Developmental Venous Anomaly Presenting as an Acute Stroke Mimic.

Several mimics of acute ischemic stroke may complicate the decision to administer intravenous thrombolysis. Developmental venous anomalies (DVA) are fairly common variants of normal cerebral vasculature and may occasionally present with acute focal neurologic symptoms. We report a case of DVA presenting with the acute onset of focal neurologic deficits and focal hypodensities on the CT of the brain, resulting in a dilemma regarding whether to administer intravenous tissue-type plasminogen activator (IV tPA) for stroke thrombolysis. Recognition of subtle brain changes on the CT that were inconsistent with an acute ischemic stroke led to further imaging and a definitive diagnosis. Developmental venous anomalies should be considered in the differential diagnosis of acute ischemic stroke.

Risk Factors for Ischaemic Stroke in an Omani Community: A case-control study.

OBJECTIVES: Stroke is recognised as the third most common cause of mortality and it has an increasing incidence in developing countries. Recognition and control of risk factors are of prime importance in the prevention of stroke. This study aimed to examine the characteristics of ischaemic stroke (IS) patients in Oman and quantify its various risk factors using a case-control model. METHODS: This case-control study was conducted from January 2012 to March 2013 at Sultan Qaboos University Hospital and Royal Hospital, Muscat. Adult Omani patients with IS who were admitted to either hospital were compared to age- and gender-matched controls. Demographic factors and frequency of various conventional risk factors were documented. Univariate and stepwise multivariate logistic regression analyses were performed to evaluate the risk factors associated with IS. RESULTS: A total of 255 patients and age-and gender-matched controls were included in this study. The mean age was 62.2 ± 13.2 years and 63.14% were male. Most cases (89.02%) were above 45 years of age. Cardio-embolism (31.76%) was the commonest mechanism of IS. Stepwise multiple logistic regression model revealed that family history of stroke was the strongest independent risk factor, followed by hypertension and high-density lipoprotein levels (odds ratio: 10.10, 5.17 and 3.34, respectively; P <0.01 each). CONCLUSION: Cardio-embolism was the predominant mechanism of IS in this study. Family history of stroke, hypertension and reduced high-density lipoprotein were the leading independent risk factors. Strong emphasis on screening for risk factors, control of hypertension and lifestyle modification for those with a family history of stroke would be expected to emerge as the major stroke-preventive measures in Oman.

Different Strokes: A management dilemma.

Stroke is a common medical emergency resulting from numerous pathophysiological mechanisms and with varied clinical manifestations; as such, the diagnosis of stroke requires diligent clinical assessment. When different stroke syndromes occur in the same patient, it may cause a dilemma in terms of diagnosis and management. This continuing medical education article describes an interesting patient with recurrent neurological events, highlighting the complex pathophysiological processes associated with cerebrovascular syndromes. It offers readers the opportunity to apply their own basic neuroscience knowledge and clinical skills to solve the challenges encountered during the course of diagnosing and treating this patient. Specifically, the article aims to familiarise readers with an approach to diagnosing brainstem strokes and the diverse manifestations of a common stroke syndrome.

Spectrum of Cerebral Venous Thrombosis in Oman.

OBJECTIVES: Cerebral venous thrombosis (CVT) can have varied and life-threatening manifestations. This study aimed to examine the spectrum of its clinical presentations and outcomes in a tertiary hospital in Oman. METHODS: This retrospective study was conducted at the Sultan Qaboos University Hospital, Muscat, Oman, between January 2009 and December 2017. The medical records of all patients with CVT were reviewed to determine demographic characteristics, clinical features and patient outcomes. RESULTS: A total of 30 patients had CVT. The mean age was 36.8 ± 11 years and the male-to-female ratio was 2:3. Common manifestations included headache (83%), altered sensorium (50%), seizures (43%) and hemiparesis (33%). Underlying risk factors were present in 16 patients (53%). Computed tomography or magnetic resonance imaging of the brain was abnormal in all patients, with indications of infarcts (40%) and major sinus thrombosis (100%). There were five cases (20%) of deep CVT. The patients were treated with low-molecular-weight heparin, mannitol and anticonvulsants. The majority (77%) had no residual neurological deficits at follow-up. CONCLUSION: These findings indicate that CVT is a relatively uncommon yet treatable disorder in Oman. A high index of suspicion, early diagnosis, prompt anticoagulation treatment and critical care may enhance favourable patient outcomes.

Full Outline of UnResponsiveness score and Glasgow Coma Scale in medical patients with altered sensorium: interrater reliability and relation to outcome.

PURPOSE: Full Outline of UnResponsiveness, or FOUR score (FS), is a recently described scoring system for evaluation of altered sensorium. This study examined interrater reliability for FS and Glasgow Coma Scale (GCS) among medical patients with altered mental status and compared outcome predictability of GCS, FS, and Sequential Organ Failure Assessment score. PATIENTS AND METHODS: Adult patients with altered mental status due to medical causes were rated by neurology consultants and internal medicine residents on FS and GCS. Interobserver reliability for GCS and FS was assessed using κ score. Relation with outcomes was explored using univariate and multivariate analyses. MAIN RESULTS: Of the 100 patients (age, 62 ± 17 years), 60 had neurologic conditions; 26, metabolic encephalopathy; 9, infections; and 7, others. Thirty-nine patients died at 3 months. κ Scores ranged from 0.71 to 0.85 for GCS and from 0.71 to 0.95 for FS. On multivariate analysis, GCS was predictive of outcome at 3 months; FS was predictive of mortality. Area under the receiver operating characteristic curves suggested equivalent performance of both scoring systems. CONCLUSIONS: Interrater reliability and outcome predictability for FS were comparable with those for GCS. This study supports the use of FS for evaluation of altered mental status in the medical wards.

Transcranial Doppler ultrasonography in acute ischemic stroke predicts stroke subtype and clinical outcome: a study in Omani population.

BACKGROUND: Transcranial Doppler ultrasonography (TCD) is being increasingly used for its ability to provide cerebral hemodynamic information in stroke. Few studies have explored its association with cerebral arteriographic changes and stroke subtype. This study explored the relation of TCD changes in acute stroke with stroke subtypes, MR cerebral arteriography and clinical outcome in Omani population. METHODS: Adult patients presenting with acute ischemic stroke within 4 days of stroke onset were subjected to TCD through the temporal and suboccipital windows using a 2 MHz probe; flow velocities, pulsatility and direction of flow were recorded from arteries at the skull base. MR arteriographic (MRA) changes on corresponding arteries were graded on a scale of 1-4. ANOVA, student's t test and ROC analysis were used to evaluate TCD in relation to stroke type, outcome and stenosis on MRA. RESULTS: Of 60 patients recruited, 52 (M:F::36:16; mean age: 60 + 13 years) had adequate bone window for TCD study. Large artery stroke occurred in 30 (58%) patients; lacunar stroke-11 (21%); cardioembolic and mixed groups 9 (17%), other specificed causes-2 (4%). 86.5% had evidence of intracranial disease. 10/52 patients (19%) died while 33 (63%) had good outcome (modified Rankin Score 0-3). Of the 186 arteries studied by the two methods, 52 had TCD evidence of stenosis while 42 were abnormal on MRA, giving a sensitivity of 60%, specificity: 81.25%; positive likelihood ratio: 3.18 and negative likelihood ratio: 0.5. 29/52 (56%) of patients had TCD changes in the arteries corresponding to stroke location. Abnormal TCD was associated with large artery strokes (p = 0.007), poor outcome (p = 0.038) and mortality (p = 0.01). CONCLUSION: This study of TCD in acute stroke in Omani population demonstrates a relatively higher burden of intracranial arterial disease. TCD changes are associated with type of stroke and outcome in this population. TCD is a simple and fairly useful method of evaluation in patients with acute stroke. Adopting TCD in evaluation of stroke patients may provide useful information regarding the pathophysiology which could enhance patient management.

Perception of stroke and knowledge of potential risk factors among Omani patients at increased risk for stroke.

BACKGROUND: Previous studies have demonstrated poor knowledge of stroke among patients with established risk factors. This study aims to assess the baseline knowledge, among patients with increased risk for stroke in Oman, of warning symptoms of stroke, impending risk factors, treatment, and sources of information. METHODS: In April 2005, trained family practice residents at Sultan Qaboos University Hospital Clinics (cardiology, neurology, diabetic, and lipid clinics), using a standardised, structured, pre-tested questionnaire, conducted a survey of 400 Omani patients. These patients all demonstrated potential risk factors for stroke. RESULTS: Only 35% of the subjects stated that the brain is the organ affected by a stroke, 68% correctly identified at least one symptom/sign of a stroke, and 43% correctly identified at least one stroke risk factor. The majority (62%) did not believe they were at increased risk for stroke, and 98% had not been advised by their attending physician that their clinical conditions were risk factors for stroke. In the multivariable logistic regression analysis, lower age and higher levels of education were associated with better knowledge regarding the organ involved in stroke, stroke symptoms, and risk factors. CONCLUSION: Because their knowledge about stroke risk factors was poor, the subjects in this study were largely unaware of their increased risk for stroke. Intensive health education is needed to improve awareness of stroke, especially among the most vulnerable groups.