Whole-exome sequencing of a Saudi epilepsy cohort reveals association signals in known and potentially novel loci.

BACKGROUND: Epilepsy, a serious chronic neurological condition effecting up to 100 million people globally, has clear genetic underpinnings including common and rare variants. In Saudi Arabia, the prevalence of epilepsy is high and caused mainly by perinatal and genetic factors. No whole-exome sequencing (WES) studies have been performed to date in Saudi Arabian epilepsy cohorts. This offers a unique opportunity for the discovery of rare genetic variants impacting this disease as there is a high rate of consanguinity among large tribal pedigrees. RESULTS: We performed WES on 144 individuals diagnosed with epilepsy, to interrogate known epilepsy-related genes for known and functional novel variants. We also used an American College of Medical Genetics (ACMG) guideline-based variant prioritization approach in an attempt to discover putative causative variants. We identified 32 potentially causative pathogenic variants across 30 different genes in 44/144 (30%) of these Saudi epilepsy individuals. We also identified 232 variants of unknown significance (VUS) across 101 different genes in 133/144 (92%) subjects. Strong enrichment of variants of likely pathogenicity was observed in previously described epilepsy-associated loci, and a number of putative pathogenic variants in novel loci are also observed. CONCLUSION: Several putative pathogenic variants in known epilepsy-related loci were identified for the first time in our population, in addition to several potential new loci which may be prioritized for further investigation.

Prevalence of Medically Resistant Epilepsy in Saudi Arabia.

OBJECTIVES: The objective of this study was to evaluate the prevalence of medically resistant epilepsy (MRE) in our hospital and to compare the prevalence with that in other populations. METHODS: We retrospectively analyzed the data of patients who visited the epilepsy clinics at King Fahd University Hospital, Al-Khobar, Saudi Arabia between January 2017 and December 2018. This study included patients aged ≥14 years who had at least 2 unprovoked seizures 24 h apart. Patients who had provoked seizure(s), paroxysmal events, or syncope or had incomplete medical records were excluded. The definition and classification of the International League Against Epilepsy were used. Moreover, we searched the En-glish literature using PubMed and Google Scholar to compare the prevalence of MRE between our population and other populations. RESULTS: In total, 1,151 patients were screened, and 751 patients were included in the final analysis. Of the 751 patients, 229 (male: 56.3%, female: 43.7%; mean age: 32.07 years, and standard deviation, 12.2 years) had MRE, with a cumulative prevalence of 30%. The etiology was as follows: unknown, 63.3% (n = 145); structural, 31.9% (n = 73); genetic, 3.1% (n = 7); and infectious, 1.7% (n = 4). None of the patients had metabolic or immune-related etiologies. CONCLUSION: The prevalence of MRE in our population (30%) is close to that in other populations (30-36.5%). Early identification of such patients is crucial to improve their management.

The etiology and risk factors of convulsive status epilepticus in pediatric patients of tertiary center in Saudi Arabia.

OBJECTIVES: To assess the etiology of status epilepticus (SE) among the pediatric patients of a tertiary center in Jeddah, Kingdom of Saudi Arabia (KSA). METHODS: Data from 88 cases was obtained retrospectively from 2006 to 2017 from King Abdulaziz University Hospital (KAUH). Patients aged between 28 days and 14 years with the symptoms of SE were selected for this study. RESULTS: The data show that the proportions of SE etiologies were 30.5% for febrile seizure, 11.9% for electrolytes imbalance, 8.5% for hydrocephalus, 6.8% for CNS infections, and 6.8% for neoplasm. The other etiologies of SE were trauma, fever, intractable epilepsy, cerebrovascular accident, hemorrhagic stroke, etc. There were no clear etiologies in 8 cases. Most of the patients were not of Saudi origin (64.3%), boys (67.8%), and had generalized epilepsy types (91.8%), and 58.6% of the patients complied with epilepsy medications. CONCLUSION: The most prevalent etiology of convulsive status epilepticus was a febrile seizure, followed by electrolyte imbalance and hydrocephalus. However, a nationwide study in KSA must be conducted to determine the major etiologies of SE for its effective management and prevention. Educating families and patients regarding antiepileptic drugs is necessary.

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.

Electrophysiologic severity of carpal tunnel syndrome in diabetic patients of the Saudi population.

OBJECTIVE: To study the frequency of multiple vascular risk factors and electrophysiological severity of carpal tunnel syndrome (CTS) in Saudi diabetic patients. METHODS: This retrospective cross-sectional study was conducted in Neurology Department, King Fahd Hospital of University, Al-Khobar, Kingdom of Saudi Arabia from April 2017 to March 2018 and included 200 patients with CTS. Body parameters, such as blood pressure (BP), weight, height, and body mass index (BMI), along with laboratory and median nerve electrophysiological parameters, of diabetic and non-diabetic patients were compared, and a p-value<0.05 was considered significant. RESULTS: Frequency of hypertension (HTN) and obesity was significantly higher in diabetic patients (p<0.05). Mean median nerve sensory amplitude (MNSA) was lower in diabetic patients (p<0.05).Non-recordable nerves, as well as bilateral and extremely severe CTS (p<0.05), were more frequently seen in diabetic patients. Age, BMI, systolic BP, low serum high density lipoprotein (HDL), high triglycerides, high fasting blood sugar, and high glycated hemoglobin (Hba1c) levels, known to affect the electrophysiological severity of CTS, had a statistically significant association with diabetes. CONCLUSION: Diabetes mellitus (DM) and obesity are the most commonly identified risk factors of CTS. Dyslipidemia, HTN and obesity are more frequently seen in diabetic patients with CTS. These concurrent risk factors are confounding the electrophysiological severity of CTS in these patients. Further larger-scale studies with the control of confounding factors are recommended.

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

OBJECTIVE: 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.

Epilepsy in pregnancy. A comprehensive literature review and suggestions for saudi practitioners.

In the context of local culture and misconceptions regarding epilepsy, Saudi practitioners need a careful management plan for women with epilepsy that satisfies all the patients` needs and ensures their spouses` understanding. Such a management strategy needs to incorporate careful selection and monitoring of anti-epileptic drugs and regular counseling of patients. Female epileptic patients in the reproductive age group, no matter whether they are pregnant or not, should be managed by safest drugs from the earliest with folic acid supplementation along with adequate pre-marriage/conception counseling. All antiepileptic drugs are potentially teratogenic. However, valproic acid, phenytoin, phenobarbitone, and topiramate are least favored for use. Monotherapy is preferred over polytherapy, and the least possible dose should be used. During pregnancy, many epileptic women may need monthly drug level monitoring and dose readjustments. Normal vaginal delivery is safe in epileptic women. Post-partum follow-up with anti-epileptic drug titration may be required.

Stroke and seizure continue to be the major brunt of in patient neurology care. An observation from teaching hospital.

OBJECTIVE: To assess the burden and describe the pattern of neurological disorders requiring admissions in a teaching hospital of Al Khobar. METHODS: This is a retrospective, cross sectional study, carried out in the Neurology Department of King Fahd Hospital of the University from January 2009 to December 2016. Neurological disorders were grouped as ischemic stroke, intracerebral hemorrhage, transient ischemic attack, cerebral venous sinus thrombosis, seizure disorders, central nervous system infection, multiple sclerosis, neuropathies, myopathies, headache, dementia and miscellaneous group. Data was entered and analyzed by Statistical Package for the Social Science (SPSS) version 22.0 (IBM Corp., Armonk, NY, USA). RESULTS: The records of 1,317 patients admitted under Neurology Service were analyzed. Out of that, 740 (56.2%) were male and 577 (43.8%) were female. Mean age was 46.9+\-24 years (mean+\-standard deviation). Ischemic stroke was the most common diagnosis (32%) followed by seizures (20%). Multiple sclerosis accounted for around 8% and central nervous system infections 5% of neurological admission. CONCLUSION: Ischemic stroke was found to be the most common etiology for hospitalization in our study. The results of our study are similar to previous literature. An urgent need to control major risk factors such as diabetes and hypertension is warranted to minimize the burden of stroke.

Adult motor phenotype differentiates Dravet syndrome from Lennox-Gastaut syndrome and links SCN1A to early onset parkinsonian features.

Distinguishing adult patients with Lennox-Gastaut syndrome from those with Dravet syndrome is challenging. We have previously reported that patients with Dravet syndrome present a very peculiar motor phenotype. Here we sought to confirm that this association was not linked to the chronic use of antiepileptic drugs or the many lifetime seizures. To this aim, we studied 14 adult patients with Lennox-Gastaut syndrome and 14 adults with Dravet syndrome because both conditions share similar seizure severity. We found that antecollis and parkinsonian gait were significantly more common in the Dravet group, thus suggesting that these features are part of the Dravet syndrome adult phenotype.

Which patients with epilepsy are at risk for psychogenic nonepileptic seizures (PNES)? A multicenter case-control study.

OBJECTIVE: We sought to examine the clinical and electrographic differences between patients with combined epileptic (ES) and psychogenic nonepileptic seizures (PNES) and age- and gender-matched patients with ES-only and PNES-only. METHODS: Data from 138 patients (105 women [77%]), including 46 with PNES/ES (39±12years), 46 with PNES-only (39±11years), and 46 with ES-only (39±11years), were compared using logistic regression analysis after adjusting for clustering effect. RESULTS: In the cohort with PNES/ES, ES antedated PNES in 28 patients (70%) and occurred simultaneously in 11 (27.5%), while PNES were the initial presentation in only 1 case (2.5%); disease duration was undetermined in 6. Compared with those with ES-only, patients with PNES/ES had higher depression and anxiety scores, shorter-duration electrographic seizures, less ES absence/staring semiology (all p≤0.01), and more ES arising in the right hemisphere, both in isolation and in combination with contralateral brain regions (61% vs. 41%; p=0.024, adjusted for anxiety and depression) and tended to have less ES arising in the left temporal lobe (13% vs. 28%; p=0.054). Compared with those with PNES-only, patients with PNES/ES tended to show fewer right-hemibody PNES events (7% vs. 23%; p=0.054) and more myoclonic semiology (10% vs. 2%; p=0.073). CONCLUSIONS: Right-hemispheric electrographic seizures may be more common among patients with ES who develop comorbid PNES, in agreement with prior neurobiological studies on functional neurological disorders.

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.

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.

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.

EEG criteria for diagnosing nonconvulsive status epilepticus in comatose - An unsolved puzzle: A narrative review.

Introduction: Nonconvulsive status epilepticus (NCSE) is an important and often unrecognized cause of impaired awareness especially in critically ill patients, which can easily be missed. Electroencephalography (EEG) findings in clinically suspected cases are the mainstay of diagnosis. Review summary: The EEG diagnostic criteria for NCSE have evolved over the past three decades. Furthermore, recent advancements in EEG technologies such as continuous EEG monitoring, and emergency department EEG, along with development of different diagnostic criteria, have increased the detection rate for NCSE in suspected cases. However, treating physicians should have a higher index of clinical suspicion and a lower threshold for recommending this valuable investigation. The introduction of different diagnostic criteria has made it easier for electroencephalographers to report NCSE; nevertheless, diagnosis is not always straightforward. This narrative review aimed to define and discuss the available literature on different EEG diagnostic criteria for NCSE. Conclusion: There is a need for further prospective research to strengthen the diagnostic accuracy of the available diagnostic criteria, the modified Salzburg Consensus Criteria for NCSE (mSCNC) and updated American Clinical Neurophysiology Society (ACNS) 21 criteria, to verify their accuracy to detect NCSE in comatose patients.

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.

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.

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.

Estimated prevalence study of attention-deficit/hyperactivity disorder among eastern province children in the Kingdom of Saudi Arabia.

Background: Studying mental disorders in children is significantly important due to the huge suffering of educational and psychosocial impairments in adult life. Attention-deficit/hyperactivity disorder (ADHD) is considered the most common mental disorder in children, especially in early school-aged children. It manifests in about 8%-12% of children in the world. In Saudi Arabia, it affects 4%-12% of children. Objective: The study aimed to count the number of undiagnosed ADHD cases and the associated risk factors in Eastern Province in Kingdom of Saudi Arabia (KSA). Methods: A cross-sectional study was performed among girls' and boys' children aged 6-10 years old in Eastern Province in KSA with a random selection of parents. Sample size is equal to 1658. The assessment was done by an online questionnaire filled it by parents using Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition diagnostic criteria and Connor's scale of ADHD excluding any developmental or mental disorder at the beginning of the questionnaire. Results: After excluding the participants who were diagnosed with behavioral and growth developmental disorder, the remaining 1430 have been screened for ADHD based on Connor's scale. 185 of a child out of 1430 were suggested to have ADHD, of which 10 out of them show the signs of ADHD, 76 of them have moderately severe ADHD, and 99 out of them have atypical or severe ADHD based on Connor's scale of ADHD. The study shows that there is a significant relationship between the positive screening of ADHD and gender males (71.35%), females (28.64%), family history (20.5%), nervous system diseases (4.32%), brain damage from trauma (9.72%), smoking habit of the mother (8.64%), smoking during pregnancy (3.78%), mother exposure to second-hand smoking (42.16%), child exposure to a toxic substance like lead during the early life (1.62%), and the preterm labor (15.13%). However, the study shows there is no significant relationship between the positive screening of ADHD with age, drinking alcohol, and central nervous system infection. Conclusion: The prevalence of undiagnosed ADHD is slightly high. Also, it has many causes of ADHD including gender, smoking, parental psychiatric disorders, and obstetric and pregnancy problems.

Résumé Background: L'étude des troubles mentaux chez les enfants est d'une importance considérable en raison des souffrances liées aux difficultés scolaires et psychosociales qui perdurent à l'âge adulte. Le trouble du déficit de l'attention avec hyperactivité (TDAH) est considéré comme le trouble mental le plus courant chez les enfants, notamment chez les enfants d'âge scolaire précoce. Il se manifeste chez environ 8% à 12% des enfants dans le monde. En Arabie saoudite, il touche entre 4% et 12% des enfants. Objective: L'étude visait à dénombrer le nombre de cas de TDAH non diagnostiqués et les facteurs de risque associés dans la province orientale du Royaume d'Arabie saoudite (KSA). Methods: Une étude transversale a été réalisée auprès d'enfants de filles et de garçons âgés de 6 à 10 ans dans la province orientale de l'Arabie saoudite, en utilisant une sélection aléatoire des parents. La taille de l'échantillon est égale à 1658. L'évaluation a été réalisée à l'aide d'un questionnaire en ligne rempli par les parents, en utilisant les critères diagnostiques du Manuel diagnostique et statistique des troubles mentaux, cinquième édition, ainsi que l'échelle de Connor pour le TDAH, en excluant tout trouble du développement ou trouble mental au début du questionnaire. Résultats: Après exclusion des participants ayant été diagnostiqués avec un trouble du comportement et du développement, les 1430 restants ont été dépistés pour le TDAH à l'aide de l'échelle de Connor. Parmi ces enfants, 185 ont été suggérés d'avoir un TDAH, dont 10 présentent des signes de TDAH, 76 présentent un TDAH modérément sévère et 99 présentent un TDAH atypique ou sévère selon l'échelle de Connor. L'étude révèle qu'il existe une relation significative entre le dépistage positif du TDAH et le genre masculin (71,35 %), féminin (28,64 %), les antécédents familiaux (20,5 %), les maladies du système nerveux (4,32 %), les lésions cérébrales suite à un traumatisme (9,72 %), la consommation de tabac par la mère (8,64 %), la consommation de tabac pendant la grossesse (3,78 %), l'exposition de la mère à la fumée secondaire (42,16 %), l'exposition de l'enfant à une substance toxique comme le plomb pendant la petite enfance (1,62 %) et le travail prématuré (15,13 %). Cependant, l'étude montre qu'il n'existe aucune relation significative entre le dépistage positif du TDAH et l'âge, la consommation d'alcool et les infections du système nerveux central. Conclusion: La prévalence du TDAH non diagnostiqué est légèrement élevée. De plus, il existe de nombreuses causes du TDAH, dont le genre, le tabagisme, les troubles psychiatriques des parents, ainsi que les problèmes obstétriques et durant la grossesse. Mots-clés: Attention, trouble du déficit de l'attention/hyperactivité, Province orientale, hyperactivité, Royaume d'Arabie saoudite.

Thymectomy in Myasthenia Gravis: A Narrative Review.

Myasthenia gravis (MG) is a rare condition caused by autoantibodies against acetylcholine receptors on postsynaptic membrane that leads to weakness of skeletal muscles. About 7 of 10 patients with MG have thymic hyperplasia and about 1 of 10 patients have thymoma. Thymectomy has increasingly been used as a treatment modality for MG. Several observational studies have shown that thymectomy results in improvement in MG and a randomized trial has established that thymectomy leads to a better outcome in non-thymomatous generalized MG. However, thymectomy is yet controversial in some disease subtypes and there are potential concerns regarding the selection of the ideal surgical approach to achieve complete removal of the thymic tissue to achieve stable remission rates. This review highlights the role of thymectomy in non-thymomatous and thymomatous MG, the effectiveness of various thymectomy methods, postoperative myasthenic crisis, and remission after thymectomy.