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.

EEG criteria for diagnosing nonconvulsive status epilepticus in comatose - An unsolved puzzle: A narrative review.

Introduction: Nonconvulsive status epilepticus (NCSE) is an important and often unrecognized cause of impaired awareness especially in critically ill patients, which can easily be missed. Electroencephalography (EEG) findings in clinically suspected cases are the mainstay of diagnosis. Review summary: The EEG diagnostic criteria for NCSE have evolved over the past three decades. Furthermore, recent advancements in EEG technologies such as continuous EEG monitoring, and emergency department EEG, along with development of different diagnostic criteria, have increased the detection rate for NCSE in suspected cases. However, treating physicians should have a higher index of clinical suspicion and a lower threshold for recommending this valuable investigation. The introduction of different diagnostic criteria has made it easier for electroencephalographers to report NCSE; nevertheless, diagnosis is not always straightforward. This narrative review aimed to define and discuss the available literature on different EEG diagnostic criteria for NCSE. Conclusion: There is a need for further prospective research to strengthen the diagnostic accuracy of the available diagnostic criteria, the modified Salzburg Consensus Criteria for NCSE (mSCNC) and updated American Clinical Neurophysiology Society (ACNS) 21 criteria, to verify their accuracy to detect NCSE in comatose patients.

Association between glycated hemoglobin and functional outcomes in patients with intracranial large artery atherosclerotic disease-related acute ischemic stroke: identifying the magic number.

Objective: This study aimed to investigate the effect of the glycated hemoglobin A1c (HbA1c) level on the functional outcome (FOC) in patients with intracranial large artery atherosclerotic disease (ICLAD)-related acute ischemic stroke (AIS). Methods: This retrospective study enrolled patients with ICLAD-related AIS who were admitted to King Fahd University Hospital between January 2017 and September 2021. Patients were divided into two groups based on the optimal cutoff HbA1c level determined using receiver operating characteristic curve analysis-those with HbA1c ≤6.9% and those with HbA1c >6.9%. Demographic and other clinical characteristics were compared between the two groups using chi-square tests. The association between HbA1c and 90-day FOC was assessed using the chi-square test and odds ratios (ORs). Multivariate analysis was performed to adjust for confounding factors. Results: A total of 140 patients were included in the analysis. A significant association was observed between the HbA1c level and FOC. Compared to patients with HbA1c ≤6.9%, patients with HbA1c >6.9% were more likely to have an unfavorable FOC [p = <0.001, OR = 2.05, 95% confidence interval (CI) = 1.33-3.14]. The association between HbA1c >6.9% and unfavorable FOC was sustained even after adjusting for confounding factors (p = 0.008) and atherosclerosis risk factors (p = 0.01). HbA1c >6.9% was also associated with higher ORs for in-hospital complications (p = 0.06, OR = 1.34, 95% CI = 1.02-1.77) and mortality (p = 0.07, OR = 1.42, 95% CI = 1.06-1.92) although these associations did not attain significant p-values. Conclusion: HbA1c >6.9% was significantly associated with unfavorable FOC in ICLAD-related AIS. However, further studies with larger sample sizes are required to verify whether HbA1c is an independent predictor of poor FOC. Nevertheless, targeting HbA1c <7% should be the goal of physicians when managing patients at high risk of ICLAD.

Important Factors to Expect the Outcome After Intracerebral Hemorrhage: An Observational Study From a University Hospital in Saudi Arabia.

BACKGROUND: Intracerebral hemorrhage (ICH) has worse clinical outcomes than other stroke types. The risk factors contributing to ICH outcomes are not entirely understood, and published literature from Saudi Arabia on ICH outcomes is limited. Our goal was to study the specific clinical and imaging determinants of ICH outcomes. METHODS: We retrospectively retrieved all patients with spontaneous ICH (SICH) from a prospective King Fahd Hospital University registry between 2017 and 2019. The clinical characteristics of ICH events and data on clinical outcomes (6 to 12 mo) were recorded. Groups of patients with a favorable modified Rankin Scale of 0 to 2 and nonfavorable outcomes of a modified Rankin Scale of 3 to 6 were investigated. The relationship between the clinical characteristics of the SICH event and its outcomes was assessed using linear and logistic regression analyses. RESULTS: A total of 148 patients with a mean age of 60.3 years (±15.2) and a median follow-up of 9 months were included. Unfavorable outcomes were reported in 98 patients (66.2%). The ICH event variables associated with unfavorable outcomes were impaired renal function, Glasgow Coma Score <8, hematoma volume, hematoma expansion, and intraventricular extension (IVE). CONCLUSIONS: Our study demonstrated important clinical and radiologic features in patients with ICH that may affect their clinical long-term functional outcomes. A larger multicenter study is required to validate our results and evaluate the methods to improve health care in patients with SICH.

Prevalence and Clinico-Radiologic Spectrum of Intracranial Atherosclerotic Disease-Related Stroke: An Observation from a Single Center in Saudi Arabia.

BACKGROUND: Intracranial atherosclerotic disease (ICAD) is an important etiologic subtype of acute ischemic stroke (AIS). However, little direct evidence is available regarding ICAD-related stroke in Saudi Arabia (SA). This study aimed to identify the prevalence and describe the clinico-radiological spectrum of ICAD-related AIS in a SA cohort. METHODS: This was a hospital-based retrospective study enrolling patients with ICAD-related AIS between 2017 and 2020. The electronic charts were reviewed. The mechanisms of stroke were identified as artery-to-artery embolization (AAE), in situ thrombotic occlusion, hypoperfusion, or perforator branch occlusion. Pearson's χ 2 test was performed to calculate the P values to establish the statistical significance of factors that could correlate with the mechanisms of stroke and functional outcome. RESULTS: ICAD was found in 133 of AIS comprising 26% of total. Data from all patients were reviewed. Left ICA (25%) was the most frequently affected vessel. Territorial pattern (63.9%) was the most common infarct pattern, and AAE (44.3%) was the most common underlying mechanism. Perforator branch occlusion was more prevalent in women than in men. Malignant and hemorrhagic transformation ( P =0.00) were more prevalent in the AAE group. Left-sided vascular involvement was statistically associated with unfavorable outcomes than the right ( P =0.019). CONCLUSIONS: The prevalence of ICAD in our cohort from Western Asia did not differ from that in Southern Asia. ICA involvement was observed more frequently than previously reported. Further research from SA is required to better understand ICAD-related strokes in this region.

Estimated prevalence study of attention-deficit/hyperactivity disorder among eastern province children in the Kingdom of Saudi Arabia.

Background: Studying mental disorders in children is significantly important due to the huge suffering of educational and psychosocial impairments in adult life. Attention-deficit/hyperactivity disorder (ADHD) is considered the most common mental disorder in children, especially in early school-aged children. It manifests in about 8%-12% of children in the world. In Saudi Arabia, it affects 4%-12% of children. Objective: The study aimed to count the number of undiagnosed ADHD cases and the associated risk factors in Eastern Province in Kingdom of Saudi Arabia (KSA). Methods: A cross-sectional study was performed among girls' and boys' children aged 6-10 years old in Eastern Province in KSA with a random selection of parents. Sample size is equal to 1658. The assessment was done by an online questionnaire filled it by parents using Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition diagnostic criteria and Connor's scale of ADHD excluding any developmental or mental disorder at the beginning of the questionnaire. Results: After excluding the participants who were diagnosed with behavioral and growth developmental disorder, the remaining 1430 have been screened for ADHD based on Connor's scale. 185 of a child out of 1430 were suggested to have ADHD, of which 10 out of them show the signs of ADHD, 76 of them have moderately severe ADHD, and 99 out of them have atypical or severe ADHD based on Connor's scale of ADHD. The study shows that there is a significant relationship between the positive screening of ADHD and gender males (71.35%), females (28.64%), family history (20.5%), nervous system diseases (4.32%), brain damage from trauma (9.72%), smoking habit of the mother (8.64%), smoking during pregnancy (3.78%), mother exposure to second-hand smoking (42.16%), child exposure to a toxic substance like lead during the early life (1.62%), and the preterm labor (15.13%). However, the study shows there is no significant relationship between the positive screening of ADHD with age, drinking alcohol, and central nervous system infection. Conclusion: The prevalence of undiagnosed ADHD is slightly high. Also, it has many causes of ADHD including gender, smoking, parental psychiatric disorders, and obstetric and pregnancy problems.

Résumé Background: L'étude des troubles mentaux chez les enfants est d'une importance considérable en raison des souffrances liées aux difficultés scolaires et psychosociales qui perdurent à l'âge adulte. Le trouble du déficit de l'attention avec hyperactivité (TDAH) est considéré comme le trouble mental le plus courant chez les enfants, notamment chez les enfants d'âge scolaire précoce. Il se manifeste chez environ 8% à 12% des enfants dans le monde. En Arabie saoudite, il touche entre 4% et 12% des enfants. Objective: L'étude visait à dénombrer le nombre de cas de TDAH non diagnostiqués et les facteurs de risque associés dans la province orientale du Royaume d'Arabie saoudite (KSA). Methods: Une étude transversale a été réalisée auprès d'enfants de filles et de garçons âgés de 6 à 10 ans dans la province orientale de l'Arabie saoudite, en utilisant une sélection aléatoire des parents. La taille de l'échantillon est égale à 1658. L'évaluation a été réalisée à l'aide d'un questionnaire en ligne rempli par les parents, en utilisant les critères diagnostiques du Manuel diagnostique et statistique des troubles mentaux, cinquième édition, ainsi que l'échelle de Connor pour le TDAH, en excluant tout trouble du développement ou trouble mental au début du questionnaire. Résultats: Après exclusion des participants ayant été diagnostiqués avec un trouble du comportement et du développement, les 1430 restants ont été dépistés pour le TDAH à l'aide de l'échelle de Connor. Parmi ces enfants, 185 ont été suggérés d'avoir un TDAH, dont 10 présentent des signes de TDAH, 76 présentent un TDAH modérément sévère et 99 présentent un TDAH atypique ou sévère selon l'échelle de Connor. L'étude révèle qu'il existe une relation significative entre le dépistage positif du TDAH et le genre masculin (71,35 %), féminin (28,64 %), les antécédents familiaux (20,5 %), les maladies du système nerveux (4,32 %), les lésions cérébrales suite à un traumatisme (9,72 %), la consommation de tabac par la mère (8,64 %), la consommation de tabac pendant la grossesse (3,78 %), l'exposition de la mère à la fumée secondaire (42,16 %), l'exposition de l'enfant à une substance toxique comme le plomb pendant la petite enfance (1,62 %) et le travail prématuré (15,13 %). Cependant, l'étude montre qu'il n'existe aucune relation significative entre le dépistage positif du TDAH et l'âge, la consommation d'alcool et les infections du système nerveux central. Conclusion: La prévalence du TDAH non diagnostiqué est légèrement élevée. De plus, il existe de nombreuses causes du TDAH, dont le genre, le tabagisme, les troubles psychiatriques des parents, ainsi que les problèmes obstétriques et durant la grossesse. Mots-clés: Attention, trouble du déficit de l'attention/hyperactivité, Province orientale, hyperactivité, Royaume d'Arabie saoudite.

Whole-exome sequencing of a Saudi epilepsy cohort reveals association signals in known and potentially novel loci.

BACKGROUND: Epilepsy, a serious chronic neurological condition effecting up to 100 million people globally, has clear genetic underpinnings including common and rare variants. In Saudi Arabia, the prevalence of epilepsy is high and caused mainly by perinatal and genetic factors. No whole-exome sequencing (WES) studies have been performed to date in Saudi Arabian epilepsy cohorts. This offers a unique opportunity for the discovery of rare genetic variants impacting this disease as there is a high rate of consanguinity among large tribal pedigrees. RESULTS: We performed WES on 144 individuals diagnosed with epilepsy, to interrogate known epilepsy-related genes for known and functional novel variants. We also used an American College of Medical Genetics (ACMG) guideline-based variant prioritization approach in an attempt to discover putative causative variants. We identified 32 potentially causative pathogenic variants across 30 different genes in 44/144 (30%) of these Saudi epilepsy individuals. We also identified 232 variants of unknown significance (VUS) across 101 different genes in 133/144 (92%) subjects. Strong enrichment of variants of likely pathogenicity was observed in previously described epilepsy-associated loci, and a number of putative pathogenic variants in novel loci are also observed. CONCLUSION: Several putative pathogenic variants in known epilepsy-related loci were identified for the first time in our population, in addition to several potential new loci which may be prioritized for further investigation.

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.

Non-HDL Cholesterol, Obesity, and Metabolic Syndrome in Epileptic Patients.

Objective: To compare cardiovascular risk factors in patients with epilepsy with those of non-epileptic neurologic patients to determine their association with antiepileptic drug therapy.Methods: This observational study with a cross-sectional design was performed in a tertiary care hospital in the Eastern Province of Saudi Arabia from January to December 2018. A total of 110 patients with epilepsy were included in the study, along with 46 age- and sex-matched non-epileptic controls (approximate ratio of 2:1). Blood pressure reading (BP), anthropometric measurements, fasting blood sugar levels, and fasting lipid profiles were performed for all subjects.Results: Raised non-high-density lipid cholesterol (nHDLC) was the most common cardiovascular risk in epileptic patients, with a frequency of 51% compared to 30.4% in controls (P = .019). Epileptic patients who were male (58.3%, 28/48, P = .012) and those aged < 35 years (47.3%, 26/55, P = .036) were more likely to have high nHDLC. Obesity was also common in epileptic patients with frequency of 49.1% (n = 54) versus 30.4% (n = 14) in controls (P = .032). Metabolic syndrome was present in 26.3% of epileptic patients versus 23.9% of controls (P = .749). Among the epileptic patients, of those with high nHDLC, 85.7% had satisfactory seizure control (P = .019).Conclusions: Raised nHDLC and obesity but not metabolic syndrome appear to be highly prevalent in epileptic patients compared to those without epilepsy. Antiepileptic drugs alone may not play a role in developing high lipid levels. More studies are needed to determine the causes of higher risk factor profile in epileptic patients and their relationship with seizure control.

Thymectomy in Myasthenia Gravis: A Narrative Review.

Myasthenia gravis (MG) is a rare condition caused by autoantibodies against acetylcholine receptors on postsynaptic membrane that leads to weakness of skeletal muscles. About 7 of 10 patients with MG have thymic hyperplasia and about 1 of 10 patients have thymoma. Thymectomy has increasingly been used as a treatment modality for MG. Several observational studies have shown that thymectomy results in improvement in MG and a randomized trial has established that thymectomy leads to a better outcome in non-thymomatous generalized MG. However, thymectomy is yet controversial in some disease subtypes and there are potential concerns regarding the selection of the ideal surgical approach to achieve complete removal of the thymic tissue to achieve stable remission rates. This review highlights the role of thymectomy in non-thymomatous and thymomatous MG, the effectiveness of various thymectomy methods, postoperative myasthenic crisis, and remission after thymectomy.

Spontaneous Simultaneous Bilateral Basal Ganglia Hemorrhage (SSBBGH): Systematic Review and Data Analysis on Epidemiology, Clinical Feature, Location of Bleeding, Etiology, Therapeutic Intervention and Outcome.

Background: Spontaneous simultaneous bilateral basal ganglia hemorrhage (SSBBGH) is an extremely rare condition with only a few published case reports and series. However, there is no systematic review that has been published yet. Objective: The study aims to conduct a systematic review on spontaneous simultaneous bilateral basal ganglion bleeding and a descriptive statistical analysis of collected data on epidemiology, clinical features, etiology, therapeutic approach and prognosis. This review aims to be a clinical reference for busy clinicians when they are faced with such a rare condition. Methodology: This review has been carried out in accordance with recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Results: Review of 60 cases showed that SSBBGH affected predominantly male patients (70%) with an average age of 50.8 ± 15.33 years and the male-to-female ratio was 2.5:1. The female patients tend to be older with an average age of 54.22 ± 16.67 years. Location of SSBBGHwas more common in the putamen (90% vs 10% non-putaminal). SSBBGH posed a significant mortality rate (33.33%). Among patients who survived, only 40.6% (13/32 report) have had favorable outcomes (mRS ≤2) and the remaining 59.4% (19/32) ended up with poor functional status (mRS ≥3-5). The most common implicated etiologies were hypertension followed by alcohol intoxication. Conclusion: SSBBGH is a rare clinical entity with significant morbidity and mortality. Systemic approach can lead to early recognition of etiology and prompt treatment. Hypertension and the putamen are the most common etiology and location of SSBBGH, respectively. History of hypertension and age can help narrow differential diagnosis and limit unnecessary testing or intervention.

Driving Habits Among Patients With Epilepsy in a Tertiary Care Hospital in Saudi Arabia.

Objective: Patients with epilepsy are instructed to avoid high-risk situations such as certain occupations and driving to prevent harm to themselves and others. There is considerable variation in standards to decide if a patient with epilepsy is fit to drive among various countries worldwide, and these patients often continue to drive despite being advised not to. The objective of this study was to determine if patients with epilepsy and uncontrolled epilepsy are driving, the awareness of epilepsy patients regarding driving, and whether physicians are advising the patients to stop driving.Methods: A clinic-based study was conducted in Saudi Arabia from June 2018 through January 2019 with structured interviews of consecutively recruited male patients with established epilepsy diagnosis. Demographic factors, employment status, control of seizures, and awareness of driving restrictions were documented.Results: The response rate was 80.6%. Of the 121 participants (mean age of 35.97 years), 110 (90.9%) were driving, and 39% of those patients were married. Also, 76.9% of participants were employed. Of the participants, 48.8% had 1 seizure in the last 6 months, and 88% of those patients were driving; 51.2% had not had a seizure in the last 6 months, and 93% of those patients were driving. Additionally, 17.4% reported a seizure attack while driving. Only 38% of respondents were aware they should stop driving, whereas 62% were unaware of driving restrictions.Conclusions: There is a definite need to establish a driving policy for patients with epilepsy and to optimize the standards of care of epilepsy patients in Saudi Arabia to ensure minimization of harm to both patients and the public.

Body mass index and its association with various features of migraine: A cross-sectional study from Saudi Arabia.

Introduction: Migraine is a highly prevalent condition, and prevalence of obesity is also increasing. Results of studies addressing association of body mass index (BMI) with migraine and its features are conflicting. In this cross-sectional study, we aim to assess association between BMI and various migraine features. Methods: This study was conducted in the Headache Clinic of King Fahd Hospital of University, Al Khobar, Saudi Arabia. Interviews were conducted by three consultant neurologists. Migraine was defined according to the International Headache Society and BMI was calculated as weight (kilograms)/height (m2). Results: Of total of 121 patients, 79% were female. Almost 87.6% of patients were taking prophylactic medications. Majority of patients had attack for more than 24 h (60.3%), pulsating character (81%), moderate-to-severe intensity (92.6%), associated with nausea and/or vomiting (75.2%), and photophobia/phonophobia (91.7%). About 29.8% of patients were normal weight, 28.1% were overweight, and 39.7% were obese and morbidly obese. There was insignificant association between various categories of BMI and features of migraine, that is, unilateral location (P = 0.385), pulsating character (P = 0.571), moderate-to-severe intensity (P = 0.187), nausea and/or vomiting (P = 0.582), and photophobia and/or phonophobia (P = 0.444). Conclusion: In our study, we did not find an association between BMI and various features of migraine.

RésuméIntroduction: La migraine est une maladie très répandue, et la prévalence de l'obésité est également en augmentation. Résultats des études portant sur l'association de l'indice de masse corporelle (IMC) avec la migraine et ses caractéristiques sont contradictoires. Dans cette étude transversale, nous visons à évaluer l'association entre IMC et diverses caractéristiques de la migraine. Méthodes: Cette étude a été menée à la Headache Clinic de l'hôpital King Fahd de l'Université, Al Khobar, Arabie Saoudite. Les entretiens ont été menés par trois neurologues consultants. La migraine a été définie selon l'International La Headache Society et l'IMC ont été calculés en poids (kilogrammes)/taille (m2). Résultats: Sur un total de 121 patients, 79 % étaient des femmes. Presque 87,6 % des patients prenaient des médicaments prophylactiques. La majorité des patients ont eu une attaque pendant plus de 24h (60,3%), caractère pulsatile (81%), intensité modérée à sévère (92,6 %), associée à des nausées et/ou vomissements (75,2 %) et photophobie/phonophobie (91,7 %). Environ 29,8 % des les patients avaient un poids normal, 28,1 % étaient en surpoids et 39,7 % étaient obèses et obèses morbides. Il y avait une association insignifiante entre diverses catégories d'IMC et caractéristiques de la migraine, c'est-à-dire localisation unilatérale (P = 0,385), caractère pulsatile (P = 0,571), modéré à sévère intensité (P = 0,187), nausées et/ou vomissements (P = 0,582) et photophobie et/ou phonophobie (P = 0,444). Conclusion: Dans notre étude, nous n'ont pas trouvé d'association entre l'IMC et diverses caractéristiques de la migraine. Mots-clés: Indice de masse corporelle, fréquence, migraine, obésité, gravité.

Preventable Etiologies of Epilepsies in Saudi Arabia: A Tertiary Care Experience.

Objective: To determine the etiologies of epilepsy in a cohort of patients using the International League Against Epilepsy 2017 classification system and to determine frequencies of preventable causes and their clinical characteristics.Methods: Epileptic patients in neurology clinics at a tertiary care hospital were prospectively recruited from June 1, 2018, to November 30, 2018. Patients were divided according to their respective etiologic categories. Traumatic brain injury, stroke, hypoxic-ischemic encephalopathy, and central nervous system infections were considered preventable etiologies.Results: A total of 160 patients were included in the study. Of these patients, 61 had epilepsy of unknown etiology, while among the remaining 99 patients in whom etiology could be identified, traumatic brain injury was the most frequent overall cause with 17 (17.2%) cases. Frequencies in other etiologies were genetic (idiopathic generalized epilepsy): n = 14, stroke: n = 13, hypoxic-ischemic encephalopathy: n = 13, cerebral tumors: n = 10, mesial temporal sclerosis: n = 9, cortical malformation: n = 7, and other structural pathologies: n = 5. Other rarer causes (including central nervous system infections) had less than 5 patients each. When the preventable etiologies were grouped, they formed 46 of 99 patients (46.5%) with identifiable etiology. Seizure control was mostly satisfactory in the total sample (126/160 [78.8%]), including patients with preventable etiologies, of whom 50% were on polytherapy.Conclusions: Epilepsies with preventable etiologies are common in our clinics. Studies are needed in other centers to identify epilepsy etiologies and confirm our findings, which may help determine better strategies for primary prevention of epilepsy.

Management of Free-Floating Thrombus in the Vertebral Artery in a Middle-Aged Smoker with Secondary Polycythemia Vera.

Free-floating thrombus (FFT) of the cervicocranial arteries is a rare neurovascular condition. Up to now, there is no standardized definition for FFT. Therefore, FFT is occasionally mistaken for intraluminal thrombus (ILT) or smooth mural thrombus. The most precise and ideal definition of FFT would be a long-extended intraarterial thrombus that is attached to the arterial wall with its one end, while its other end is surrounded by blood flow and moves freely with the cardiac cycle. FFT usually manifests as an ischemic stroke, thus it is considered as an emergency case. Herein, we report a rare case of symptomatic FFT in the left vertebral artery extending from V0 to V2 segments in a middle-aged smoker, who presented with multiple embolic strokes in different territories of posterior circulation and was successfully treated medically. This case sheds light on the challenges of the clinical approach of FFT in the vertebral artery and it is an attempt to draw attention to the necessity of conducting a large-scale study to find out the ideal approach to manage such conditions.

Migraine Prevalence, Characteristics, Triggers, and Coping Strategies Among Medical Students in Saudi Arabia.

Objective: To determine the prevalence, characteristics, and triggers of migraine and coping strategies used among medical students in Saudi Arabia.Methods: This cross-sectional descriptive study was conducted among undergraduate students in the College of Medicine of Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia. Included students were in their second to sixth academic year of the Bachelor of Medicine or Bachelor of Surgery programs during the 2019-2020 academic year. The diagnosis of migraine was made according to the International Classification of Headache Disorders, Third Edition criteria.Results: A total of 396 students participated in the study; 238 (60.1%) were female and 158 (39.9%) were male. Their age ranged between 18 and 26 years old, with a mean age of 21.32 ± 1.659 years. Only 16 of 396 students fulfilled the criteria for migraine, with a prevalence of 4.04%. Migraine prevalence was higher in females (n = 11, 4.6%) compared to males (n = 5, 3.1%), with a female:male ratio of 1.5:1. The most common triggers associated with migraine were study-related stress (88%) and emotional-related stress (81%).Conclusions: This project was undertaken to evaluate prevalence, triggers, and coping strategies of migraine among medical students. The prevalence of migraine headache in this study was lower compared to other national and international universities, with a higher female to male ratio. Stress was a major trigger among our study population. The findings of this study will add to the growing body of literature on migraine.

Large Vessel Occlusion Causing Cerebral Ischemic Stroke in Previously Healthy Middle-Aged Recently Recovered from Severe COVID-19 Infection.

BACKGROUND: Severe acute respiratory syndrome coronavirus (SARS-CoV-2) due to novel coronavirus disease 2019 (COVID-19) has led to an unprecedented worldwide pandemic with diverse respiratory symptoms as well as systemic manifestations and complications. The neurological manifestations of COVID-19 include, but are not limited to, headache, cerebrovascular disease, and skeletal muscle injury. CASE REPORT: Herein, we present a case of stroke with large vessel occlusion in a middle-aged man, who recently recovered from severe SARS-CoV-2 infection. This patient is not known to have any medical illness or surgical history and has no cerebrovascular risk factors. Moreover, the patient underwent extensive investigations, including neuroimaging, cardiac and laboratory work-up with no evidence of stroke etiology. CONCLUSION: The mechanism of cerebrovascular events in the setting of COVID-19 is still uncertain and probably multi-factorial. The prevailing hypothesis is a strong thrombotic tendency, which may even be prolonged after complete recovery. In our patient's case, hypercoagulability in the context of viral infection is the most likely mechanism for the stroke. Further studies are needed to find out the exact pathogenesis of thromboembolic events in the setting of COVID-19 infection as well as the efficacy, safety, dosage, and duration of anticoagulants in such conditions.

Miller Fisher Variant of Guillain-Barré Syndrome Triggered by Ventilator-Associated Pneumonia.

BACKGROUND: Miller Fisher syndrome (MFS), a triad of ophthalmoplegia, areflexia and ataxia, is one of the regional variants of Guillain-Barré syndrome (GBS) that might account for a quarter of all cases of GBS, especially in Asian countries. There is history of an antecedent upper respiratory tract infection in up to two thirds of MFS cases. However, association of MFS in adults and pneumonia is rarely reported and in those cases causative pathogen was Mycoplasma pneumonia e. To our knowledge, association of MFS and ventilator-associated pneumonia has never been reported. So, we hereby report the first case of MFS which followed ventilator-associated pneumonia (VAP). CASE REPORT: We report case of a 22-year-old male who was known to have temporal lobe epilepsy and mental retardation. He presented with status epilepticus. He was sedated and put on mechanical ventilation. Two days later, he developed a fever associated with increased tracheobronchial secretions and new infiltrates on chest X-ray. Diagnosis of VAP was made. Upon improvement, he was extubated and shifted out of ICU. Ten days after the onset of fever, he developed gradual onset bulbar weakness and ataxia. On examination, he had generalized areflexia and ataxia. CSF analysis showed cytoalbuminic dissociation. Antibodies against ganglioside complex were elevated. Diagnosis of sero-negative MFS was made, and intravenous immunoglobulin (IVIG) was started. He improved remarkably within two days. CONCLUSION: MFS is immune-mediated entity which is usually triggered by upper respiratory tract infection but in rare cases it can be consequence of pneumonia including VAP. Further research is needed to establish link between MFS and VAP.

Hypertensive Intracerebral Hemorrhage in Young Patients From a Tertiary Care Center in Saudi Arabia: An Observational Study.

Objective: Young patients with intracerebral hemorrhage (ICH) make up a small but important subgroup of patients with ICH. This study investigated the clinical characteristics and outcomes of hypertensive ICH in very young (18-45 years) and young (46-55 years) patients.Methods: This was a retrospective study of patients aged 18-55 years with hypertensive ICH admitted to a hospital from April 2014 to April 2019. Clinical and radiologic features as well as long-term clinical outcomes were compared between 2 age groups: group 1 (18-45 years) and group 2 (46-55 years). Factors affecting the clinical outcome were investigated as well.Results: Of 63 patients with hypertensive ICH, 24 (38.1%) were in group 1 (mean ± SD age of 38 ± 4.6 years), and 39 (61.9%) were in group 2 (50 ± 2.5 years). The risk factor profile was similar except for diabetes, which was more prevalent in group 1 (odds ratio [OR] = 4.65; 95% CI, 1.4-15.2). Patients in group 1 had higher mean ± SD NIH Stroke Scale scores (15.7 ± 4.6, P = .044), had lower Glasgow Coma Scale (GCS) scores (OR = 3.33; 95% CI, 1.0-10.8), were at higher risk of intubation (OR = 2.79; 95% CI, 1.1-9.9), and had higher ICH volume (21 ± 18, P = .034). Worse clinical outcome was higher in group 1 (OR = 5.14; 95% CI, 1.0-26.1). Low GCS score, mean hematoma volume, and intraventricular extension were independently associated with worse outcome.Conclusions: Relatively young patients with hypertensive ICH have higher prevalence of diabetes and worse clinical outcome in comparison to older patients with hypertensive ICH. Such patients should be monitored and treated more aggressively.