Endovascular stenting for cerebral venous sinus stenosis secondary to meningioma invasion.

INTRODUCTION: Symptomatic intracranial hypertension (IH) due to venous outflow obstruction secondary to dural venous sinus (DVS) tumoral invasion affects up to 3% of intracranial meningioma patients. The literature regarding endovascular therapies of such patients is limited to a few case reports and a recent single-centre case series. PURPOSE: We describe our single-centre experience of endovascular therapy in patients with clinically symptomatic IH secondary to DVS meningioma invasion. METHODS: We performed a retrospective review of clinical and radiological data of all patients with refractory IH and meningiomas invading the DVS who were referred for possible DVS venoplasty and stenting. Seven endovascular procedures in six female patients were done. Presumed secondarily induced lateral transverse sinus stenosis was also stented in four patients as part of the primary intervention. RESULTS: All patients experienced complete symptomatic resolution at 6-month follow-up. Five patients had no symptom recurrence over a mean follow-up period of 3.5 years. One patient with multiple meningiomas developed recurrent IH 2 years following stenting secondary to in-stent tumour re-invasion. This was re-stented with consequent 6 months post-retreatment symptomatic relief at the time of writing. No procedure-related complications occurred. CONCLUSION: In the setting of DVS stenosis secondary to meningioma invasion, endovascular therapy is a safe and successful therapeutic option with promising mid-term results. The procedure should be considered in cases where complete surgical tumour resection is unlikely or carries a significant risk. If present, secondarily induced stenoses at the lateral ends of the transverse sinuses should also be considered for treatment.

Rare Case of Multiple Intradural Extramedullary Spinal Schwannomas With Intramedullary Extension.

Spinal schwannomas are benign WHO grade I nerve sheath tumors that account for nearly 30% of all spinal neoplasm. Typically, these lesions are intradural extramedullary in location and are composed entirely of well-differentiated eosinophilic Schwann cells. Intramedullary schwannomas, however, are extremely rare due to the lack of Schwan cells in the normal spinal cord and represent 1% of all the spinal schwannoma population. The presence of such an intramedullary component makes diagnosis challenging as imaging features may resemble other intramedullary neoplastic entities. Here, we describe a case of a 56-year-old male patient who presented with an 18-month history of intermittent right-sided mid-thoracic pain secondary to multiple intradural extramedullary spinal schwannoma with intramedullary extensions. We also review the literature pertaining to the condition.

Predominantly Solid Hemangioblastoma Presenting as an Extra-Axial Cerebellopontine Angle Lesion.

Hemangioblastomas (HBs) are typically intra-axial, highly vascular tumors of the central nervous system and account for up to 2.5% of all intracranial tumors and up to 12% of posterior fossa neoplasms. Extra-axial HBs are rarely described in the literature. The radiological appearances of cerebellopontine angle (CPA) extra-axial HB can lead to a diagnostic conundrum as they may mimic the appearance of dural metastasis, vestibular schwannoma, or meningioma. Here, we describe a patient who presented with an extra-axial CPA HB and explore the literature of the condition.

Evolution of Vascular Access Use among Incident Patients during the First Year on Hemodialysis: A National Cohort Study.

Background: Although the arteriovenous fistula (AVF) confers superior benefits over central venous catheters (CVCs), utilization rates remain low among prevalent patients on hemodialysis (HD). The goal of this study was to determine the evolution of vascular access type in the first year of dialysis and identify factors associated with conversion from CVC to a functioning AVF. Methods: We studiedadult patients (n=610) who began HD between the January 1, 2015 and December 31, 2016 and were treated for at least 90 days, using data from the National Kidney Disease Clinical Patient Management System in the Irish health system. Prevalence of vascular access type was determined at days 90 and 360 after dialysis initiation and at 30-day intervals. Multivariable logistic regression explored factors associated with CVC at day 90, and Cox regression evaluated predictors of conversion from CVC to AVF on day 360. Results: CVC use was present in 77% of incident patients at day 90, with significant variation across HD centers (from 63% to 91%, P<0.001), which persisted after case-mix adjustment. From day 90 to day 360, AVF use increased modestly from 23% to 41%. Conversion from CVC to AVF increased over time, but the likelihood was lower for older patients (for age >77 years versus referent, adjusted hazard ratio [HR], 0.43; 95% CI, 0.19 to 0.96), for patients with a lower BMI (per unit decrease in BMI, HR, 0.95; 95% CI, 0.93 to 0.98), and varied significantly across HD centers (from an HR of 0.25 [95% CI, 0.08 to 0.74] to 2.09 [95% CI, 1.04 to 4.18]). Conclusion: CVCs are the predominant type of vascular access observed during the first year of dialysis, with low conversion rates from CVC to AVF. There is substantial center variation in the Irish health system that is not explained by patient-related factors alone.

Unusual case of upper gastrointestinal haemorrhage secondary to a ruptured gastroduodenal artery pseudoaneurysm: case presentation and literature review.

Pseudoaneurysm rupture of the gastroduodenal artery (GDA) is life-threatening and can present as an acute upper gastrointestinal haemorrhage. Here, we present a case of upper gastrointestinal haemorrhage arising from a ruptured GDA pseudoaneurysm. A 56-year-old woman presented acutely with haematemesis. She reported ongoing upper epigastric pain for a few weeks. Laboratory evaluation revealed severe microcytic hypochromic anaemia (haemoglobin, 69 g/L; normal, 120-140 g/L) and a mildly raised serum amylase level. Upper gastrointestinal endoscopy revealed dark blood collection between the rugae of the distal stomach. An abdominal CT scan detected a homogeneously enhancing rounded lesion arising from the GDA adjacent to the second part of the duodenum. The median arcuate ligament was causing stenosis of the coeliac axis origin. The diagnosis of haematemesis secondary to a ruptured GDA pseudoaneurysm was confirmed by mesenteric angiography, and aneurysmal embolisation was done. The haemoglobin level stabilised after aneurysmal embolisation.

Unilateral right closed-lip schizencephaly.

Schizencephaly is a rare central nervous system (CNS) malformation secondary to neuronal migration defects. The pathogenesis is complex and is secondary to environmental and genetic factors. Clinically, the majority of patients present with varying degrees of motor and psychological disturbances. Imaging plays a cornerstone in the diagnosis by identifying the characteristic lesional features and recognising other associated abnormalities such as an absent septum pellucidum and corpus callosum dysgenesis. Here, we present a male paediatric case who presented with an interestingly asymptomatic unilateral right closed-lip schizencephaly and review the aetiology, clinical presentation and imaging characteristics of the disease and associated literature.

Palliative Care: Knowledge and Attitude among Saudi Residents, 2016.

Introduction: Palliative care is a medical specialty, which focuses on relieving the suffering and improving the quality of life for patients who are facing life-threatening illnesses and their families. Looking after dying patients is inseparable from our responsibility as physicians. However, dealing with the dying patients is challenging for the majority of physicians. Aim: To document the knowledge and attitudes of palliative care among residents from major specialties, Eastern Province, Saudi Arabia. Methodology: A cross-sectional study was carried out using a self-administered questionnaire to a convenient sample of residents from major specialties from various training centers in Eastern Province, Saudi Arabia, during 2015-2016. A total of 433 residents have been participated in the study. Results: About 46% of the residents showed lack of overall palliative care knowledge, and almost half of them had negative views toward palliative care. Almost 60% of them achieved good score in pain management. The majority of respondents had never received training in palliative medicine (91.7%). It was observed that higher training level has a positive effect on the overall knowledge, including basic concept, pain, and psychiatric symptoms' management. Also, previous exposure to patients who would benefit from palliative care has a direct effect on overall knowledge and attitude scores. Conclusion: The results indicate a low level of knowledge and attitude regarding palliative medicine among sampled residents. Also, it highlights the importance of exposing the residents to palliative medicine field to improve their knowledge and attitude.

Factors associated with perceptions of child sexual abuse and lack of parental knowledge: a community-based cross-sectional study from the Eastern Province of Saudi Arabia.

BACKGROUND: Child sexual abuse (CSA) has serious consequences that can affect the physical, social and mental health of a child. In the last two decades, concern about CSA has increased around the world including Saudi Arabia. OBJECTIVE: Evaluate factors associated with parental perceptions and knowledge of CSA. DESIGN: Cross-sectional survey. SETTINGS: Primary health care clinic. SUBJECTS AND METHODS: Simple random sampling was used to select participants. The main tool for data collection was a self-administered questionnaire. MAIN OUTCOME MEASURES: Factors associated with knowledge and perceptions of CSA. SAMPLE SIZE: 400. RESULTS: Most respondents (69%) had good knowledge of the signs of sexual abuse in children. For perception scores, statistically significant variables were age (P=.004), educational level (P=.005), income (P less than .001), number of wives (P=.004), number of male children (P=.021), and number of female children (P=.027). For knowledge scores, statistically significant variables were income (P=.008), number of wives (P less than .005), number of male children (P=.003) and number of female chil.dren (P less than .003). Logistic regression showed that the older age group was significantly associated with a good perception score (P less than .046). CONCLUSIONS: Risk factors for parental lack of knowledge and poor perception associated with CSA are poverty and low education. Protective factors included the older parent age, size of the family and families with more than one wife. Education should be designed for parents and the community to increase the knowledge and perception of CSA. LIMITATIONS: Single-center study and short study period. CONFLICT OF INTEREST: None.

Association of Plasma Ghrelin Levels with Insulin Resistance in Type 2 Diabetes Mellitus among Saudi Subjects.

BACKGROUND: Although the exact mechanism of insulin resistance (IR) has not yet been established, IR is the hallmark characteristic of type 2 diabetes mellitus (T2DM). The aim of this study was to examine the relationship between plasma ghrelin levels and IR in Saudi subjects with T2DM. METHODS: Patients with T2DM (n=107, cases) and non-diabetic apparently healthy subjects (n=101, controls) from Saudi Arabia were included in this study. The biochemical profiles and plasma insulin levels of all subjects were analyzed, and IR was estimated using the homeostatic model assessment of insulin resistance (HOMA-IR) index. Active ghrelin levels in plasma were measured using the radioimmunoassay technique. RESULTS: Only 46.7% (50 of 107) of the T2DM subjects had IR, including 26% (28 of 107) with severe IR (HOMA-IR ≥5), while 5.9% (six of 101) of the controls had moderate IR (3 ≤HOMA-IR <5). HOMA-IR values were not associated with age, disease duration, or gender. Importantly, T2DM itself and the co-occurrence of IR with T2DM were significantly associated with low plasma ghrelin levels. However, ghrelin levels were inversely correlated with the HOMA-IR index, body weight, and fasting plasma insulin levels, mainly in the control subjects, which was indicative of the breakdown of metabolic homeostasis in T2DM. CONCLUSION: The prevalence of IR was relatively low, and IR may be inversely associated with plasma ghrelin levels among Saudi patients with T2DM.

Association of Plasma Ghrelin Levels with Insulin Resistance in Type 2 Diabetes Mellitus among Saudi Subjects

BACKGROUND: Although the exact mechanism of insulin resistance (IR) has not yet been established, IR is the hallmark characteristic of type 2 diabetes mellitus (T2DM). The aim of this study was to examine the relationship between plasma ghrelin levels and IR in Saudi subjects with T2DM. METHODS: Patients with T2DM (n=107, cases) and non-diabetic apparently healthy subjects (n=101, controls) from Saudi Arabia were included in this study. The biochemical profiles and plasma insulin levels of all subjects were analyzed, and IR was estimated using the homeostatic model assessment of insulin resistance (HOMA-IR) index. Active ghrelin levels in plasma were measured using the radioimmunoassay technique. RESULTS: Only 46.7% (50 of 107) of the T2DM subjects had IR, including 26% (28 of 107) with severe IR (HOMA-IR ≥5), while 5.9% (six of 101) of the controls had moderate IR (3 ≤HOMA-IR <5). HOMA-IR values were not associated with age, disease duration, or gender. Importantly, T2DM itself and the co-occurrence of IR with T2DM were significantly associated with low plasma ghrelin levels. However, ghrelin levels were inversely correlated with the HOMA-IR index, body weight, and fasting plasma insulin levels, mainly in the control subjects, which was indicative of the breakdown of metabolic homeostasis in T2DM. CONCLUSION: The prevalence of IR was relatively low, and IR may be inversely associated with plasma ghrelin levels among Saudi patients with T2DM.

Neurosyphilis presenting with a stroke-like syndrome.

Neurosyphilis results from infection of the central nervous system (CNS) by Treponema pallidum. Neurosyphilis can occur at any time after initial infection, particularly in immunocompromised patients. We describe a case of a 47-year-old man who presented with mixed dysphasia, right upper motor neuron facial palsy and right hemiparesis. Collateral history from the family revealed slowly progressive cognitive impairment and behavioural changes. Neuroimaging was unremarkable, suggesting a non-vascular aetiology. As there was no clear cause for the presentation, a lumbar puncture was performed and serum samples were sent for syphilis serology. The diagnosis of neurosyphilis was made on the basis of a positive RPR test in cerebrospinal fluid. The patient was treated with benzylpenicillin and made a full recovery, with restoration of cognitive function to baseline.

Hashimoto's thyroiditis presenting as Hoffman's syndrome, rhabdomyolysis and acute kidney injury.

An otherwise healthy young man presented with gradual progressive fatigue for the past 12 months disturbing his daily activities. Clinical examination revealed marked generalised muscular hypertrophy including the temporalis muscles bilaterally. Investigation revealed that the patient was grossly hypothyroid due to Hashimoto's thyroiditis with rhabdomyolysis and acute kidney injury. The finding of muscle weakness and pseudohypertrophy in association with hypothyroidism is called Hoffman's syndrome. The patient was hydrated and thyroxine replacement initiated. On follow-up, the patient showed clinical as well as biochemical improvement.