Successful Use of Neurovascular Plug for Embolization of Scalp Arteriovenous Fistula: A Novel Technique.

PURPOSE: We report a case of a pediatric patient developing a delayed-onset scalp arteriovenous fistula (AVF) and pseudoaneurysm managed with a new technique. TECHNIQUE: A 10-year-old boy presented to the outpatient clinic complaining of a growing pulsatile mass in the right side of the skull after head trauma 6 months ago. He had no neurological deficits. Imaging studies revealed scalp AVF with pseudoaneurysm. The arterial feeding was from the right temporal artery, while the blood was drained into the superior sagittal sinus and the facial vein. The fistula was occluded successfully by a microvascular plug (MVP). Follow-up angiography 1 year later showed that the AVF was no longer seen with complete embolization of pseudoaneurysm, total occlusion of the abnormal vessels, and the absence of MVP migration. CONCLUSION: To the best of our knowledge, we report the first case of successfully using MVP to treat scalp AVF. The MVP is a novel technique with its unique ability to achieve rapid, safe, effective, and permanent vascular occlusion through a single device. Besides, the possibility of delayed-onset traumatic vascular injuries should be considered in a patient with head or facial trauma.

Ventriculo-femoro-caval shunt: a salvage surgery.

Ventriculo-femoral vein shunts have been described in few case reports as an alternative for treating complex cases of hydrocephalus in which other accesses are discarded. To our best knowledge, only 6 cases have been reported in the literature to date. We present a case of a 2-year-old female patient with hydrocephalus secondary to neonatal sepsis and meningitis. Patient was operated with various types of shunting procedures, such as ventriculo-peritoneal (V-P) shunt, ventriculo-atrial (V-A) shunt, ventriculo-pleural (V-PL) shunt, ventriculo-vesical shunt, ventriculo-superior sagittal sinus (V-SSS) shunt, and ventriculo-caval (V-C) shunt. All previous procedures were unsuccessful in treating the hydrocephalus. Finally, right ventriculo-femoro-caval shunt procedure was performed. Distal catheter was inserted into the right femoral vein and passed toward inferior vena cava under fluoroscopy guidance. The early postoperative period was uneventful. Late postoperative complications consisting of few periods of shunt dysfunction and distal obstruction were managed as an outpatient with injection for diluted heparin in the shunt valve, resulting in recovery of the shunt function. This was the management until the age of 4 when the femoral vein shunt was removed and right ventriculo-pleural shunt was placed. The patient tolerated this surgery and long-term follow-up showed good neurological status without episodes of shunt dysfunction.

Prevalence of seropositivity of selected herpesviruses in patients with multiple sclerosis in the North of Jordan.

BACKGROUND: Multiple sclerosis (MS) is a neurological disease that is caused by an autoimmune response that results in the neuron's demyelination in the central nervous system. The exact etiology of MS is not clear; however, several environmental and genetic factors are believed to participate in its initiation and development, including exposure to viruses. This study aims to investigate the association between the seropositivity and antibody titer of selected herpesviruses and MS in Jordanian MS patients. METHOD: In this study, 55 MS patients and 40 age- and gender-matching apparently healthy volunteers were recruited from two main hospitals in the north of Jordan. MS patients were grouped into three types of MS based on the clinical presentation of the disease. Blood samples were collected from the participants and the IgG antibodies for human herpesvirus 6 (HHV-6), Epstein-Barr virus (EBV) nuclear antigen (EBNA), EBV viral capsid antigen (VCA) and varicella-zoster virus (VZV) were assayed by ELISA. The prevalence of seropositivity and the antibody level for each of the antibodies were compared between MS patients and controls and between the three types of MS. RESULTS: There was no significant difference in the prevalence of seropositivity and in the levels of antibodies for HHV-6, EBNA and VCA between MS patients and controls and between the three types of MS. In contrast, the number of seropositive patients and the level of IgG antibodies for VZV were significantly higher in MS patients compared to the control. CONCLUSION: This study showed that patients with MS in the north of Jordan were more likely to be seropositive for VZV than the general population. Based on this finding, we recommend further studies to evaluate the seropositivity to VZV to be carried out in other parts of Jordan and the greater middle east to find out if there is a correlation between MS and previous infection with VZV.

Delayed Supratentorial Intracerebral Hemorrhage After Posterior Fossa Acoustic Neuroma Surgery.

A 72-year-old female patient was complaining from gradual loss of hearing in the left ear, left facial palsy with gait imbalance. Neuroimaging showed left cerebellopontine angle extra-axial mass and was diagnosed as acoustic neuroma. She was operated with left retromastoid suboccipital and gross total excision of the tumor was achieved. Early postoperative period was uneventful and brain computed tomographic (CT) scan in the postoperative day 1 showed gross total resection of the tumor without complications, and patient was discharged at the postoperative day 4. In the postoperative day 7, the patient showed decrease level of consciousness and brain CT scan showed a small hematoma in the anterior part of the left temporal lobe, which was evolved to large intraparanchymal hemorrhage with midline shift in postoperative day 9.

Alpha Calcitonin Gene-related Peptide, Neuropeptide Y, and Substance P as Biomarkers for Diagnosis and Disease Activity and Severity in Multiple Sclerosis.

BACKGROUND: Alpha calcitonin gene-related peptide (aCGRP), neuropeptide Y (NPY), and substance P (SP) are neuropeptides that have emerged recently as potent immunomodulatory factors with potential as novel biomarkers and therapeutic targets in multiple sclerosis (MS). OBJECTIVE: The study aimed to detect serum levels of aCGRP, NPY, and SP in MS patients versus healthy controls and their association with disease activity and severity. METHODS: Serum levels were measured in MS patients and age and sex-matched healthy controls using ELISA. RESULTS: We included 67 MS patients: 61 relapsing-remitting MS (RR-MS) and 6 progressive MS (PR-MS), and 67 healthy controls. Serum NPY level was found to be lower in MS patients than in healthy controls (p < 0.001). Serum aCGRP level was higher in PR-MS compared to RR-MS (p = 0.007) and healthy controls (p = 0.001), and it positively correlated with EDSS (r = 0.270, p = 0.028). Serum NPY level was significantly higher in RR-MS and PR-MS than in healthy controls (p < 0.001 and p = 0.001, respectively), and it was lower in patients with mild or moderate/severe disease than in healthy controls (p < 0.001). Significant inverse correlations were found between SP level and MS disease duration (r = -0.279, p = 0.022) and duration of current DMT (r = -0.315, p = 0.042). CONCLUSION: Lower serum levels of NPY were revealed in MS patients compared to healthy controls. Since serum levels of aCGRP are significantly associated with disease activity and severity, it is a potential disease progression marker.

Ischemic stroke demographics, clinical features and scales and their correlations: an exploratory study from Jordan.

Aims: The authors aimed to assess the ischemic stroke risk factors and scales. Materials & methods: A retrospective cohort study was conducted on patients with acute ischemic stroke (from January 2017 to December 2018). The scores of the National Institutes of Health Stroke Scale (NIHSS) at admission and discharge and of the modified Rankin Scale (mRS) and Barthel Index (BI) scale post-month of the stroke were collected. Results: Out of 376 patients, 359 were included, with a mean (standard deviation) age of 67.8 (12.2) years and male predominance (56.2%). Hyperlipidemia and hypertension were the most prevalent comorbidities (91.1% and 80.5%, respectively). The NIHSS, BI and mRS scores were worse among women, with no significant effects for comorbidities. The NIHSS scores at admission and discharge were significantly correlated with the post-month BI and mRS scores. Conclusion: The study findings suggest a complex interplay of gender, strict control and prevention of the modifiable stroke risk factors, as well as the association of neurological deficits' intensity with the functional outcomes.

Serum vitamin d inversely correlates with depression scores in people with multiple sclerosis.

BACKGROUND: Vitamin D (Vit.D) deficiency is a risk factor for multiple sclerosis (MS) and correlates with its severity. Depression is also common in people with MS (PWMS). We aim to investigate Vit.D correlation with depression risk scores in PWMS. METHODS: A cross-sectional cohort of PWMS were studied. Clinical and demographic data were collected. The Hospital Anxiety Depression Scale (HADS) and the Beck Depression Inventory-II (BDI-II) were used to evaluate the risk of depression. Expanded Disability Status Scale (EDSS) and Patient Determined Disease Steps (PDDS) were used to evaluate the disability. Serum concentrations of 25-hydroxyvitamin D were measured. Bivariate and partial correlations of Vit.D status and scores of depressive and disability scales were statistically analyzed. The IBM Statistical Package for Social Sciences software, version 25.0, was used for data processing. RESULTS: A total of 88 PWMS were enrolled. More than half of them had potential depression, and 68% had below-normal serum Vit.D levels (normal ≥ 30 ng/ml, insufficient = 21-29 ng/ml, and deficient ≤ 20 ng/ml). Serum Vit.D levels significantly correlated with scores of depression scales in both males and females, which was more robust in males. This association was maintained with a partial correlation analysis controlling for age, sex, body mass index, disease duration, type of MS, and EDDS HADS: r=-0.513, p<0.001; BDI-II: r=-0.401, p<0.001). Serum Vit.D had significant inverse correlations with EDSS score (r=-0.353, p = 0.001) and PDDS score (r=-0.341, p = 0.001), with more robust correlations in females compared to the whole group. CONCLUSION: Vit.D levels correlate with depression risk scores in PWMS with differential sex effects.

Association of Multiple Sclerosis Phenotypes with Single Nucleotide Polymorphisms of IL7R, LAG3, and CD40 Genes in a Jordanian Population: A Genotype-Phenotype Study.

It is thought that genetic variations play a vital role in the Multiple Sclerosis (MS) etiology. However, the role of genetic factors that influence the clinical features of MS remains unclear. We investigated the correlation between 21 single nucleotide polymorphisms within three genes (IL7R, LAG3, and CD40) and MS clinical characteristics in the Jordanian population. Blood samples and clinical phenotypic data were collected from 218 Arab Jordanian MS patients, vitamin D was measured, genomic DNA was extracted, and genotyping of the candidate genes' polymorphisms were analyzed using the Sequenom MassARRAY® system. The association of these single nucleotide polymorphisms (SNPs) with MS was performed using a Chi-square, Fisher exact test, and one-way ANOVA. We found a significant association between vitamin D deficiency and three SNPs of the IL7R gene, namely rs987107 (P-value = 0.047), rs3194051 (P-value = 0.03), and rs1494571 (P-value = 0.036), in addition to two SNPs of CD40, namely rs1883832 and rs6074022 (P-value = 0.049 for both). rs3194051 of the IL7R gene (P-value = 0.003) and rs1922452 of the LAG3 gene (P-value = 0.028) were strongly associated with comorbidity. The number of relapses before drug onset was found to be correlated with IL7R SNPs rs969128 (P-value = 0.04) and rs1494555 (P-value = 0.027), whereas the expanded disability status scale (EDSS) was associated with rs1494555 polymorphism of IL7R gene (P-value = 0.026). Current findings indicate important correlations between certain SNPs and the risk of various phenotypes of multiple sclerosis in the Jordanian community. Therefore, this will not only contribute to the understanding of MS, but will also assist with the development of personalized treatment procedures.

Epidemiology, Risk Factors, and Predictors of Disability in a Cohort of Jordanian Patients with the First Ischemic Stroke.

OBJECTIVE: To identify the risk factors, etiologies, length of stay, severity, and predictors of disability among patients with the first ischemic stroke in Jordan. METHODS: A retrospective cohort study of 142 patients who were admitted to the Neurology Department at King Abdullah University Hospital between July/2017 and March/2018 with a first ischemic stroke. Etiology was classified according to the TOAST criteria. Severity was represented by NIHSS score, disability by mRS score, and prolonged length of stay as hospitalizations more than 75th percentile of the cohort's median length of stay. Analysis of the sample demographics and descriptive statistics were done, including frequencies of prevalence of independent variables (risk factors) and frequencies of stroke and etiology work-up. Chi-square and univariate analysis of variance "ANOVA" were used to investigate the relationship between risk factors and type of stroke. Finally, logistic regression analysis was used to measure the contribution of each of the independent variables. IRB approval was obtained as necessary. RESULTS: The mean age for the cohort was 66.5 years. The most common risk factors were hypertension (78.8%), diabetes mellitus (60.5%), and ischemic heart disease (29.4%). The most common stroke etiology was small-vessel occlusion (54.2%). Median length of stay was 4 days. Prolonged length of stay was observed in 23.23% of patients, which was associated with several factors, the most common of which were persistent dysphagia (57.5%), nosocomial infection (39.3%), and combined dysphagia and nosocomial infection (21.2%). The mean admission NIHSS score was 7.94, and on discharge was 5.76. In-hospital mortality was 2.81%, while 50% of patients had a favorable outcome on discharge (mRS score between 0-2). The mean discharge mRS score for the cohort was 2.47 (SD ± 1.79). Large artery atherosclerosis was associated with the highest residual disability with a mean score of 3.67 (SD ± 1.88), while the stroke of undetermined etiology was associated with the lowest residual disability with a mean score of 1.60 (SD ± 1.78). Significant predictors of mRS score were smoking (t 3.24, P < 0.001), age (t 1.98, P < 0.049), and NIHSS score (t 9.979, P 0.000). CONCLUSION: Ischemic strokes have different etiologies that are associated with different levels of impact on the patient's clinical status and prognosis. Large artery atherosclerosis was associated with the highest residual disability. Regarding predictors of prognosis, current smoking status, age above 50, gender, and NIHSS on admission appear to be the strongest predictors of prognosis. Finally, higher NIHSS score on admission resulted in a longer hospital stay.

WITHDRAWN: Evaluation of the factors that may contribute to the responsiveness of anti-epileptic treatments in pediatric patients, a study from Jordan.

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