Tobacco use and risk of acute stroke in 32 countries in the INTERSTROKE study: a case-control study.

Background: Smoking is a major risk factor for the global burden of stroke. We have previously reported a global population attributable risk (PAR) of stroke of 12.4% associated with current smoking. In this study we aimed to explore the association of current tobacco use with different types of tobacco exposure and environmental tobacco smoke (ETS) exposure on the risk of stroke and stroke subtypes, and by regions and country income levels. Methods: The INTERSTROKE study is a case-control study of acute first stroke and was undertaken with 13,462 stroke cases and 13,488 controls recruited between January 11, 2007 and August 8, 2015 in 32 countries worldwide. Association of risk of tobacco use and ETS exposure were analysed with overall stroke, ischemic and intracerebral hemorrhage (ICH), and with TOAST etiological stroke subtypes (large vessel, small vessel, cardioembolism, and undetermined). Findings: Current smoking was associated with an increased risk of all stroke (odds ratio [OR] 1.64, 95% CI 1.46-1.84), and had a stronger association with ischemic stroke (OR 1.85, 95% CI 1.61-2.11) than ICH (OR 1.19 95% CI 1.00-1.41). The OR and PAR of stroke among current smokers varied significantly between regions and income levels with high income countries (HIC) having the highest odds (OR 3.02 95% CI 2.24-4.10) and PAR (18.6%, 15.1-22.8%). Among etiological subtypes of ischemic stroke, the strongest association of current smoking was seen for large vessel stroke (OR 2.16, 95% CI 1.63-2.87) and undetermined cause (OR 1.97, 95% CI 1.55-2.50). Both filtered (OR 1.73, 95% CI 1.50-1.99) and non-filtered (OR 2.59, 95% CI 1.79-3.77) cigarettes were associated with stroke risk. ETS exposure increased the risk of stroke in a dose-dependent manner, exposure for more than 10 h per week increased risk for all stroke (OR 1.95, 95% CI 1.69-2.27), ischemic stroke (OR 1.89, 95% CI 1.59-2.24) and ICH (OR 2.00, 95% CI 1.60-2.50). Interpretation: There are significant variations in the magnitude of risk and PAR of stroke according to the types of tobacco used, active and ETS exposure, and countries with different income levels. Specific strategies to discourage tobacco use by any form and to build a smoke free environment should be implemented to ease the global burden of stroke. Funding: The Canadian Institutes of Health Research, Heart and Stroke Foundation of Canada, Canadian Stroke Network, Swedish Research Council, Swedish Heart and Lung Foundation, The Health & Medical Care Committee of the Regional Executive Board, Region Västra Götaland, and through unrestricted grants from several pharmaceutical companies with major contributions from Astra Zeneca, Boehringer Ingelheim (Canada), Pfizer (Canada), MERCK, Sharp and Dohme, Swedish Heart and Lung Foundation, UK Chest, and UK Heart and Stroke.

Depressive symptoms and risk of acute stroke: INTERSTROKE case-control study

METHODS: The INTERSTROKE is an international case-control study of risk factors of first acute stroke, conducted in 32 countries. Cases were patients with CT- or MRI-confirmed incident acute hospitalized stroke, and controls were matched for age, sex, and within sites. Standardized questions asked about self-reported depressive symptoms during the previous 12 months and the use of prescribed antidepressant medications were recorded. Multivariable conditional logistic regression was used to determine the association of prestroke depressive symptoms with acute stroke risk. Adjusted ordinal logistic regression was used to explore the association of prestroke depressive symptoms with poststroke functional outcome, measured with the modified Rankin scale at 1 month after stroke. RESULTS: Of 26,877 participants, 40.4% were women, and the mean age was 61.7 ± 13.4 years. The prevalence of depressive symptoms within the last 12 months was higher in cases compared with that in controls (18.3% vs 14.1%, p < 0.001) and differed by region (p interaction <0.001), with lowest prevalence in China (6.9% in controls) and highest in South America (32.2% of controls). In multivariable analyses, prestroke depressive symptoms were associated with greater odds of acute stroke (odds ratio [OR] 1.46, 95% CI 1.34-1.58), which was significant for both intracerebral hemorrhage (OR 1.56, 95% CI 1.28-1.91) and ischemic stroke (OR 1.44, 95% CI 1.31-1.58). A larger magnitude of association with stroke was seen in patients with a greater burden of depressive symptoms. While preadmission depressive symptoms were not associated with a greater odds of worse baseline stroke severity (OR 1.02, 95% CI 0.94-1.10), they were associated with a greater odds of poor functional outcome at 1 month after acute stroke (OR 1.09, 95% CI 1.01-1.19). DISCUSSION: In this global study, we recorded that depressive symptoms are an important risk factor of acute stroke, including both ischemic and hemorrhagic stroke. Preadmission depressive symptoms were associated with poorer functional outcome, but not baseline stroke severity, suggesting an adverse role of depressive symptoms in poststroke recovery.

Depressive Symptoms and Risk of Acute Stroke: INTERSTROKE Case-Control Study.

BACKGROUND AND OBJECTIVES: Depression has been reported to be a risk factor of acute stroke, based largely on studies in high-income countries. In the INTERSTROKE study, we explored the contribution of depressive symptoms to acute stroke risk and 1-month outcome across regions of the world, within subpopulations and by stroke type. METHODS: The INTERSTROKE is an international case-control study of risk factors of first acute stroke, conducted in 32 countries. Cases were patients with CT- or MRI-confirmed incident acute hospitalized stroke, and controls were matched for age, sex, and within sites. Standardized questions asked about self-reported depressive symptoms during the previous 12 months and the use of prescribed antidepressant medications were recorded. Multivariable conditional logistic regression was used to determine the association of prestroke depressive symptoms with acute stroke risk. Adjusted ordinal logistic regression was used to explore the association of prestroke depressive symptoms with poststroke functional outcome, measured with the modified Rankin scale at 1 month after stroke. RESULTS: Of 26,877 participants, 40.4% were women, and the mean age was 61.7 ± 13.4 years. The prevalence of depressive symptoms within the last 12 months was higher in cases compared with that in controls (18.3% vs 14.1%, p < 0.001) and differed by region (p interaction <0.001), with lowest prevalence in China (6.9% in controls) and highest in South America (32.2% of controls). In multivariable analyses, prestroke depressive symptoms were associated with greater odds of acute stroke (odds ratio [OR] 1.46, 95% CI 1.34-1.58), which was significant for both intracerebral hemorrhage (OR 1.56, 95% CI 1.28-1.91) and ischemic stroke (OR 1.44, 95% CI 1.31-1.58). A larger magnitude of association with stroke was seen in patients with a greater burden of depressive symptoms. While preadmission depressive symptoms were not associated with a greater odds of worse baseline stroke severity (OR 1.02, 95% CI 0.94-1.10), they were associated with a greater odds of poor functional outcome at 1 month after acute stroke (OR 1.09, 95% CI 1.01-1.19). DISCUSSION: In this global study, we recorded that depressive symptoms are an important risk factor of acute stroke, including both ischemic and hemorrhagic stroke. Preadmission depressive symptoms were associated with poorer functional outcome, but not baseline stroke severity, suggesting an adverse role of depressive symptoms in poststroke recovery.

Association of Lipids, Lipoproteins, and Apolipoproteins with Stroke Subtypes in an International Case Control Study (INTERSTROKE).

BACKGROUND AND PURPOSE: The association of dyslipidemia with stroke has been inconsistent, which may be due to differing associations within etiological stroke subtypes. We sought to determine the association of lipoproteins and apolipoproteins within stroke subtypes. METHODS: Standardized incident case-control STROKE study in 32 countries. Cases were patients with acute hospitalized first stroke, and matched by age, sex and site to controls. Concentrations of total cholesterol, high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), apolipoprotein A1 (apoA1), and apoB were measured. Non-HDL-C was calculated. We estimated multivariable odds ratio (OR) and population attributable risk percentage (PAR%). Outcome measures were all stroke, ischemic stroke (and subtypes), and intracerebral hemorrhage (ICH). RESULTS: Our analysis included 11,898 matched case-control pairs; 77.3% with ischemic stroke and 22.7% with ICH. Increasing apoB (OR, 1.10; 95% confidence interval [CI], 1.06 to 1.14 per standard deviation [SD]) and LDL-C (OR, 1.06; 95% CI, 1.02 to 1.10 per SD) were associated with an increase in risk of ischemic stroke, but a reduced risk of ICH. Increased apoB was significantly associated with large vessel stroke (PAR 13.4%; 95% CI, 5.6 to 28.4) and stroke of undetermined cause. Higher HDL-C (OR, 0.75; 95% CI, 0.72 to 0.78 per SD) and apoA1 (OR, 0.63; 95% CI, 0.61 to 0.66 per SD) were associated with ischemic stroke (and subtypes). While increasing HDL-C was associated with an increased risk of ICH (OR, 1.20; 95% CI, 1.14 to 1.27 per SD), apoA1 was associated with a reduced risk (OR, 0.80; 95% CI, 0.75 to 0.85 per SD). ApoB/A1 (OR, 1.38; 95% CI, 1.32 to 1.44 per SD) had a stronger magnitude of association than the ratio of LDL-C/HDL-C (OR, 1.26; 95% CI, 1.21 to 1.31 per SD) with ischemic stroke (P<0.0001). CONCLUSIONS: The pattern and magnitude of association of lipoproteins and apolipoproteins with stroke varies by etiological stroke subtype. While the directions of association for LDL, HDL, and apoB were opposing for ischemic stroke and ICH, apoA1 was associated with a reduction in both ischemic stroke and ICH. The ratio of apoB/A1 was the best lipid predictor of ischemic stroke risk.

Nicotine smoking is associated with impaired cognitive performance in Pakistani young people.

Nicotine smoking is the most common mode of tobacco smoking among young people. It affects the areas of the brain associated with memory, attention, and learning. This study has investigated the effect of nicotine smoking on cognitive performance. One hundred male volunteers (50 nicotine smokers and 50 nonsmokers) aged 18-30 years with similar socioeconomic backgrounds were recruited for this study. Clinical history of participants was obtained using a questionnaire. Their brain health and handedness were determined using the Mini Mental State Examination (MMSE) and the Edinburgh Handedness Inventory (EHI), respectively. The dependent variables examined in the study were attention-switching tasks (AST), pattern recognition memory (PRM), and choice reaction time (CRT). These parameters were assessed using the Cambridge Neuropsychological Automated Battery (CANTAB). The average ages of participating smokers and nonsmokers were 24.02 ± 3.41 years (mean ± standard deviation) and 22.68 ± 1.87 years, respectively. MMSE and EHI scores of smokers were 28.42 ± 1.09 and 99.75 ± 1.77, respectively; for nonsmokers, these scores were 28.54 ± 1.34 and 98 ± 1.91, respectively. The mean score for AST correct latency/delay was significantly higher (p = 0.050) in smokers (620.26 ± 142.03) than in nonsmokers (570.11 ± 108.39). The percentage of correct AST trials was significantly higher (p = 0.000) in nonsmokers (96.95 ± 2.18) than in smokers (83.75 ± 11.22). The PRM percent correct were significantly higher (p = 0.000) of nonsmokers (93.42 ± 8.34) than of smokers (79.75 ± 13.44). The mean correct latency for CRT was significantly higher (p = 0.009) in smokers (509.87 ± 129.83) than in nonsmokers (455.20 ± 65.73). From this data, it can be concluded that nicotine smoking is linked with impaired cognitive functions in smokers.

Renal Impairment and Risk of Acute Stroke: The INTERSTROKE Study.

BACKGROUND: Previous studies reported an association of renal impairment with stroke, but there are uncertainties underpinning this association. AIMS: We explored if the association is explained by shared risk factors or is independent and whether there are regional or stroke subtype variations. METHODS: INTERSTROKE is a case-control study and the largest international study of risk factors for first acute stroke, completed in 27 countries. We included individuals with available serum creatinine values and calculated estimated glomerular filtration rate (eGFR). Renal impairment was defined as eGFR <60 mL/min/1.73 m2. Multivariable conditional logistic regression was used to determine the association of renal function with stroke. RESULTS: Of 21,127 participants, 41.0% were female, the mean age was 62.3 ± 13.4 years, and the mean eGFR was 79.9 ± 23.5 mL/min/1.73 m2. The prevalence of renal impairment was higher in cases (22.9% vs. 17.7%, p < 0.001) and differed by region (p < 0.001). After adjustment, lower eGFR was associated with increased odds of stroke. Renal impairment was associated with increased odds of all stroke (OR 1.35; 95% CI: 1.24-1.47), with higher odds for intracerebral hemorrhage (OR 1.60; 95% CI: 1.35-1.89) than ischemic stroke (OR 1.29; 95% CI: 1.17-1.42) (pinteraction 0.12). The largest magnitudes of association were seen in younger participants and those living in Africa, South Asia, or South America (pinteraction < 0.001 for all stroke). Renal impairment was also associated with poorer clinical outcome (RRR 2.97; 95% CI: 2.50-3.54 for death within 1 month). CONCLUSION: Renal impairment is an important risk factor for stroke, particularly in younger patients, and is associated with more severe stroke and worse outcomes.

Incidence of Silent Ischemic Infarct after Diagnostic Conventional Cerebral Angiogram.

This study was carried out to determine the risk of new ischemic events, demonstrated by diffusion weighted magnetic resonance imaging (DW-MRI) in patients undergoing diagnostic conventional cerebral angiogram. MEDLINE, EMBASE, Current Contents, Cochrane Central, Expert Files, and bibliographies of included articles were systematically searched to identify prospective studies that reported MRI findings after diagnostic angiogram. Eligibility criteria included the following elements: manuscripts published between 1999 and 2019; prospective design; only diagnostic angiogram imaging performed prior to the MRI; DW-MRI done before and after the angiogram procedure; and number of new diffusion weighted lesions documented after each procedure. Six studies met the eligibility criteria. The total number of diagnostic angiograms reported was 430. DWI lesions were associated with diagnostic angiograms in 106 (24.65%) of total procedures. Mean time fluoroscopy, procedure by resident operator, and vascular risk factors were the recognised independent risk factors for silent cerebral ischemia after diagnostic angiogram. Key Words: Stroke, Diffusion magnetic resonance imaging, Cerebral infarction, Angiography, Brain ischemia.

The effect of transcranial direct current stimulation combined with functional task training on motor recovery in stroke patients.

BACKGROUND: Motor deficits are common after stroke and are a major contributor to stroke-related disability and the potential for long-lasting neurobiological consequences of stroke remains unresolved. There are only a few treatments available for the improvement of motor function in stroke patients. However, the mechanisms underlying stroke recovery remain poorly understood, and effective neurorehabilitation interventions remain insufficiently proven for widespread implementation. METHODS: Herein, we propose to enhance the effects of brain plasticity using a powerful noninvasive technique for brain modulation consisting of navigated transcranial magnetic stimulation (TMS) priming with transcranial direct current stimulation (tDCS) in combination with motor-training-like constraint-induced movement therapy (CIMT). Our hypothesis is that navigated low-frequency rTMS stimulus priming with precise location provided by neuronavigation on the healthy side of the brain and with anodal tDCS on the affected side combined with CIMT will induce a greater motor function improvement than that obtained with sham tDCS combined with CIMT alone. We predict that the application of this technique will result in a large reduction in cortical excitability and dis-inhibition in the affected hemisphere and lead to improvements in behavioral measures of hand function in stroke patients. DISCUSSION: The proposed study, therefore, is important for several reasons. The results could potentially lead to improved stroke therapeutics, and the approach makes use of 2 potential pathways to modulate brain function. TRIAL REGISTRATION: This study protocol was registered in Clinical Trials Registry (https://clinicaltrials.gov/ct2/show/NCT04646577). ETHICS AND DISSEMINATION: The study has been reviewed and approved by the Human Research Ethics Committee of the King Fahad Specialist Hospital Dammam. The results will be actively disseminated through peer-reviewed journals, conference presentations, social media, broadcast media, print media, the internet and various community/stakeholder engagement activities.

Effects of transcranial direct current stimulation on cortex modulation by stimulation of the primary motor cortex and parietal cortex in humans.

AIM OF THE STUDY: Transcranial magnetic stimulation (TMS) is used to measure corticospinal excitability (CSE) from the primary motor cortex (M1) in humans through motor-evoked potentials (MEPs). The variability of CSE responses to transcranial direct current stimulation (tDCS) protocols is high and needs to be reproduced in the healthy population. The M1 and posterior parietal cortex (PPC) are anatomically and functionally connected and could play a role in understanding the variability in CSE responses. We tested the individual MEPs following a common cathodal (ctDCS) protocol over the M1 and PPC. MATERIALS AND METHODS: Twenty-eight healthy subjects were randomized for a ctDCS stimulation over the left M1 and PPC for 20 min on a separate days. The first dorsal interosseous muscle (FDI) contralateral stimulation of the left M1 was used as the resting motor threshold (RMT), while 15 single pulses 4-8 s apart at an intensity of 120% RMT were used to determine the baseline MEP amplitude and at T0, 5, 10, 20, 30, 40, 50, and 60 min after ctDCS stimulation in both sessions. RESULTS: A 20 min duration of ctDCS stimulation significantly deceased the CSE only at T0 (p = 0.046 at M1, p = 0.010 at PPC). CONCLUSION: Our results suggested that PPC stimulation can modulate M1 excitability and PPC-M1 connectivity, but a significant effect is only observed immediately post ctDCS. The tDCS showed variability in response to the tDCS protocol is consistent with other non-invasive brain stimulation studies.

Urinary Sodium and Potassium, and Risk of Ischemic and Hemorrhagic Stroke (INTERSTROKE): A Case-Control Study.

BACKGROUND: Although low sodium intake (<2 g/day) and high potassium intake (>3.5 g/day) are proposed as public health interventions to reduce stroke risk, there is uncertainty about the benefit and feasibility of this combined recommendation on prevention of stroke. METHODS: We obtained random urine samples from 9,275 cases of acute first stroke and 9,726 matched controls from 27 countries and estimated the 24-hour sodium and potassium excretion, a surrogate for intake, using the Tanaka formula. Using multivariable conditional logistic regression, we determined the associations of estimated 24-hour urinary sodium and potassium excretion with stroke and its subtypes. RESULTS: Compared with an estimated urinary sodium excretion of 2.8-3.5 g/day (reference), higher (>4.26 g/day) (odds ratio [OR] 1.81; 95% confidence interval [CI], 1.65-2.00) and lower (<2.8 g/day) sodium excretion (OR 1.39; 95% CI, 1.26-1.53) were significantly associated with increased risk of stroke. The stroke risk associated with the highest quartile of sodium intake (sodium excretion >4.26 g/day) was significantly greater (P < 0.001) for intracerebral hemorrhage (ICH) (OR 2.38; 95% CI, 1.93-2.92) than for ischemic stroke (OR 1.67; 95% CI, 1.50-1.87). Urinary potassium was inversely and linearly associated with risk of stroke, and stronger for ischemic stroke than ICH (P = 0.026). In an analysis of combined sodium and potassium excretion, the combination of high potassium intake (>1.58 g/day) and moderate sodium intake (2.8-3.5 g/day) was associated with the lowest risk of stroke. CONCLUSIONS: The association of sodium intake and stroke is J-shaped, with high sodium intake a stronger risk factor for ICH than ischemic stroke. Our data suggest that moderate sodium intake-rather than low sodium intake-combined with high potassium intake may be associated with the lowest risk of stroke and expected to be a more feasible combined dietary target.

Role of Single Low Pulse Intensity of Transcranial Magnetic Stimulation Over the Frontal Cortex for Cognitive Function.

Background: The principal aim of this study was to measure the effect of online single-pulse transcranial magnetic stimulation (TMS) over the right dorsolateral prefrontal cortex (DLPFC) on cognition via the Cambridge Neuropsychological Test Automated Battery (CANTAB) in healthy individuals. Methods: In a single-blind, sham-controlled study, we assessed both 50% and 60% of the resting motor threshold (RMT) over the right DLPFC in healthy right-handed (n = 42) adults using cognitive function, such as attention and memory, as a measure via CANTAB. Results: We observed an improvement in the cognitive function level during the use of online low intensities of 50% and 60% RMT active stimulation of the DLPFC compared to the sham stimulation. Conclusions: The results showed that low-intensity TMS can indeed effectively modulate cognitive function in DLPFC. Future research is, however, necessary to investigate the potential effects of low-intensity TMS on different brain areas to increase confidence in the observed results.

Lacune is the stroke subtype linked to obstructive sleep apnea.

BACKGROUND: Each stroke subtype is associated with specific risk factors, and stroke prevention depends solely on the control of the underlying risk factors for each stroke subtype. Obstructive sleep apnea has been established as a major risk factor for stroke and cardiovascular disease. However, information on the stroke subtype linked to obstructive sleep apnea is scarce. METHODS: This was a single-center, observational case series study conducted on patients who were admitted with acute ischemic stroke to King Khalid University Hospital. The TOAST criteria were used to determine the stroke subtype in each of these patients. The Berlin questionnaire was utilized to assess the presence of obstructive sleep apnea. The proportion of each stroke subtype was then calculated and compared between the group with associated obstructive sleep apnea and the group without associated obstructive sleep apnea. RESULTS: A total of 170 consecutive patients with acute ischemic stroke were admitted between January 2018 and September 2018. Eighty-seven (51%) patients were found to have obstructive sleep apnea. The proportion of small artery disease was significantly greater in the obstructive sleep apnea group (44% vs. 26%, P = 0.02). There was no difference in the distribution of the other stroke subtypes between the two groups. Univariate analysis revealed that small artery disease was associated with body mass index, hypertension, and obstructive sleep apnea. However, in a multivariate logistic analysis, only hypertension was found to be independently associated with small artery disease. CONCLUSION: Small artery disease is the most common stroke subtype associated with obstructive sleep apnea. Clinicians must vigilantly assess the presence of obstructive sleep apnea in ischemic stroke patients, especially in patients whose stroke is attributed to small artery disease.

Cardiovascular MRI: A valuable tool to detect cardiac source of emboli in cryptogenic ischemic strokes.

OBJECTIVES: Despite a thorough work-up including transesophageal echocardiography, 20%-30% of stroke etiology remains cryptogenic. Transesophageal echocardiogram is considered the gold standard procedure to detect cardiac or aortic sources of emboli. In the recent years, cardiovascular MRI has emerged as a noninvasive, sound, and reliable modality to image morphological and functional abnormalities. In this study, we compared none contrast cardiovascular MRI to transesophageal echocardiogram, in the ability to detect cardiovascular source of embolus in cryptogenic ischemic strokes. METHODS: A series of 24 patients who were labeled, after a thorough stroke work-up, as having cryptogenic stroke, were examined with both transesophageal echocardiogram and noncontrast cardiovascular MRI to assess for cardiac or aortic source of emboli. The cardiologist who interpreted the transesophageal echocardiograms was blinded to the results of cardiovascular MRI. At the same time, the radiologist who interpreted the cardiovascular MRI was also blinded to the results of transesophageal echocardiogram. The cardiac lesions, with potential source of emboli that were assessed in our study included left ventricular thrombus, atrial septal aneurysm, and aortic atherosclerotic disease. The ability of cardiovascular MRI to identify potential source of cardiac embolus was then compared to that of transesophageal echocardiogram. RESULTS: Transesophageal echocardiogram detected ascending or arch aortic atherosclerotic plaque in 14 of the 24 patients. Other abnormalities detected include two atrial septal aneurysms and two left ventricular thrombus. Cardiovascular MRI was able to identify aortic atheroma in 13 patients; as well as three atrial septal aneurysms and two left ventricular thrombus. The accuracy of cardiovascular MRI to detect aortic atheroma, atrial septal aneurysm or left ventricular thrombus was great; 96%, 95.83%, and 100%, respectively. CONCLUSION: This small study suggests that, in patients with cryptogenic stroke, cardiovascular MRI is comparable to transesophageal echocardiogram in detecting cardiac and aortic source of emboli.

Knowledge of and attitudes toward epilepsy surgery among neurologists in Saudi Arabia.

OBJECTIVE: To investigate the levels of knowledge and attitudes toward epilepsy surgery among neurologists in Saudi Arabia and evaluate the factors that affect the physicians` knowledge and attitudes. METHODS: A quantitative observational cross-sectional study conducted at King Saud University Medical City, Riyadh. The data were collected using a newly developed, self-administered online questionnaire. The questionnaire contained 3 sections: demographic information, knowledge, and attitudes which then sent to neurologist in Saudi Arabia from December 2016 to March 2017. RESULTS: A total of 106 neurologists met our inclusion criteria. Eighty percent of the participants had at least one epilepsy center in their city, and 78% indicated that they had access to adequate expertise and resources to enable the appropriate selection of epilepsy surgical candidates. Only 57.5% of the neurologists had a sufficient level of knowledge regarding epilepsy surgery. Neurologists with higher level of knowledge referred more patients to EMU and discussed epilepsy surgery more often with their patients. Overall, more than half of the neurologists (52.8%) had a positive attitude toward epilepsy surgery. There was a significantly positive correlation between the scores of knowledge and attitude (p less than 0.001). CONCLUSION: Neurologists in Saudi Arabia appear to have moderate knowledge of and positive attitudes toward epilepsy surgery. The place of the last neurology certificate, type of practicing hospital, and access to expertise and resources, affected their knowledge. Adequate knowledge was positively correlated with attitude.

The Risk Of Seizure-Related Hospitalization Among Older Adults On Levetiracetam Monotherapy: A Retrospective Comparative Cohort Study.

BACKGROUND: Antiepileptic drug monotherapy is the mainstay of treatment for epilepsy; however, the efficacy of different antiepileptic drugs in reducing the incidence of seizure-related hospitalization among older adults, who are at higher risk of developing epilepsy compared to their younger counterparts, has not been examined. PURPOSE: The objective of the present study was to compare the rate of seizure-related hospitalization among older adults on levetiracetam compared to different antiepileptic drugs (AEDs). PATIENTS AND METHODS: This was a retrospective cohort study of older adults (≥60 years) in two tertiary care hospitals. Patients who are 60 years of age and older, have a confirmed diagnosis of epilepsy, and are taking a single and the same antiepileptic drug for at least 36 months were included. The patients were followed up for 24 months after 12 months of treatment with no incidence of seizure-related hospitalization via their health records. Multiple Poisson regression with robust error variance was used to estimate the relative risk of hospitalization for patients on levetiracetam compared to different antiepileptic drugs controlling for age, gender, number of prescription medications, dosage strengths, and Charlson Comorbidity Index (CCI) score. RESULTS: One hundred and thirty-six patients met the inclusion criteria and were included in the study. The recruited patients were on one of the following four antiepileptic drugs: carbamazepine (n=44), levetiracetam (n=39), phenytoin (n=31), and valproic acid (n=22). Patients on levetiracetam were more than twice as likely to be hospitalized due to seizures within the 24 months of follow-up compared to their counterparts on other AEDs (RR=2.76, 95% CI=1.16-6.53, P=0.021). CONCLUSION: This study suggests that older adults on old generation AEDs such as phenytoin, carbamazepine, and valproic acid appear to have a lower risk of seizure-related hospitalization compared to their counterparts on levetiracetam.

Cognitive function assessment during 2 mA transcranial direct current stimulation in DLPFC in healthy volunteers.

Although cognitive function has been reported to change following the anodal transcranial direct current stimulation (tDCS) but still variable results have been reported in healthy subject and there is paucity of data on the cognitive effects of online tDCS. Therefore, we aimed to assess the online effect of tDCS over the left dorsolateral prefrontal cortex (DLPFC) on cognitive function and obtain safety data in healthy adults. We recruited 36 healthy (20 male) participants for this double-blind, sham-controlled parallel design. We used Stop Signal Task (SST) Go Trial and Pattern Recognition Memory (PRM) tests to evaluate cognitive function during 2 mA (20 min) anodal or sham tDCS stimulation over the left DLPFC. In active conditions, left dorsolateral prefrontal cortex was selected for electrode placement with reference over right supraorbital cortex. All related tasks were done during the online tDCS section in both groups (active/sham). There were statistically significant differences in cognitive function according to the PRM test (P = 0.003), SST (P = 0.021), and SST correct response time on Go Trials (P = 0.02) during active stimulation compared to the sham group. Our results reveal that cognitive performance is affected by a single dose of active online tDCS over DLPFC area compared to sham stimulation. In our study, tDCS is well-tolerated and safe that further supports the safety of tDCS in local healthy population.

Stroke during sleep and obstructive sleep apnea: there is a link.

OBJECTIVES: The onset of ischemic stroke symptoms has been established to have a diurnal variation, with a sizeable proportion (8-28%) occurring during sleep. Obstructive sleep apnea (OSA) has been established as an important risk factor for ischemic stroke. However, data on the relationship between OSA and wake-up stroke (WUS) has been scarce. The aim of our study is to determine the relationship between OSA and WUS. METHODS: This is a case-control study conducted on acute stroke patients who presented to one of two major medical centers in Riyadh of Saudi Arabia. Those who woke up with the symptoms were labeled as WUS, and those whose stroke occurred while awake were labeled as non wake-up stroke (NWUS). The Berlin Questionnaire, which was submitted to either the patient or his/her partner, was used to determine the frequency of OSA in the two groups. RESULTS: One hundred seven patients (60% males) with acute stroke were admitted between March 2016 and March 2017. Of the 40 patients with WUS, 29 (72.5%) had underlying OSA based on the Berlin Questionnaire, whereas only 30 (45%) of the 67 patients with NWUS have underlying OSA. Logistic regression analysis showed OSA is highly prevalent in the patients with WUS (OR = 3.25; 95% CI = 1.397-8.38; p = 0.0053). CONCLUSION: OSA is an important risk factor for ischemic stroke during sleep. Health care providers must be vigilant in inquiring about symptoms suggestive of OSA in every ischemic stroke patient, especially the patient whose stroke occurred during sleep.

Accuracy of seizure semiology obtained from first-time seizure witnesses.

BACKGROUND: Little is known of how accurately a first-time seizure witness can provide reliable details of a semiology. Our goal was to determine how accurately first-time seizure witnesses could identify key elements of an epileptic event that would aid the clinician in diagnosing a seizure. METHODS: A total of 172 participants over 17 years of age, with a mean (sd) of 33.12 (13.2) years and 49.4% female, composed of two groups of community dwelling volunteers, were shown two different seizure videos; one with a focal seizure that generalized (GSV), and the other with a partial seizure that did not generalize (PSV). Participants were first asked about what they thought was the event that had occurred. They then went through a history-taking scenario by an assessor using a battery of pre-determined questions about involvement of major regions: the head, eyes, mouth, upper limbs, lower limbs, or change in consciousness. Further details were then sought about direction of movement in the eyes, upper and lower limbs, the side of limb movements and the type of movements in the upper and lower limbs. Analysis was with descriptive statistics and logistic regression. RESULTS: One hundred twenty-two (71.4%) identified the events as seizure or epilepsy. The accuracy of identifying major areas of involvement ranged from 60 to 89.5%. Horizontal head movements were significantly more recognized in the PSV, while involvement of the eyes, lateralization of arm movement, type of left arm movement, leg involvement, and lateralization of leg movement were significantly more recognized in the GSV. Those shown the GSV were more likely to recognize the event as "seizure" or "epilepsy" than those shown the PSV; 78 (84.8%) vs 44 (55.7%), (OR 0.22, p < 0.0001). Younger age was also associated with correct recognition (OR 0.96, P 0.049). False positive responses ranged from 2.5 to 32.5%. CONCLUSION: First-time witnesses can identify important elements more than by chance alone, and are more likely to associate generalized semiologies with seizures or epilepsy than partial semiologies. However, clinicians still need to navigate the witness's account carefully for additional information since routine questioning could result in a misleading false positive answer.

The impact of old versus new antiepileptic drugs on costs and patient reported outcomes among older adults.

The aim of this prospective questionnaire-based cross-sectional study was to examine whether the new generation of Antiepileptic drugs (AEDs) with higher acquisition cost generate lower adverse effects than the old AEDs among a sample of 102 Arabic-speaking older adults (60 years of age or older) with seizure disorders. The mean scores of the Arabic version of the Liverpool Adverse Events Profile (LAEP), which assessed the adverse effects of the AEDs, did not differ between patients taking the old and new generations of AEDs. Despite their 4-fold higher cost, the new generation of AEDs were not characterized by lower LAEP scores of adverse effects. However, higher LAEP scores were associated with better health literacy. In conclusion, the use of new AEDs was not associated with lower self-reported adverse effects scores among Arabic-speaking older adults with seizure disorders despite their higher acquisition costs.