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

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

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

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

Intermittent EGFR-TKI Therapy is Associated with Durable Response in Advanced EGFR-Mutant NSCLC: A Case Report

@#Madam S, who diagnosed to have stage IV lung adenocarcinoma with exon 21 L858R point mutation (T3N2M1a) was admitted for massive pericardial effusion in April 2016. She was ECOG 4 on admission. Her ECOG improved to 1 after pericardial tapping and initiation of free sample erlotinib 100 mg daily. Repeated CT thorax post treatment showed the disease was partial responded. Due to financial constraints, she had never bought any EGFR-TKI. She was given a free sample of erlotinib intermittently for total of 12 months followed by intermittent afatinib supply for 2 years. Due to this limited supply, she took half doses of afatinib by cutting a 40 mg tablet once every few days to sustain the continuation of cancer treatment. No major side effects were observed and she remained ECOG 0 with good weight gain. Up to her last clinic visit in September 2021, her PFS was more than 5 years. Intermittent doses of EGFR-TKI may prolong PFS in patients with advanced EGFRm+ NSCLC who has limited treatment options.

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

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

Spontaneous Intracerebral Hemorrhage among Hypertensive Patients in Saudi Arabia: Study from a Tertiary Center.

Background: Spontaneous intracerebral hemorrhage (ICH) is the second most common cause of stroke, yet there is paucity of evidence regarding the same from Saudi Arabia. Objectives: To describe the clinical characteristics of spontaneous ICH as well as determine the role of gender in ICH and the usefulness of the ICH scoring system for assessing the 30-day mortality risk. Patients and Methods: This retrospective study included all patients diagnosed with spontaneous ICH at King Fahd Hospital of the University, Al Khobar, Saudi Arabia, between April 01, 2014, and April 30, 2019. Data regarding clinical characteristics, risk factors, and radiological features of ICH were extracted. Further, gender-related differences were determined. The 30-day mortality rates were assessed using the ICH score. Results: A total of 148 patients were diagnosed with spontaneous ICH during the study period. Of these, 100 (67.5%) were male and the overall mean age was 60 ± 15 years. About 48% of the male patients were aged ≤50 years compared to 27% of the female patients (P = 0.016). Impaired renal function (35.8%) and diabetes (33.7%) were the most frequent risk factors; hemiparesis (51%) and language impairment (42%) were the most common presenting symptoms; and basal ganglia (40.5%) was the most common location. The 30-day mortality rate was 30%. The mean ICH score at presentation was significantly high in those who died within 30 days of presentation (2.2 ± 1.6; P < 0.0001). Each increase in the ICH score was associated with an increase in mortality rate (P < 0.001 for trend). Conclusion: Patients with spontaneous ICH were found to have a high prevalence of vascular risk factors and mortality rate. The ICH scoring system was shown to be a useful clinical tool for evaluating the 30-day mortality risk.

Cerebral Venous Sinus Thrombosis in Inflammatory Bowel Disease: A Review of Published Case Reports.

Cerebral venous sinus thrombosis (CVST) is a rare extraintestinal manifestation of inflammatory bowel disease (IBD), and the risk of poor clinical outcomes remains high in patients with delayed CVST diagnoses. This study aimed to highlight the need to recognize the critical nature of CVST complications in IBD and the challenges associated with managing concurrent conditions. We retrospectively reviewed previously reported cases of CVST in patients with IBD by searching the PubMed, Web of Science, and Google Scholar databases for articles published between 2013 and 2020. Our search identified 35 cases of IBD complicated by CVST. The mean patient age was 24.6 years (range, 31 months-47 years; men > women, ratio, 1.18:1). CVST was 3.8 times more common among patients with ulcerative colitis than among those with Crohn's disease. Active IBD was reported in 91.4% of patients. The mean interval between IBD diagnosis and CVST occurrence was 3 years (range, 2 days-16 years). Headache was the most frequently reported symptom (85.7%), and involvement of multiple sinuses was reported in almost two-thirds of the patients. Corticosteroid therapy at the time of the CVST event was the most common prothrombotic risk factor, present in 57.14% of patients. The overall recovery rate after treatment was 77.14%; whereas the bleeding complication rate was 10%. This review provides essential information that can aid clinicians in making earlier diagnoses and promotes preventive strategies for CVST in patients with IBD. Given that CVST management can be challenging in these patients, a multidisciplinary approach is warranted.

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.

Timing to start anticoagulants after acute ischemic stroke with non-valvular atrial fibrillation.

OBJECTIVE: To identify timing for initiation of anticoagulation therapy in acute ischemic stroke (AIS) with non-valvular AF as regards safety and efficacy by detecting the rate of intracranial haemorrhage (ICH) and recurrent ischemic symptoms (RIS) during follow-up. METHODS: This is a prospective observational cohort study conducted at King Fahd Hospital of the University including 120 patients with AIS/TIAs from July 2016 till July 2018. We compared patients who received anticoagulants 1-6 days (Group I (45.83%), 7-14 days, Group II (35%), and > 14 days after the ischemic event (Group III (19.17%). Follow-up was at least 3 months and included identifying ICH or RIS. RESULT: ICH has occurred in 26.67% (n = 32) patients with a highly statistically significant association with time of treatment (P-value = .01) being higher in group I (n = 17) compared to only 1 case in group III. Subgroup analyses on the ICH patients (n = 32) has revealed statistical significant association with higher NIHSS score (P = .001). Also, the type of anticoagulants used between three groups pointed to an association existence (p = .02), however, the direction of this association cannot be determined. There was no statistical significant association between RIS (occurred in 4.16% (n = 5) with time of treatment (P = .754). Functional outcome at 3-6 months measured by mRS did not differ between 3 groups (worst mRS in group I). CONCLUSION: Early initiation of anticoagulation after stroke, especially in cases of large infarction, is associated with significant risk of ICH. This risk is highest with warfarin and lowest with DOAC.

Personalised management of Chronic Obstructive Pulmonary Disease (COPD): Malaysian consensus algorithm for appropriate use of inhaled corticosteroid (ICS) in COPD patients

@#Background: Regarding the long-term safety issues with the use of inhaled corticosteroids (ICS) and the clinical predominance of dual bronchodilators in enhancing treatment outcomes in chronic obstructive pulmonary disease (COPD), ICS is no longer a “preferred therapy” according to the Global Initiative for Chronic Obstructive Lung Disease except on top of a dual bronchodilator. This has necessitated a change in the current therapy for many COPD patients. Objective: To determine a standardised algorithm to reassess and personalise the treatment COPD patients based on the available evidence. Methods: A consensus statement was agreed upon by a panel of pulmonologists in from 11 institutes in Malaysia whose members formed this consensus group. Results: According to the consensus, which was unanimously adopted, all COPD patients who are currently receiving an ICS-based treatment should be reassessed based on the presence of co-existence of asthma or high eosinophil counts and frequency of moderate or severe exacerbations in the previous 12 months. When that the patients meet any of the aforementioned criteria, then the patient can continue taking ICS-based therapy. However, if the patients do not meet the criteria, then the treatment of patients need to be personalised based on whether the patient is currently receiving long-acting beta-agonists (LABA)/ICS or triple therapy. Conclusion: A flowchart of the consensus providing a guidance to Malaysian clinicians was elucidated based on evidences and international guidelines that identifies the right patients who should receive inhaled corticosteroids and enable to switch non ICS based therapies in patients less likely to benefit from such treatments.

Etiologic and Clinical Features of Cerebral Venous Sinus Thrombosis in Saudi Arabia.

OBJECTIVE: Our study aims to evaluate the etiologic and clinical features of cerebral venous sinus thrombosis (CVST) in Saudi Arabia, and secondarily whether gender plays a role in CVST. MATERIALS AND METHODS: Data were collected retrospectively from the stroke registry during the period from January 2008 to April 2018, and the patients with the diagnosis of CVST were identified, and data were analyzed for any gender-specific differences in clinical presentation and etiology of cerebral venous thrombosis. RESULTS: There were 15 females while 11 males with a female:male ratio of 1.4:1. The mean age was 29.4± standard deviation 8.9 with the age range of 15-49. Headache was the most common and usually the first presenting symptoms present in 65% followed by hemiparesis and cranial nerve palsies. The first neurological examination was normal in 9/26 (34.6%) of the patients, while the common abnormality was cranial nerve palsies. Infections and trauma played an important part in risk factor analysis of our patient after the pregnancy- and hormone-related conditions. Some significant differences between the clinical presentation and risk factors among males and females were noted as age at presentation was higher in females while trauma and infections were common in male patients, although the involvement of the sinuses and response to treatment did not prove to be statistically significant. CONCLUSION: The results of this study were similar to the available literature with few differences. The relatively higher proportion of males in our study can be explained partly with more cases of traumatic CVST. Some important differences were noted between the risk factors and clinical presentation among genders. Large-scale prospective studies are needed to further clarify these differences.

Leiomyosarcoma of the breast: A case report

Leiomyosarcoma is a rare cancer and the presence of this type of cancer in the breast is even rarer. Due to its rarity, the management options for leiomyosarcoma of the breast are not well documented. Literature review was done to establish the best treatment options for this type of breast cancer.