (p=0.0123). Loss of consciousness (p=0.0402) and confusion (<0.0007) were associated with ES, whereas unilateral weakness (p=0.001) and unilateral numbness (p=0.0317) at presentation decreased the risk of ES. Vascular risk factors did not differ between patients with and without ES. Hemorrhagic stroke was associated with ES (p=0.0054), whereas patients with small vessel disease were less likely to develop ES (p=0.0013). Patients with ES had more severe stroke (NIHSS >5) (p=0.0139), more ICU admissions (49% vs. 26.2%; p=0.0005), longer length of hospital stay (44.9 days vs. 24.9 days; p=0.0018), higher rates of stroke-related complications (e.g. recurrent stroke, pulmonary embolism, hospital acquired infections, and need for tracheostomy and gastrostomy tube placement) (p≤0.0001), and were likely to be more severely disabled defined as mRS 3-5 at discharge (47.7% vs. 40.8%; p=0.0055) or to die in hospital (11.8% vs. 4.6%; p≤0.0001). CONCLUSION: The ES after stroke were common in our cohort. Increased stroke severity and confusion were independent predictors of ES. The ES were associated with higher rates of in-hospital complications, longer length of hospital stay, and worse outcomes at discharge.

Decompressive craniectomy is a life-saving procedure in malignant MCA infarction.

OBJECTIVES: To investigate the indications, timings, and outcomes of decompressive craniectomy (DC) performed for malignant middle cerebral artery (MCA) infarctions at our tertiary care center. METHODS: This retrospective case series involved patients who underwent DC for malignant MCA infarction at King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, between January 2012 and December 2018. Demographic, clinical, and radiological data were collected, and stroke- and surgery-related complications and discharge outcomes were assessed. RESULTS: Eighteen patients (mean age: 50±10 years), of whom 13 (72%) were men, underwent DC during the study period. Of the patients, 9 (50%) had severe stroke (NIHSS 16-25), 10 (56%) had right MCA infarction, and 11 (61%) received either intravenous thrombolysis or endovascular thrombectomy or their combination. Indications for surgery included clinical deterioration as seen in 16 (89%) patients, ipsilateral pupillary dilatation as seen in 11 (61%) patients, and signs of raised intracranial pressure in 6 (33%) patients. Surgery was performed within 48 h in 14 (78%) patients. The mean Intensive Care Unit stay was 15±7 days. Seven (39%) patients were discharged home and 3 (17%) were transferred to an inpatient rehabilitation unit, and 2 (11%) patients died. All patients had stroke-related complications; one (6%) patient developed cerebrospinal fluid leak, 3 (17%) had sunken skin flap syndrome and wound infection each, and 2 (11%) developed epidural hematoma. CONCLUSION: The DC was life-saving in the our patients with malignant MCA infarction. Most of the patients had surgery within 48 hours. More than one-third of the patients were discharged home, while mortality occurred in only 2 patients. Moreover, stroke- and surgery-related complications were common in our cohort.

Patterns and outcomes of stroke thrombolysis in a large tertiary care hospital in Riyadh, Saudi Arabia.

OBJECTIVES: To present the experience on stroke thrombolysis of a tertiary care center in Riyadh, KSA. METHODS: Cross-sectional, observational study of patients thrombolyzed between January 2012 and December 2018. RESULTS: Thrombolysis was performed in 148 patients (mean age: 58.2±14.5 years), 94 (63.5%) of them were men. The median onset-to-door time was 81 minutes, and 25% of the patients arrived within 1 hour. The median National Institute of Health Stroke Scale score upon admission was 13. Hypertension (68.9%), diabetes (56.1%), and dyslipidemia (40.5%) were the most common risk factors for stroke. The most common mechanism of stroke was cardioembolism (43.2%), which was associated with a more severe presentation (p=0.031). Intravenous thrombolysis alone was given to 98 patients (66.2%); the rest received intravenous tissue plasminogen activator plus endovascular therapy or endovascular therapy alone. The median door-to-needle (DTN) time was 70.5 min, with a significant improvement from 2012 (111.6 minutes) to 2018 (69.9 minutes) (p<0.001). Among the patients, 53 (35.8%) showed a good outcome (with a modified Rankin score of 0-2) whereas 14 (9.5%) died. Symptomatic intracranial hemorrhage (sICH) was seen in 8.1%. All vascular risk factors were more common in patients aged >60 years, except smoking, which was more common in the younger age group (p=0.007). CONCLUSION: In our cohort, the utilization of thrombolysis and the DTN time improved over time. One-thirds of the patients received endovascular treatment. Moreover, the frequency of the vascular risk factors was high. Compared with the published findings, our results showed that cardioembolic strokes were the most frequent and had severe presentation and were likely the cause of the slight increase in mortality and sICH.

Stroke literacy in the population of the Eastern Province of Saudi Arabia; immediate steps are essential to bridge the gap.

BACKGROUND AND PURPOSE: Stroke is a medical emergency that demands early recognition for time sensitive acute management. Knowledge about stroke in public has not been found satisfactory in most of the studies worldwide. Studies describing the awareness of public about recognition of stroke and its treatment from Saudi Arabia (SA) are deficient. This study aimed to assess the knowledge of general population living in the Eastern Province of SA about stroke in relation to recognition of warning signs, risk factors and available acute treatment. METHODS: A prospective, cross sectional study was conducted using a structured questionnaire distributed through an electronic web site over a period of six months. The data was analyzed with SPSS version 22.0. RESULTS: Among a total of 1,213 respondents, 62.4% were women. Three fourth identified the affected organ correctly. Psychological stress was the most commonly identified risk factor (73.5%) followed by hypertension (63.8%). More than half of the respondents (58.5%) were not aware of diabetes mellitus as a risk factor for stroke. Speech difficulty was the most commonly identified stroke warning sign (64.4%) followed by focal weakness (62.4%). More than half (59.9%) did not recognize facial asymmetry as stroke warning sign. Nearly three fourth of the participants were unaware of t-PA (73.7%) and nearest available health care center for acute stroke management (74.9%). CONCLUSION: Our survey found the stroke literacy in the population of the Eastern Province of SA as non- satisfactory and highlights the importance of taking immediate measure such as mass media campaign and hospital based activities to improve it.

Brainstem hemorrhage is uncommon and is associated with high morbidity, mortality, and prolonged hospitalization.

OBJECTIVE: To determine the frequency, risk factors, and outcomes of patients with brainstem hemorrhage in stroke center at King Abdulaziz Medical City, Riyadh. METHODS: A retrospective, observational cohort study including all patients with brainstem hemorrhage from January 2014 to December 2017. The clinical presentation, location of hemorrhage, complications and clinical outcomes were analyzed. RESULTS: Of 1921 stroke patients, 219 had hemorrhagic stroke (11.4%), of whom only 10 (4.6%) had brainstem hemorrhage, comprising 0.5% of all stroke patients. All patients were men; mean age was 58.5 years. Most frequent presenting symptoms were headache (70%), unilateral weakness (60%), and loss of consciousness (50%). All patients had hemorrhage in pons, 5 had concomitant cerebellar hemorrhage (50%), one had medullary hemorrhage, and one midbrain hemorrhage (10% each). Mean ICU stay was 17 days; mean hospital stay was 58 days. At the time of discharge, three (30%) had mRS of 0-2, 5 (50%) had mRS of 3-5, whereas 2 (20%) had died. Glasgow coma scale (GCS) of >8 at presentation was associated with a good outcome at three months (p=0.03). Presentation within six hours of symptom onset (p=0.233), hypertension on presentation (p=0.233), and age less than 60 years (p=0.065) did not affect discharge outcomes. CONCLUSION: Brainstem hemorrhage occurred in 0.5% of all stroke patients. It was associated with high morbidity and mortality. Low Glasgow Coma Scale at presentation was associated with poor outcomes.

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

OBJECTIVE: 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.

An overview of complications affecting the Central Nervous System following bariatric surgery.

Bariatric surgery has been considered as an effective treatment for morbid obesity. Apart from procedures related complications, a broad spectrum of neurological disorders affecting any part of neuraxis has been reported following BS. Central nervous system complications, although less common than peripheral nervous system complications, carry significant morbidity and potential mortality. Encephalopathy, behavioral and psychiatric disorders, myelopathy and optic neuropathy are the most frequently reported CNS complications. Early detection and prompt management may improve or completely reverse these neurological complications. It is essential that the treating physicians must be aware of their clinical manifestations and management, so early diagnosis and treatment can prevent patients from suffering significant neurological deficits and even death. This review discusses the clinical manifestations of these complications in detail which will help concerned physician in earlier recognition and hence prevent the delay in specific treatment.

Renal dysfunction as a predictor of acute stroke outcomes.

OBJECTIVE: To explore if renal dysfunction in terms of estimated glomerular filtration rate (eGFR) can be considered a risk factor for stroke outcomes. METHODS: The study population consisted of adults diagnosed with acute stroke admitted to the King Abdulaziz Medical City, Riyadh, Kingdom of Saudi Arabia between 2012 and 2015. Data was collected by chart review. The Modification of Diet in Renal Disease equation was used to estimate GFR. Patients were classified into 2 eGFR categories: eGFR more than 60 (normal) and eGFR less than or equal 60 (low). RESULTS: A total of 727 patients were studied of whom 596 (82%) had normal eGFR and 131 (18%) had low eGFR. There were more males (68.5%). Ischemic strokes were more prevalent (87.2%). Urinary tract infections were more likely to occur in the low eGFR group (OR=2.047, 95% CI=1.024 - 4.093). They were also significantly more likely to die during admission (OR=3.772, 95% CI=1.609-8.844). There was a statistically significant degree of disability reflected by higher mRS (p=0.010) as well as higher post-stroke National Institute of Health Stroke Score scores in the low eGFR group (p=0.011). CONCLUSION: Estimated glomerular filtration rate is a possible predictor of stroke severity, disability and mortality.

A case of fatal acute bacterial meningoencephalitis with extremely high cerebrospinal fluid white blood cell count.

Acute bacterial meningoencephalitis is still prevalent despite the widespread vaccination and still fatal despite the advances in antimicrobial therapy. Identifying patients at risk, lowering the threshold of clinical diagnosis and early treatment of such a curable disease will save patients' lives.

Guillain-Barré Syndrome in Adults in a Decade: The Largest, Single-Center, Cross-Sectional Study From the Kingdom of Saudi Arabia.

BACKGROUND: Guillain-Barré Syndrome (GBS) is the most common cause of acute, usually post-infectious, peripheral neuropathy resulting in a symmetrical, ascending paralysis. We evaluated the clinical and neurophysiological features, treatment, and outcomes of patients with GBS in our center. METHODS: A retrospective chart review on patients with GBS admitted to King Abdulaziz Medical City, Riyadh, Saudi Arabia, from January 2011 to December 2020. Data were analyzed using JMP statistical software version 15 pro. RESULTS: A total of 86 patients who met the criteria were included, 55 (64%) were males, with a mean age of 49.5+/-17.5 years. Antecedent infection was reported in 53 (61.6%), 51 (62.2%) presented within one week of symptoms onset. Ascending weakness was seen in 55 (70.5%), while 70 (81.4%) had areflexia. Acute motor axonal neuropathy (AMAN) was the commonest electrophysiological type of GBS in 41 (51.9%) patients. Albuminocytologic dissociation was seen in 48 (57%) who had lumbar puncture. Nearly half, 41 (47.7%) were admitted to the intensive care unit (ICU). Seventy (81.3%) were treated with intravenous immunoglobulin. There was no significant difference in the clinical presentation, management, ICU requirement, and discharge disposition between males and females. Females were more likely to have a higher disability at discharge (p=0.01). Patients younger than 60 years were more likely to require ICU admission (p=<0.01). CONCLUSION: Our patients with GBS were slightly older than previously reported from the region. AMAN was the commonest type of GBS. Younger patients were more likely to need ICU admission, whereas females were more likely to have a more severe disability.

Temporal trends in risk factors and outcome of intracerebral hemorrhage over 18 years at a tertiary care hospital in Karachi, Pakistan.

BACKGROUND: The purpose of this study was to analyze the baseline characteristics and outcomes of intracerebral hemorrhage (ICH) patients at our center over the last 18 years. METHODS: Patients with ICH (first-time) were identified from medical records using International Classification of Diseases, Ninth Revision codes from 1988 to 2005. Patients were divided into 2 groups, with each group spanning 9 years based on the year of admission: the old group (admitted between 1988 and 1996) and the newer group (admitted between 1997 and 2005). RESULTS: Out of 920 patients, the number of admissions with ICH increased from <40 per year (average) during 1988 to 1996 to >60 per year (average) during 1997 to 2005. The findings indicate that the percentage of cases in males decreased from 72% to 55% in the newer group as compared to the older group, while female ICH admissions increased from 28% to 45%. Mean age of ICH onset for both men and women decreased about 5 years, but this difference was not statistically significant. Frequency of diabetes (14% v 30%), dyslipidemia (3% v 18%), and the use of antihypertensive medications (29% v 69%) was higher in newer group, while the frequency of lobar hemorrhage was found to be reduced (40% v 20%) in newer group. Lower mortality (22% in the newer group v 32% in the older group) was noted. A decreased length of hospital stay for the newer group was recorded, but this difference was not found to be statistically significant. CONCLUSION: The mean age of ICH onset for both men and women has decreased about 5 years in the newer group. Men and women were equally affected in recent years as compared to male predominance in the older group.

Stroke at Moderate and High Altitude.

Syed, Maryam J., Ismail A. Khatri, Wasim Alamgir, and Mohammad Wasay. Stroke at moderate and high altitude. High Alt Med Biol. 23:1-7, 2022. Background: Stroke at high altitude is an understudied area in stroke research. With improvements in road infrastructure, access to high-altitude areas for recreation and living purposes has risen. Subsequently, it has been anticipated that due to normal physiological changes to high altitude the incidence of stroke is also likely to increase in these regions. Methods: We searched PubMed for available literature about stroke at high altitude. Cross-referencing was done from available articles and through other scientific search engines. Relevant case series and case reports were included in this review of the topic. Results: Only one review article, eight case series (including review of literature), and seven case reports were identified that could be included in this review. Most of the available data come from moderate and high altitude. Conclusions: There is limited available literature about stroke at high and extreme altitudes. Stroke at high altitude is likely to become an important subset of stroke population. Currently, there is inadequate knowledge about the incidence and prevalence, mechanisms, and stroke outcomes. Cerebral venous thrombosis is more common than arterial stroke. Stroke is probably secondary to conventional risk factors, polycythemia, and other coagulopathies. A case-control study may identify the at-risk population for stroke at moderate and high altitudes.

The Assessment of Knowledge about Tourette's Syndrome among Medical Students and Primary Physicians in Riyadh, Saudi Arabia: A Cross-Sectional Study.

Background: Tourette's syndrome (TS), a chronic, often disabling neuropsychiatric disorder characterized by motor and vocal tics, is frequently misdiagnosed, or patients are delayed in diagnosis. There is severe deficiency of research about Tourette's syndrome (TS) in the Middle East region. Objectives: To evaluate the knowledge and attitude of medical students and primary care physicians (PCPs) about TS and tic disorders. Methods: IRB approved, cross-sectional study. A total of 316 medical students of King Saud bin Abdulaziz University and 59 primary care physicians of Riyadh participated. Convenient, cluster sampling was used. A validated, self-administered questionnaire was used. Sum of all knowledge questions was calculated. Data were analyzed using SPSS software. Results: Survey was completed by 375 students and physicians, of whom 253 (67.5%) were men. Mean general knowledge score was 61.5 (±12.04) out of 100. Majority (66.1%) knew the diagnostic criteria for TS; only 46.1% considered antipsychotics as effective treatment. Only 25.1% had ever heard of habit reversal; 70% wanted to learn more. Only 10% of physicians had treated a patient with TS. There was no difference in knowledge between men and women (p=0.776). Board-certified physicians had a higher knowledge score (p < 0.05). Family physicians demonstrated higher level of knowledge compared to other physicians (p < 0.05). There was no difference between knowledge of students of different years (p=0.859) or between students and physicians (p=0.569). Conclusion: There was alarming lack of knowledge about Tourette syndrome at various level of medical training and practice including students and physicians. Those who achieved board certification and practiced as family physicians fared better in knowledge about Tourette's syndrome.

The Management and Outcome of Stroke Patients Admitted on Weekdays Compared to Weekends at the King Abdulaziz Medical City, Riyadh, Saudi Arabia.

Background and Purpose: Stroke is an unexpected medical emergency that can result in significant disability. The weekend effect suggests that individuals with acute medical problems are not treated the same way on weekends as they are on weekdays. There is no previous published study about weekend effect on stroke patients from Saudi Arabia. Methods: This was an IRB approved, retrospective, cohort study. All stroke patients admitted between January 2017 and December 2018 were included. Ten standards of care were chosen to assess compliance with standardized care. Seven measures were chosen for acute management of stroke. Results: A total of 731 patients were included, 68.5% were males; 493 (67%) were admitted during weekdays and 238 (33%) on weekends. There was no difference for age (P = .32), gender (P = .32), nationality (P = .62), stroke subtype (P = .27) and stroke severity (P = .69) on weekday or weekend admission. In two-third patients, more than 70% of stroke orders were utilized, with no difference in thrombolysis rate (P = .81). There was no difference in recurrent stroke (P = .86), mortality or discharge disposition (P = .34) between the patients. The patients admitted during weekdays had less complications (38 vs 46%; P = .04). Conclusions: There was no difference in the quality of care provided to stroke patients admitted during weekdays or weekends. There was no difference in the use of acute intervention on weekends and weekdays. Patients had similar outcomes and discharge disposition whether admitted on weekdays or weekends, except that those admitted on weekends had a significantly greater overall number of complications.

Novel LMNA mutations in patients with Emery-Dreifuss muscular dystrophy and functional characterization of four LMNA mutations.

Mutations in LMNA cause a variety of diseases affecting striated muscle including autosomal Emery-Dreifuss muscular dystrophy (EDMD), LMNA-associated congenital muscular dystrophy (L-CMD), and limb-girdle muscular dystrophy type 1B (LGMD1B). Here, we describe novel and recurrent LMNA mutations identified in 50 patients from the United States and Canada, which is the first report of the distribution of LMNA mutations from a large cohort outside Europe. This augments the number of LMNA mutations known to cause EDMD by 16.5%, equating to an increase of 5.9% in the total known LMNA mutations. Eight patients presented with either p.R249W/Q or p.E358K mutations and an early onset EDMD phenotype: two mutations recently associated with L-CMD. Importantly, 15 mutations are novel and include eight missense mutations (p.R189P, p.F206L, p.S268P, p.S295P, p.E361K, p.G449D, p.L454P, and p.W467R), three splice site mutations (c.IVS4 + 1G>A, c.IVS6 - 2A>G, and c.IVS8 + 1G>A), one duplication/in frame insertion (p.R190dup), one deletion (p.Q355del), and two silent mutations (p.R119R and p.K270K). Analysis of 4 of our lamin A mutations showed that some caused nuclear deformations and lamin B redistribution in a mutation specific manner. Together, this study significantly augments the number of EDMD patients on the database and describes 15 novel mutations that underlie EDMD, which will contribute to establishing genotype-phenotype correlations.

Social Anxiety and Obsessive-Compulsive Disorder Are Common Among Persons With Multiple Sclerosis at King Abdulaziz Medical City, Riyadh.

Background Multiple sclerosis (MS) is associated with a physical disability and disturbed psychosocial functioning in young people. Many psychological and psychiatric comorbidities have been reported in MS. Objective To determine the frequency of social anxiety disorder (SAD) and obsessive-compulsive disorder (OCD) among MS patients and their relation to MS severity. Methods A cross-sectional survey was conducted in an adult MS cohort. Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) and Social Phobia Inventory (SPIN) were used to determine the presence and severity of OCD and SAD. The Statistical Package for the Social Sciences (SPSS) version 22 (IBM Corp., Armonk, NY) was used for statistical analysis. The Mann-Whitney U test and logistic regression were used to assess the association of the two diseases with the severity of MS. Results A total of 145 persons with MS (pwMS) were studied. The mean age was 33.5 (±8.5) years; the mean duration of MS was 7.2 (± 5.1) years. The majority (74.1%) were women; 57.3% were married; 63% had a college education; 50% belonged to the higher middle-class socioeconomic strata. Relapsing-remitting multiple sclerosis was the most common type of MS (92.2%). The mean Expanded Disability Status Scale (EDSS) score was 2.24 (±2.19). SAD was reported by 26.9%, and OCD was reported by 31% of the cohort. PwMS with walking difficulty but not wheelchair-bound had a statistically significant increased risk of SAD (p = 0.036). There was no direct association between MS-related disability and OCD. However, pwMS with SAD were more likely to have concomitant OCD (t=4.68, p-value <0.001, 95% CI: 0.47-1.16). Increasing disability was associated with higher chances of developing social anxiety and, in turn, OCD (t=3.39, p-value <0.001, 95% CI: 0.66-2.52). Conclusions Social anxiety and obsessive-compulsive disorders were present in nearly one-third of pwMS. Impaired walking but not wheelchair dependence was associated with social anxiety. PwMS with SAD were more likely to have obsessive-compulsive disorder.

Common Carotid Artery Occlusion in a Young Patient: Can Large-Vessel Stroke Be the Initial Clinical Manifestation of Coronavirus Disease 2019?

BACKGROUND: The occurrence of large-vessel occlusion in young patients with coronavirus disease 2019 (COVID-19) infection has been exceedingly rare. An extensive review of reported studies revealed a few reported cases. In the present report, we have described the clinical presentation, radiological findings, and outcome of large-vessel occlusion in a young patient with COVID-19 and reviewed the pertinent reported data on this condition. CASE DESCRIPTION: A 31-year-old woman was in her usual state of health until she had presented with a 3-day history of right-sided weakness, slurred speech, and decreased vision. The patient had been taken to several hospitals where she had been treated conservatively with analgesics and discharged. Shortly thereafter, her weakness had become progressive. She had become severely dysarthric and unresponsive. On arrival to the emergency department, her physical examination revealed that she was stuporous, with a Glasgow coma scale of 10 (eye response, 3; verbal response, 2; motor response, 5). The National Institutes of Health Stroke Scale score was 19 on presentation. Brain computed tomography and computed tomography venography revealed an occluded left internal carotid artery and left middle cerebral artery with subacute left middle cerebral artery territory infarction and midline shift. Computed tomography angiography revealed complete occlusion of the left common carotid artery. An emergent decompressive craniectomy was successfully performed. The patient was shifted to the intensive care unit. She was later found to be positive for COVID-19. CONCLUSIONS: Although rare, patients with COVID-19 can present with large-vessel occlusion. Prompt identification of COVID-19-related coagulopathy is essential to assess young patients with clinical manifestations of infarction.

The association of diabetes with ischemic stroke and transient ischemic attacks in a tertiary center in Saudi Arabia.

BACKGROUND: Diabetes mellitus increases stroke risk 1.5 to 3 fold, particularly ischemic stroke. There is limited literature on the impact of diabetes on stroke patients in Saudi Arabia. OBJECTIVES: Determine the association of diabetes on the presentation, subtypes, in-hospital complications and outcomes of ischemic stroke and transient ischemic attacks (TIA). DESIGN: IRB approved, retrospective chart review. SETTING: Tertiary care center. PATIENTS AND METHODS: All adult patients with ischemic stroke or TIA aged 18 years or older admitted from January 2016 to December 2017 were included. MAIN OUTCOME MEASURES: Stroke severity at presentation, stroke-related complications, discharge disposition and discharge modified Rankin Scale (mRS) in relation to diabetes. SAMPLE SIZE: 802 patients. RESULTS: Among 802 cases, 584 (72.8%) had diabetes; the majority (63.1%) were males. The mean age was younger in the non-diabetic stroke group (54.6 [15.5] years vs. 63.3 [9.9], P<.001). Hypertension (83.6% vs 49.1%, P<.001), dyslipidemia (38.9% vs. 28.9%, P=.009), prior stroke (27.7% vs. 19.3% P=.014), and ischemic heart disease (20.4% vs. 7.8%, P<.001) were more common in diabetic patients whereas smoking was more common (19.3% vs. 11.1%, P=.003) in the non-diabetic patients. The commonest subtype of stroke was large artery disease followed by small vessel disease. Both were more common in diabetic vs. non-diabetic patients (55.8% vs. 44%, P=.003), and (16.6% vs. 11%, P=.05) respectively. Diabetic stroke patients were more likely to have lacunar stroke (16.4% versus 9.2%, P=.009). TIAs occurred more commonly in the non-diabetic group (26.1% vs. 13.7%, P<.001). Non-diabetic patients had a better outcome (mRS score of 0-2) at discharge (62.4% vs. 45.9%, P=.002). CONCLUSIONS: Almost three-fourth stroke patients were diabetic in our cohort. Diabetic stroke patients were older, had multiple vascular comorbid conditions, presented late to the hospital, and were likely to have more disability at the time of discharge. Large vessel atherosclerosis as well as lacunar infarctions were more common in diabetic stroke patients. LIMITATIONS: Missing data about time of presentation in few patients, missing modified Rankin Scale score at discharge. CONFLICT OF INTEREST: None.