The burden of headache disorders in the adult general population of the Kingdom of Saudi Arabia: estimates from a cross-sectional population-based study including a health-care needs assessment.

BACKGROUND: We have previously shown headache to be highly prevalent among adults in Saudi Arabia. Here we estimate associated symptom burden and impaired participation (impaired use of time, lost productivity and disengagement from social activity), and use these estimates to assess headache-related health-care needs in Saudi Arabia. METHODS: A randomised cross-sectional survey included 2,316 adults (18-65 years) from all 13 regions of the country. It used the standardised methodology of the Global Campaign against Headache with a culturally mandated modification: engagement by cellphone using random digit-dialling rather than door-to-door visits. Enquiry used the HARDSHIP questionnaire, with diagnostic questions based on ICHD-3 beta, questions on symptom burden, enquiries into impaired participation using the HALT index and questions about activity yesterday in those reporting headache yesterday (HY). Health-care "need" was defined in terms of likelihood of benefit. We counted all those with headache on ≥ 15 days/month, with migraine on ≥ 3 days/month, or with migraine or TTH and meeting either of two criteria: a) proportion of time in ictal state (pTIS) > 3.3% and intensity ≥ 2 (moderate-severe); b) ≥ 3 lost days from paid work and/or household chores during 3 months. RESULTS: For all headache, mean frequency was 4.3 days/month, mean duration 8.4 h, mean intensity 2.3 (moderate). Mean pTIS was 3.6%. Mean lost days from work were 3.9, from household chores 6.6, from social/leisure activities 2.0. Of participants reporting HY, 37.3% could do less than half their expected activity, 19.8% could do nothing. At population-level (i.e., for every adult), 2.5 workdays (potentially translating into lost GDP), 3.6 household days and 1.3 social/leisure days were lost to headache. According to HY data, mean total impaired participation (not distinguishing between work, household and social/leisure) was 6.8%. A total of 830 individuals (35.8%) fulfilled one or more of our needs assessment criteria. CONCLUSION: A very high symptom burden is associated with a commensurately high burden of impaired participation. The economic cost appears to be enormous. Over a third of the adult population are revealed to require headache-related health care on the basis of being likely to benefit, demanding highly efficient organization of care.

Impact of a national collaborative project to improve the care of mechanically ventilated patients.

This prospective quasi-experimental study from the NASAM (National Approach to Standardize and Improve Mechanical Ventilation) collaborative assessed the impact of evidence-based practices including subglottic suctioning, daily assessment for spontaneous awakening trial (SAT), spontaneous breathing trial (SBT), head of bed elevation, and avoidance of neuromuscular blockers unless otherwise indicated. The study outcomes included VAE (primary) and intensive care unit (ICU) mortality. Changes in daily care process measures and outcomes were evaluated using repeated measures mixed modeling. The results were reported as incident rate ratio (IRR) for each additional month with 95% confidence interval (CI). A comprehensive program that included education on evidence-based practices for optimal care of mechanically ventilated patients with real-time benchmarking of daily care process measures to drive improvement in forty-two ICUs from 26 hospitals in Saudi Arabia (>27,000 days of observation). Compliance with subglottic suctioning, SAT and SBT increased monthly during the project by 3.5%, 2.1% and 1.9%, respectively (IRR 1.035, 95%CI 1.007-1.064, p = 0.0148; 1.021, 95% CI 1.010-1.032, p = 0.0003; and 1.019, 95%CI 1.009-1.029, p = 0.0001, respectively). The use of neuromuscular blockers decreased monthly by 2.5% (IRR 0.975, 95%CI 0.953-0.998, p = 0.0341). The compliance with head of bed elevation was high at baseline and did not change over time. Based on data for 83153 ventilator days, VAE rate was 15.2/1000 ventilator day (95%CI 12.6-18.1) at baseline and did not change during the project (IRR 1.019, 95%CI 0.985-1.053, p = 0.2812). Based on data for 8523 patients; the mortality was 30.4% (95%CI 27.4-33.6) at baseline, and decreased monthly during the project by 1.6% (IRR 0.984, 95%CI 0.973-0.996, p = 0.0067). A national quality improvement collaborative was associated with improvements in daily care processes. These changes were associated with a reduction in mortality but not VAEs. Registration The study is registered in clinicaltrials.gov (NCT03790150).

Clinical characteristics and outcomes of ischemic stroke patients during Ramadan vs. non-Ramadan months: Is there a difference?

Objectives: To study the clinical characteristics and outcomes of patients experiencing an ischemic stroke during Ramadan vs. non-Ramadan months in a tertiary academic center in an Islamic country. Methods: We retrospectively reviewed all patients with ischemic stroke (IS) in Ramadan and non-Ramadan months for four consecutive years (February 2016-June 2019). All demographics, vascular risk factors, laboratory results, modified Rankin Scale (mRS) at admission and discharge, National Institute Stroke Scale (NIHSS), and in-hospital complication data were collected for all patients. Results: One thousand and 58 patients were included (non-Ramadan, n = 960; during Ramadan, n = 98). The mean age during Ramadan was 59 ± 13 years. Most non-Ramadan IS patients during Ramadan were male (68.5%; 57.1%, respectively). There was no statistical difference in vascular risk factors and medical history between the two groups. However, Ramadan patients had higher median NIHSS scores at discharge (p = 0.0045). In addition, more ICU admissions were noted among Ramadan patients (p = 0.009). In the gender-specific analysis for Ramadan patients, we found a statistically significant difference in smoking and urinary tract infection (p = 0.006, p = 0.005, respectively). Conclusion: Based on our results, there was no difference, in general, between patients with IS during Ramadan and non-Ramadan months. However, IS patients had higher NIHSS scores at discharge and more ICU admissions during Ramadan. Last, we suggest future studies with larger sample sizes, longer duration, and including all types of strokes.

Prevalence and Clinical Characteristics of Lacunar Stroke: A Hospital-Based Study.

Lacunar stroke (LS) is responsible for one-quarter of the overall number of ischemic strokes with long-term complications and carries health and economic issues for patients and health care systems. Therefore, we aimed to investigate lacunar versus non-lacunar strokes in a tertiary academic center. From February 2016 to July 2019, all patients admitted to the stroke unit were retrospectively reviewed. We included LS patients and compared them to other TOAST subtypes. Hemorrhagic stroke and conditions mimicking stroke were excluded. Regression analysis was done to determine LS predictors and outcomes. A 35.5% rate of LS among 989 ischemic stroke patients was found. Most patients (71.9%) were males. Lower National Institutes of Health Stroke Scale (NIHSS) scores at admission and negative history for cardiac diseases were predictors for LS in our population. At discharge, LS patients had low NIHSS scores and shorter hospitalization periods compared to non-LS patients. In conclusion, LS was prevalent among ischemic stroke patients in our cohort. Future studies are highly needed with long follow-up intervals to identify the stroke recurrence, complications, and outcomes.

Stroke Seasonality and Weather Association in a Middle East Country: A Single Tertiary Center Experience.

Background: Stroke is a medical condition that leads to major disability and mortality worldwide. Some evidence suggests that weather and seasonal variations could have an impact on stroke incidence and outcome. However, the current evidence is inconclusive. Therefore, this study examines the seasonal variations and meteorological influences on stroke incidence and outcome in the largest city in Saudi Arabia. Methods: From February 2016 to July 2019, we retrospectively reviewed data from all patients with acute ischemic (AIS) or hemorrhagic stroke (HS) admitted to the stroke unit in a tertiary academic center in Saudi Arabia. The corresponding daily meteorological data were obtained for the same period. We considered the months from November to March as the cold season and April to October as the hot season. Results: The final cohort included 1,271 stroke patients; 60.89% (n = 774) cases occurred in the hot season, while 39.1% (n = 497) in the cold season. Males accounted for 69.6% (n = 884) of the cases. The proportion of ischemic stroke was 83.2% [hot season 83.9% (n = 649) vs. cold season 82.3% (n = 409)]. We found no statistically significant difference between seasons (hot or cold) in stroke incidence, severity [National Institutes of Health Stroke Scale (NIHSS)], hospital course (pneumonia, thromboembolism, intensive care stay, or length of stay), or outcome [modified Rankin scale (mRS) on discharge and death]. Conclusions: In Riyadh, Saudi Arabia, our study found no impact of weather or seasonal variations on stroke incidence, hospital course, or outcomes. However, our findings warrant further research in different country regions.

Electronic early notification of sepsis in hospitalized ward patients: a study protocol for a stepped-wedge cluster randomized controlled trial.

BACKGROUND: To evaluate the effect of screening for sepsis using an electronic sepsis alert vs. no alert in hospitalized ward patients on 90-day in-hospital mortality. METHODS: The SCREEN trial is designed as a stepped-wedge cluster randomized controlled trial. Hospital wards (total of 45 wards, constituting clusters in this design) are randomized to have active alert vs. masked alert, 5 wards at a time, with each 5 wards constituting a sequence. The study consists of ten 2-month periods with a phased introduction of the intervention. In the first period, all wards have a masked alert for 2 months. Afterwards the intervention (alert system) is implemented in a new sequence every 2-month period until the intervention is implemented in all sequences. The intervention includes the implementation of an electronic alert system developed in the hospital electronic medical records based on the quick sequential organ failure assessment (qSOFA). The alert system sends notifications of "possible sepsis alert" to the bedside nurse, charge nurse, and primary medical team and requires an acknowledgment in the health information system from the bedside nurse and physician. The calculated sample size is 65,250. The primary endpoint is in-hospital mortality by 90 days. DISCUSSION: The trial started on October 1, 2019, and is expected to complete patient follow-up by the end of October 2021. TRIAL REGISTRATION: ClinicalTrials.gov NCT04078594 . Registered on September 6, 2019.

Structured headache services as the solution to the ill-health burden of headache: 1. Rationale and description

In countries where headache services exist at all, their focus is usually on specialist (tertiary) care. This is clinically and economically inappropriate: most headache disorders can effectively and more efficiently (and at lower cost) be treated in educationally supported primary care. At the same time, compartmentalizing divisions between primary, secondary and tertiary care in many health-care systems create multiple inefficiencies, confronting patients attempting to navigate these levels (the "patient journey") with perplexing obstacles.High demand for headache care, estimated here in a needs-assessment exercise, is the biggest of the challenges to reform. It is also the principal reason why reform is necessary.The structured headache services model presented here by experts from all world regions on behalf of the Global Campaign against Headache is the suggested health-care solution to headache. It develops and refines previous proposals, responding to the challenge of high demand by basing headache services in primary care, with two supporting arguments. First, only primary care can deliver headache services equitably to the large numbers of people needing it. Second, with educational supports, they can do so effectively to most of these people. The model calls for vertical integration between care levels (primary, secondary and tertiary), and protection of the more advanced levels for the minority of patients who need them. At the same time, it is amenable to horizontal integration with other care services. It is adaptable according to the broader national or regional health services in which headache services should be embedded.It is, according to evidence and argument presented, an efficient and cost-effective model, but these are claims to be tested in formal economic analyses.

Anterior circulation large vessel occlusion stroke in Saudi Arabia: Prevalence, predictors, and outcome.

OBJECTIVE: Anterior circulation Large Vessel Occlusion (LVO) stroke comes with significant morbidity and mortality. With the advent of endovascular interventions, its management has revolutionized. For health authorities to build systems and allocate resources, its burden, predictors, and outcome must be determined. METHODS: In a single tertiary care center, we retrospectively collected data from 1495 ischemic stroke patients to determine anterior circulation LVO prevalence, predictors, and outcome. Patients must have radiologically proven ischemic stroke within 24 hours before arrival at the emergency department. Anterior circulation LVO related stroke was defined as evidence of new anterior circulation infarct detected on neuroimaging, and vascular imaging confirming anterior circulation Large Vessel Occlusion. Data on demographics, vascular risk factors, treatment with reperfusion therapy, modified Rankin Scale (mRS) at admission, National Institute of Health Stroke Scale (NIHSS) at admission, length of stay (LOS) in days, and in-hospital comorbidities and death were collected. Regression analysis was done to determine the predictors and outcomes of anterior circulation LVO ischemic strokes. RESULTS: We found anterior circulation LVO in 27.8% (95 % CI 25.5-30.0) of all ischemic stroke patients. Atrial fibrillation and admission National Institute of Health Stroke Scale (NIHSS) were the strongest predictors of LVO [OR 2.33, P = 0.0011 and OR 1.17, P < 0.0001] respectively. Occurrence of LVO was associated with worse disability score (mRS ≥ 3) [47.22 vs. 19.81% (P = 0.0073)], longer hospitalization in days [Median 9.0 vs. 3.0, IQR (14.0 vs. 5.0) P = 0.0432)], and was more likely to results in patient admission to intensive care unit [Mean 17.59 vs. 3.70 % (P = 0.0002)]. CONCLUSION: Stroke with large vessel occlusion in Saudi Arabia is not uncommon. Its burden and outcome deserve national attention, as effective treatment is now readily available.

Neuromyelitis optica spectrum disorders in Arabian Gulf (NMOAG); establishment and initial characterization of a patient registry.

OBJECTIVE: To describe the clinical and radiological characteristics of neuromyelitis optica spectrum disorders (NMOSD) patients from the Arabian Gulf relative to anti-aquaporin 4 antibody serostatus. METHODS: Retrospective multicentre study of hospital records of patients diagnosed with NMOSD based on 2015 International Panel on NMOSD Diagnosis (IPND) consensus criteria. RESULTS: One hundred forty four patients were evaluated, 64.3% were anti-AQP4 antibody positive. Mean age at onset and disease duration were 31±12 and 7 ±â€¯6 years respectively. Patients were predominantly female (4.7:1). Overall; relapsing course (80%) was more common than monophasic (20%). Optic neuritis was the most frequent presentation (48.6%), regardless of serostatus. The proportion of patients (54.3%) with visual acuity of ≤ 0.1 was higher in the seropositive group (p = 0.018). Primary presenting symptoms of transverse myelitis (TM) were observed in 29% of patients, and were the most significant correlate of hospitalization (p<0.001). Relative to anti-APQ4 serostatus, there were no significant differences in terms of age of onset, course, relapse rates or efficacy outcomes except for oligoclonal bands (OCB), which were more often present in seronegative patients (40% vs.22.5%; p = 0.054). Irrespective of serostatus, several disease modifying therapies were instituted including steroids or immunosuppressives, mostly, rituximab and azathioprine in the cohort irrespective of serostatus. The use of rituximab resulted in reduction in disease activity. CONCLUSION: This is the first descriptive NMOSD cohort in the Arabian Gulf region. Seropositive patients were more prevalent with female predominance. Relapsing course was more common than monophasic. However, anti-AQP4 serostatus did not impact disease duration, relapse rate or therapeutic effectiveness. These findings offer new insights into natural history of NMOSD in patients of the Arabian Gulf and allow comparison with patient populations in different World regions.

Utilization of Intravenous Tissue Plasminogen Activator and Reasons for Nonuse in Acute Ischemic Stroke in Saudi Arabia.

BACKGROUND: Recombinant tissue plasminogen activator (rt-PA, alteplase) within 4.5 hours of symptom onset decreases the rate of disability after acute ischemic stroke (AIS). Due to various reasons, alteplase remains underutilized in certain regions (∼3% in low- and middle-income countries). AIMS: We aimed to estimate the alteplase utilization rate and identify the reasons for nonuse in Saudi Arabia. METHODS: We retrospectively reviewed all patients admitted with suspected stroke in the past 24 hours to the stroke unit at King Abdulaziz Medical City, Riyadh, Saudi Arabia from February 2016 to July 2018. We estimated the alteplase utilization rate among patients with AIS who could be treated within 4.5 hours of symptoms onset (≤225 minutes, allowing 45 minutes for door to needle time). We examined potential predictors of alteplase use using multivariable logistic regression analyses. Study was approved by local IRB. RESULTS: Of 1366 patients with suspected stroke, 819 (60%) had AIS. The alteplase utilization rates were 8.6% and 29% for all AIS and AIS arrived within the therapeutic window, respectively. The most common reason for no alteplase treatment was late arrival. Only 244 (29.8%) of AIS patients arrived within the time window for treatment. Among patients with sudden neurological deficit who arrived within the therapeutic time window, the most common reasons were mild neurological deficit (National Institutes of Health Stroke Scale score <5, 29.9%), stroke mimics (16.6%), and hemorrhagic stroke (8.1%). CONCLUSIONS: Our study showed a comparable alteplase utilization rate with most international estimates. The low utilization rate was mainly attributed to late patient arrival. Urgent interventions are needed to improve public awareness of stroke recognition and prehospital stroke care.

The prevalence of primary headache disorders in Saudi Arabia: a cross-sectional population-based study.

BACKGROUND: The large geographical gaps in our knowledge of the prevalence and burden of headache disorders include most of Eastern Mediterranean Region (EMR). Following a nationwide population-based study in Pakistan, we present here a similar study from Kingdom of Saudi Arabia (KSA). Both were conducted as projects within the Global Campaign against Headache The two purposes of this study were to inform national health policy and contribute to global knowledge of headache disorders. METHODS: We surveyed Arabic-speaking adults aged 18-65 years in all 13 regions of KSA. While previous Global Campaign studies have engaged participants by calling at randomly selected households, the culture of KSA made this unacceptable. Participants were, instead, contacted by cell-phone (since cell-phone coverage exceeded 100% in KSA), using random-digit dialling. Trained interviewers used a culturally adapted version of the Headache-Attributed Restriction, Disability, Social Handicap and Impaired Participation (HARDSHIP) questionnaire, with diagnostic enquiry based on ICHD-II. We estimated 1-year prevalences of the headache disorders of public-health importance (migraine, tension-type headache [TTH] and probable medication-overuse headache [pMOH]) and examined their associations with demographic variables. RESULTS: A total of 2316 participants (mean age of 32.2 ± 10.7 years; 62.3% male; 37.7% female) were included (participation proportion 86.5%). Gender and age distributions imperfectly matched those of the national population, requiring adjustments for these to prevalence estimates. Observed 1-year prevalence of all headache was 77.2%, reducing to 65.8% when adjusted. For headache types, adjusted 1-year prevalences were migraine 25.0%, TTH 34.1%, pMOH 2.0% and other headache on ≥15 days/month 2.3%. Adjusted 1-day prevalence of any headache was 11.5%. Migraine and pMOH were associated with female gender (ORs: 1.7 and 4.7; p < 0.0001). Migraine was negatively associated with age > 45 years (OR: 0.4; p = 0.0143) while pMOH was most prevalent in those aged 46-55 years (OR: 2.7; p = 0.0415). TTH reportedly became more common with increasing level of education. CONCLUSION: Prevalences of migraine and TTH in KSA are considerably higher than global averages (which may be underestimated), and not very different from those in Pakistan. There is more pMOH in KSA than in Pakistan, reflecting, probably, its higher-income status and greater urbanisation (facilitating access to medication).

Stroke mimics: Clinical characteristics and outcome.

OBJECTIVE: To study the prevalence and nature of stroke mimics (SM) among Saudi patients who came to the emergency department with a sudden neurological deficit and suspected stroke. METHODS: The electronic health records from February 2016 to July 2018 of patients who were admitted to the Stroke Unit at King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, Kingdom of Saudi Arabia (KAMC-RD) with a suspected stroke were all reviewed. A comparison between SM and stroke was established. Our study identified the predictors of SM by using logistic regression analysis. This study was approved by the local institutional review board. RESULTS: Out of 1,063 patients, 131 (12.3%) had SM. The most common causes were a peripheral vestibular disorder (27.4%) followed by psychogenic causes (24.4%). Stroke mimics were more common among younger individuals and women. Arterial hypertension, diabetes, and smoking were less likely to be found in SMs. At discharge, individuals with SM were more likely to be independent, had milder deficits, and shorter hospital stays. Predictors of SM were young age, female gender, mild deficit at presentation, and good functional status before the stroke. CONCLUSION: The incidence of stroke mimics is common among suspected stroke patients. Practicing physicians should consider potential diagnostic errors, particularly in the hyperacute phase of the stroke.

Characteristics and Outcomes of Younger Adults with Embolic Stroke of Undetermined Source (ESUS): A Retrospective Study.

INTRODUCTION: Embolic stroke of undetermined source (ESUS) in younger adults may have different risk factors compared with ESUS in elderly, and the approach to ESUS in young adults may require new therapies. We aimed to investigate the characteristics and outcomes in younger adults with ESUS at a single centre in Saudi Arabia. PATIENTS AND METHODS: A retrospective study was conducted using the medical records of younger adults with ESUS according to the criteria of the Cryptogenic Stroke/ESUS International Working Group. Younger adults (aged ≤50 years) with ESUS were compared with older patients, on admission and discharge from hospital, using the modified Rankin scale (mRS) and the National Institute of Health Stroke Scale (NIHSS). RESULTS: Among 147 patients with ESUS, 39 (26.5%) were younger adults. Younger adults compared with older adults with ESUS had fewer vascular risk factors, including lower rates of hypertension (43.6% vs. 70.3%; P = 0.004), diabetes (35.9% vs. 57.4%; P = 0.03), and dyslipidaemia (12.8% vs. 28.7%; P = 0.05). There was no significant difference in poor outcome at discharge (defined as mRS > 2), which was observed in 17.9% of younger adults and 28.7% of older adults. Further, there were no significant differences in stroke severity at discharge (NIHSS score ≤5) or median length of stay. DISCUSSION: Although the outcomes of ESUS do not differ between younger and older patients, younger patients have fewer identified risk factors. CONCLUSION: This study showed that 26.5% of patients with ESUS were aged ≤50 years. Although younger adults with ESUS had fewer risk factors, there were no significant differences in neurologic disability or mortality at discharge, stroke severity, or median length of stay.

Embolic Stroke of Undetermined Source in Saudi Arabia: Prevalence, Patient Characteristics, and Outcomes.

BACKGROUND: Embolic stroke of undetermined source (ESUS) is a newly introduced clinical construct to better characterize cryptogenic stroke. It is associated with considerable morbidity and mortality and a high recurrence rate. It has not previously been investigated in Saudi stroke patients. We aimed to conduct a descriptive analysis of ESUS in Saudi Arabia, including its frequency among patients with acute stroke, characteristics, and outcomes. METHODS: We reviewed all ischemic stroke patients admitted to the stroke unit at King Abdulaziz Medical City-Riyadh, Saudi Arabia, from February 2016 to July 2018. We applied the criteria proposed by the Cryptogenic Stroke/ESUS International Working Group, which defines ESUS as a radiologically confirmed nonlacunar brain infarct without (a) extracranial or intracranial atherosclerosis causing ≥50% stenosis in arteries supplying the ischemic area, (b) a major-risk cardioembolic source, (c) any other specific cause of stroke. We compared ESUS patients with the other stroke patients. Study was approved by local institutional review board. RESULTS: Of the 736 patients admitted with ischemic stroke, 147 (20%) had ESUS. Patients with ESUS had fewer vascular risk factors compared to patients without ESUS. Nearly third were either dead or dependent at discharge. There were no significant differences between ESUS and other types of ischemic strokes in mortality rate and independence at discharge. CONCLUSION: ESUS is common in Saudi stroke patients. Despite of the lack of definite etiology, it is associated with considerable morbidity and mortality.

Predictors of poor outcome in embolic stroke of undetermined source.

OBJECTIVE: To identify the clinical predictors of death or disability at discharge. METHODS: We retrospectively reviewed all ischemic stroke patients admitted to the stroke unit of King Abdulaziz Medical City, Riyadh, Saudi Arabia, from February 2016 - July 2018. We applied the Cryptogenic Stroke/ESUS International Working Group Embolic stroke of undetermined source (ESUS) criteria. We compared patients with poor outcomes (death or modified Rankin Scale [mRS] score more than 2 ) to those with favorable outcomes. Multivariate logistic regression was used to identify predictors of poor outcome. The regression model included age more than 60 years, gender, body mass index more than 25 kg/meter square, smoking history, comorbidities, previous ischemic/transient ischemic attack, pre-stroke mRS score more than 1, National Institutes of Health Stroke Scale (NIHSS) score at admission more than 5, pre-stroke antiplatelet use, and thrombolysis treatment. RESULTS: Out of 147 patients who met the ESUS criteria, 28.8% had poor outcomes. Predictors of poor outcome were NIHSS score more than 5 (odds ratio [OR] 11.1, 95% confidence interval [CI] 4.4-28.2), pre-stroke mRS score more than 1 (OR 3.7, 95% CI 1.14-11.59), and age more than 60 years (OR 2.4, 95% CI 1.14-5.22). CONCLUSION: A significant proportion of ESUS patients were dead or disabled at discharge. Poor outcome was more in older patients with pre-stroke functional disability and moderate to severe stroke.

Knowledge and Attitudes of Saudi Emergency Physicians toward t-PA Use in Stroke.

BACKGROUND AND OBJECTIVES: Tissue plasminogen activator (t-PA) within 4.5 hours from onset improves outcome in patients with ischemic stroke and has been recommended by several international guidelines. Since its approval in 1996, the debate among emergency physicians continues particularly around the result interpretation of the first positive randomized controlled trial, the National Institute of Neurological Disorders and Stroke (NINDS) clinical trial. This lack of consensus might negatively affect the delivery of effective stroke care. Here we aimed to assess the knowledge and attitude of Saudi emergency physicians toward t-PA use within 4.5 hours of onset in acute ischemic stroke. METHODS: A web-based, self-administered, locally designed questionnaire was sent to all emergency physicians practicing in the city of Riyadh from January to September 2017. RESULTS: Out of 450 emergency physicians, 122 from ten hospitals in Riyadh participated in the survey, with a 27% response rate. The majority of participants were men (78%), and their mean age was 40 ± 8 years. Half of the participants were board certified, and 36% were consultants. Half of the participants consider the evidence for t-PA use in stroke within 4.5 hours of stroke onset to be controversial, and 41% recommend against its use due to lack of proven efficacy (37%), the risk of hemorrhagic complications (35%), lack of stroke expertise (21%), and medicolegal liability (9%). Nearly half were willing to administer IV t-PA for ischemic stroke in collaboration with remote stroke neurology consultation if telestroke is implemented. CONCLUSION: Our study detected inadequate knowledge and a negative attitude among Saudi emergency physicians toward t-PA use in acute stroke. This might negatively impact patient outcome. Therefore, we recommend developing urgent strategies to improve emergency physicians' knowledge, attitudes, and beliefs in the management of acute stroke.

Factors associated with late arrival of acute stroke patients to emergency department in Saudi Arabia.

BACKGROUND: Tissue plasminogen activator within 4.5 h of onset is effective for acute ischemic stroke. However, only small proportion of patients is treated due to delayed presentation. We aimed to examine the factors associated with delays of stroke patients in Riyadh, Saudi Arabia. METHODS: A cross-sectional survey was conducted at King Abdulaziz Medical City, Riyadh, Saudi Arabia, during a 6-month period. An interviewer administered structured questionnaire addressed to the acute stroke patients or their relatives was used to explore the factors associated with delayed arrival. RESULTS: A total of 227 patients attending the emergency department were interviewed. The mean age was 60.4 ± 15.6 years. Approximately 56.4% presented after 4.5 h of stroke onset. Factors associated with late arrival were being alone during the onset of stroke, not being transported in an ambulance, not knowing that they were experiencing a stroke, and residing outside the city of Riyadh. CONCLUSION: More than half of patients missed the golden hours for thrombolysis due to delayed presentation. Reasons include lack of knowledge, underuse of ambulance and difficult access to care. Urgent community-based interventions are needed to address these factors.

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.