Patterns and prognosis of Ventriculoperitoneal shunt malfunction among pediatrics in Saudi Arabia

Objectives:To examine the predictors of pediatric ventriculoperitoneal (VP) shunt malfunction in a university hospital.Methods:A retrospective cohort was conducted. Patients under 18 years old who underwent VP shunt revision at least once between 2016 and 2019 were included. Data were stratified based on age, gender, diagnosis, type of valve, valve position, cause of revision, and part revised.Results:A total of 45 patients (64% males and 36% females) were included in this study. Eighty-two revision surgeries were identified. The most common revised part was the entire shunt system. The most common type of valve which required revision was the low-pressure valve (15.5%). Since a p-value of less than 0.05 was considered significant, no significant differences among the 4 groups for different points.Conclusions:Younger age at initial VP shunt insertion is associated with a higher rate of shunt malfunction. Valve mechanical failures followed by infections are the most common causes for the first 3 revisions. A prospective multi-center study to confirm the current findings is recommended.

Ventriculoperitoneal (VP) shunt insertion is one of the most common procedures in pediatric neurosurgery for treating hydrocephalus.1 Among pediatric age group hydrocephalus is considered a common, surgically correctable condition in which there is an increase in the volume cerebrospinal fluid (CSF), leading to cerebral ventricles dilatation, thinning of the cerebral mantle, and elevation of intracranial pressure.2 Patients with VP shunts represent more than 30,000 hospital admissions per year.2 Although VP shunting has decreased the morbidity and mortality of hydrocephalus, it is still associated with multiple complications, many of which require surgical revision.1–4 Recent studies have reported the rate of complications following VP shunting to be between 30% and 50%.3–6 Shunt malfunctions causes can be categorized into infectious, mechanical, or functional.2–4 Shunt failure definition is revision or replacement of the original shunt between 30-days and 1-year.2 Mechanical failure can happen at the proximal end, valve, or distal end, and it includes obstruction, disconnection, fracture, distal end migration, or inflammation. Functional failure happens when there is overdrainage or underdrainage of cerebrospinal fluid while the whole shunt system is properly functioning. Infection happens when the patients demonstrate clinical findings and positive fluid sampling results.3 The most common complication necessitating revision are obstruction, infection, and displacement.2,3,6,7 Shunt failure is most common within the first 2 years postoperatively.3 Many important predictors of VP shunt failure have been reported in the literature, including etiologies of the hydrocephalus, prematurity, and age at the initial placement of the shunt.1,8,9 Clinical factors that may increase the risk of shunt revision include time from the first surgery, surgical procedure duration, prior treatments, number of surgeons, surgical expertise, surgical technique, anatomic site of the shunt, and diagnosis.1,7–10 Proximal catheter tip location is another predictor, as tip positions in the Foramen of Monro, lateral ventricles, or the third ventricle all were associated with lower rates of surgical revision.11 Other predictors of shunt failure were reported to be poor catheter placement and use of a non-programmable valve.12Previous studies have emphasized the need to identify children at risk, and for prospective cohorts to to investigate the relationship of risk factors and incidence of shunt revisions.1,9,10 Risk factors for VP shunt complications vary across institutions and populations, and a very limited number of studies addressing VP shunt malfunction have been conducted in Saudi Arabia, and only one in the last 10 years was published.13The goal of this study was to determine patterns and predictors of pediatric VP shunt malfunction, causes of the hydrocephalus and VP shunt revision and type of valve malfunction and define the best preventive measures. This knowledge will contribute to lowering the incidence of shunt malfunction, decreasing the number of surgeries, and increasing complication-free intervals between surgeries in hydrocephalic pediatric patients.     

Complementary and alternative medicine use among ischemic stroke survivors in Jeddah,Saudi Arabia

Objectives:To determine the prevalence and pattern of complementary and alternative medicine (CAM) use and the CAM types used by stroke patients in Jeddah, Kingdom of Saudi Arabia.Methods:This cross-sectional study included 152 ischemic stroke survivors who visited King Fahad Hospital, Jeddah, Kingdom of Saudi Arabia, between January 2018 and December 2019. Phone-based and face-to-face surveys were conducted. Data on the patients’ demographic characteristics, their use of CAM, and their pattern of CAM use were gatheredResults:Ninety (59.2%) stroke patients used CAM, mainly cauterization (29.61%) and Quran recitation by a religious sheik (28.95%). Most of the patients (72.22%) used CAM post-hospitalization and within less than one month from stroke onset (62.22%). A minority (6.67%) of the patients stopped their medication while on CAM. Some patients (25.56% to 31.11%) discussed with their physician their use of CAM. The CAM users reported a subjective improvement in their physical weakness (45.6%) and psychological wellbeing (62.2%). The patients learned about CAM mainly from their relatives and friends (96.7%), and the most common reason for their CAM use was their belief in this intervention (42.22%).Conclusion:The CAM use was prevalent among our cohort of Saudi ischemic stroke patients, and cauterization and Quran recitation were the most commonly used CAM interventions. An effective communication was lacking between the medical professionals and the stroke patients as regards CAM use despite the interest of the patients in this intervention.

Over the past 2 decades, the burden of stroke has increased globally.1 Stroke is the second leading cause of morbidity and mortality; the annual incidence of stroke is approximately 15 million, and over 5.5 million stroke-related deaths occur annually.2–4 Also, the prevalence of the modifiable risk factors of stroke is increasing, and the burden of stroke increases with the aging of the population.5 Adults aged >25 years have an estimated lifetime stroke risk of 24.9%.6 Despite the advancements in acute stroke care, highly effective treatments for the later phases of stroke are lacking. This shortcoming in the stroke care leads patients and their relatives to seek other treatment options, such as complementary and alternative medicine (CAM).7 The CAM is defined by the United State of America National Institutes of Health as “a group of diverse medical and health care systems, practices, and products that are not generally considered conventional medicine.”8 The CAM has been used for a long time now,9 and people widely practice CAM for various health conditions, such as cancer, epilepsy, multiple sclerosis, infertility, surgical procedure, dermatological conditions, hypertension, pain, and other types of illnesses.1,9–11 The prevalence of CAM use varies by country. For example, the prevalence of CAM use is 82% in the United States,12 61% in Australia,13 51% in Malaysia,14 and 61% in Turkey.15 Religion, cultures, and values influence the types and patterns of its use.16 People in Western countries practice herbal medicine, reflexology, aromatherapy, massage, osteopathy, meditation, and spiritual healing;10,17–19 by contrast, those in Asian countries such as China, India, and Taiwan commonly use therapies such as traditional Chinese medicine, Ayurvedic medicine, physical exercises, acupuncture, Tai Chi, yoga, and homeopathy.20–23 In Saudi Arabia, different types of CAM are used including the Quran recitation therapy, honey consumption, plant-based traditional medicine (e.g., Murrah and black seed consumption), cupping (“Hojamah”), and cauterization (“skin ironing”)9,24–27Research highlighted that aside from their potential benefits, some types of CAM have many side effects and potential toxicities, and patients are commonly unaware of these possible dangers.28 One study reported 2 cases wherein the cauterization led to severe complications, such as skin burn.29 Another study that investigated the components of herbal medicines in Saudi Arabia indicated that 15.7% of the tested samples contain toxic amounts of heavy metals, including arsenic and mercury.30 Despite the potential risk of many CAM interventions, it has been noted that many patients do not inform their physicians about their practice of CAM.31Stroke patients in many countries, including the United States (30.6%–46%)32,33 and South Korea (54%), use CAM.34 In Riyadh, Saudi Arabia, 67% of patients with neurological problems use CAM,9 and most of them use cupping (Hojamah) (45.4%), herbal medicine (42.3%), cauterization (33.7%), and Quran recitation (20.4%).9 However, no available study has analyzed the use of CAM particularly by stroke patients in Saudi Arabia. Thus, this study aimed to determine the prevalence and pattern of CAM use and the types of CAM being practiced by ischemic stroke patients relation to their demographic data.     

The role of ketogenic diet in controlling epileptic seizures

Objectives:To study the role of the ketogenic diet (KD) in controlling seizures in children with medically resistant epilepsy in Saudi Arabia.Methods:This retrospective study was conducted in the Pediatric Neurology Clinic at a tertiary care epilepsy center. Thirty-one patients with medically resistant epilepsy were enrolled from 2013 to 2018. The seizure reduction variables were evaluated at 6, 12, 18 and 24 months after enrollment.Results:Of the 31 patients, 14 (45.2%) were males and 17 (54.8%) were females. The most common types of seizures were myoclonic seizures and mixed seizures, both of which occurred in 9 (29%) of the participants. Of the participants, 15 (48.4%) had seizures one to 5 times per day. Six months after starting a KD, 2 (6.45%) of participants were seizure-free; 6 (19.35%) were seizure-free after 12 months of treatment.Conclusion:The present study highlighted the effectiveness of KD in medically resistant epilepsy children to local population. A larger cohort is warrant to confirm these findings.

Epilepsy is a common neurological disorder. It is characterized by seizures and affects approximately 65–70 million people worldwide.1 Children and the elderly are most commonly affected by seizures; the condition is rarer in adults.2 Epilepsy remains a challenging neurological disorder despite effective pharmacological therapies.3 More than 30% of epileptic patients do not achieve complete control of seizures with available anti-epileptic drugs (AEDs).1,4 Around 20-40% of patients with epilepsy have refractory epilepsy “failure of, adequate trials of 2 tolerated, appropriately chosen and used AED schedules (whether as monotherapies or in combination) to achieve the sustained seizure freedom” and who are not candidates for surgery, non-pharmacological interventions should be considered for ketogenic diet (KD) treatment.5,6The KD has been proposed for first time in 1920s as a non-pharmacologic treatment to control refractory childhood epilepsy.1 The KD is a high-fat, low-protein, low-carbohydrate diet, with ketogenic ratio of 4:1 or 3:1 in grams which is the most commonly administered ratio.7,8 The KD increases the production of ketone bodies, which brain uses these ketone bodies as an energy source instead of glucose.2 Some hypotheses have been proposed regarding the KD’s anti-seizure effects, suggesting that changes in the nature and degree of energy metabolism in the brain, changes in neurotransmitter function, changes in synaptic transmission, and changes in neuronal cellular properties may explain the diet’s effectiveness.9 Higher ketone levels correlate with better seizure control.9 Ten to 15% of children with epilepsy become completely seizure free on a KD.3 Furthermore, the KD has a prolonged beneficial effect even after it is discontinued.9The International Ketogenic Diet Study Group strongly recommends that the KD be considered as a treatment for children with epilepsy who fail to respond to two or three anticonvulsant medications, regardless of age or gender.9 Our objective was to study the efficacy of the KD in children with medically resistant epilepsy in Saudi Arabia.     

Expiratory muscle strength as a predictor of functional exercise capacity in generalized myasthenia gravis

Objectives:To investigate the correlations between the 6-minute walk test and disease severity, pulmonary functions, and respiratory muscle performance in patients with generalized myasthenia gravis (MG) and to determine whether MG disease severity, pulmonary functions, and respiratory muscle performance contribute to 6-minute walk test distance in generalized MG.Methods:This cross-sectional trial was conducted at Hacettepe University in Ankara, Turkey. The study was carried out from February to August 2017. Twenty-eight class II-III MG patients participated inthe study. Patients’ disease severity was determined with the Myasthenia gravis composite scale. All participants underwent the 6-minute walk test, pulmonary function tests, and respiratory muscle strength and endurance assessment.Results:Approximately 40% of patients’ expiratory muscle strength were under the lower limit of normal. Multiple linear regression analysis revealed that the percentage of predicted expiratory muscle strength that patients reached were significant and independent predictor of percentage of 6-minute walk test distance that patients reached according to reference values (R2=0.493, F [1-27]=25.275, p<0.001).Conclusion:Expiratory muscle strength is a significant determinant of functional exercise performance in generalized MG with mild or moderate weakness affecting muscles other than the ocular muscles.

Myasthenia gravis (MG) is an autoimmune disease caused by antibodies against components of the postsynaptic membrane at the neuromuscular junction. These antibodies block function by binding to their target and inducing antigen crosslinking, complement activation, and increased degradation. These cause muscle fatigue and weakness in patients with MG.1 Comorbid conditions may be critical for quality of life, daily functions, short- and long-term outcome, and mortality in MG patients.2Inspiratory and expiratory muscle strength is shown to be reduced in patients with generalized MG compared to controls or ocular MG patients.3-5 Patients with MG often have a “myasthenic pattern” characterized by reduced ventilatory muscle endurance and volumes in lung function tests.6,7 Patients usually report dyspnea upon extreme effort due to muscle weakness, and ventilatory muscle impairment adversely affects the performance of physical activities and patients’ daily lives due to perceived fatigue.8The 6-minute walk test (6MWT) has been shown to be relatively reliable in patients with neuromuscular diseases and 6MWT distance (6MWD) was reported to be lower in generalized MG patients than in healthy controls.8,9 In addition, composite disease severity scales have become increasingly important to show prognosis. The myasthenia gravis composite scale (MGCS) is a reliable, valid, and easily applicable instrument for assessing the clinical status of MG patients and differs from other MG severity scales because it incorporates physician-reported and patient-reported test items.10Therefore, the aims of this study were: to investigate correlations between 6MWD and pulmonary functions, respiratory muscle performance, and MG severity determined by the MGCS in patients with generalized MG and to determine whether disease severity assessed by a composite score, pulmonary functions, and respiratory muscle performance contribute to or reflect decreased functional exercise capacity in generalized MG.     

Multiple Sclerosis Patients Knowledge in Saudi Arabia

Objectives:To assess Multiple Sclerosis (MS) patients’ knowledge in Saudi Arabia (SA) and in which aspect of the disease do patient need more awareness.Methods:A cross-sectional web-based survey has been conducted between June and August 2017. It consisted of 2 parts: sociodemographic and 23 multiple choice questions chosen from the previously validated MS Knowledge Questionnaire (MSKQ). The survey has been sent to 500 MS patients.Results:A total of 218 MS patients filled the questionnaire where only 200 included in the study. Female MS patient represents 66% of all the participants. More than half of the patients had achieved their bachelor degree. The total mean of the correct answer for both male and female found to be 58.98%(±SD 15.06%). Most patients were aware that MS is a disease of central nervous system (93%), autoimmune disease (79%), not contagious (90.5%), or inherited (64.5%). However, few patients were aware that there is no single test to diagnose MS (28.5%), and intravenous injection of contrast during MRI reveals new lesions (18.5%). Only (37%) knew what is “Relapsing–remitting”MS. The MS knowledge is positively correlated with the educational level.Conclusion:Patients with MS in SA have less knowledge in the disease’s types, workups, and treatment efficacy. While in contrast, they have more awareness of the disease’s pathophysiology. Patient’s awareness programs should aid more knowledge among MS patients in SA.

Multiple sclerosis (MS) is an autoimmune, chronic, inflammatory disease of the central nervous system; its behavior is highly varied and unpredictable, and the cause, until now, is not known.1 Nevertheless, it appears to be multifactorial; it involves a combination of genetic and environmental factors.1-3 Moreover, it is a common autoimmune disease of the central nervous system.4,5The prevalence of MS in the Middle East is low to medium.6 Incidences of MS in the Gulf countries including Saudi Arabia, in particular, suggest an indication of its increase.7 The Prevalence of the disease in Saudi Arabia has not been studied yet. Not to mention that MS awareness and knowledge is sub-optimal in the country.4Patients’ knowledge of pathophysiology, types, diagnostic modalities and medication effectiveness is critical to facilitate decision-making, achieving emotional stability, and help the patient cope with the disease. Because of the lack of published research in this area, as the literature review of this study indicates, the aim of this study is to measure patient’s knowledge of MS.     

Association between craniovertebral junction abnormalities and syringomyelia in patients with chiari malformation type-1

Objectives:To assess the correlation between craniovertebral junction (CVJ) abnormalities and syringomyelia in patients with Chiari malformation type-1 (CM1).Methods:This was a retrospective study including patients with CM1. Identification of cases was done by searching a radiology database at a university hospital from 2012 to 2017. Patients were divided into 2 groups based on whether CVJ abnormalities were present (CVJ+) or absent (CVJ-). The patients’ demographic and clinical data were reviewed. All magnetic resonance imaging studies were examined by a certified neuroradiologist.Results:Sixty-four consecutive patients with CM1 were included. The mean age was 24±17 years; 59% were females. The CVJ+ group had more female patients (p = 0.012). The most frequent CVJ abnormality was platybasia (71%), followed by short clivus (44%) and cervical kyphosis (33%). The CVJ abnormalities were more in Syringomyelia cases (p = 0.045). However, the results were not significant when hydrocephalus cases were excluded.Conclusion:Among CM1 patients, CVJ abnormalities were found more in patients with syringomyelia. Future studies with larger sample size are required to further study the correlation between CVJ abnormalities and both syringomyelia and hydrocephalus in CM1 patients.

Chiari malformation type-1 (CM1) was first described in 1891 by Austrian pathologist Hans Chiari.1,2 The CM1 is defined as caudal displacement of the cerebellar tonsils below the foramen magnum by 5 mm or more.3,4 This definition is merely a radiological definition. In the literature, the degree of cerebellar tonsil displacement varies from 3 mm to 5 mm.4 CM1 affects approximately 1% of the population and may involve a spectrum of neurologic involvement.2 Syringomyelia is reported in 25% of CM1 cases and may cause irreversible damage to the spinal cord with subsequent neurological deficits.5The pathophysiology of syringomyelia development in patients with CM1 has been extensively studied.6-9 Majority of publications indicated a block to the cerebrospinal fluid (CSF) circulation at the level of the craniovertebral junction (CVJ).8,9 Subsequently, the cerebrospinal fluid (CSF) accumulates and forms syringomyelia.8,9 The source of the CSF forming the syringomyelia can be from the fourth ventricle, the subarachnoid space (SAS), or from an extracellular source.8,9 From the 1950s to the 1970s, syringomyelia was believed to result from a difference in CSF pressure between the fourth ventricle and the central canal of the spinal canal.7 Theories to explain this mechanism include James Gardner’s water-hammer theory, Bernard Williams’ cranio-spinal pressure dissociation theory, and Ball and Dayan’s theory of tonsillar obstruction to the CSF pathway.10-12 In the 1990s, Oldfield believed that the mechanism of the development of syringomyelia involved abnormal CSF flow at the level of the foramen magnum.6,7 The descent of the cerebellar tonsils with each cardiac cycle produces a pressure wave in the spinal SAS, and thereby compresses the spinal cord from the outside and propagates a syrinx.7,9Several intradural and extradural factors have been implicated in the pathophysiology of CM1. Among the intradural factors identified during surgery for CM1, the presence of an arachnoid membrane obstructing the foramen of Magendie (i.e., an arachnoid veil) was significantly more frequent in patients with an associated syringomyelia.6 Other studies have examined whether the degree of tonsillar descent below foramen magnum in the CM1 patients is a contributing factor to the development of syringomyelia; however, the impact of tonsillar descent is controversial.6,9,13 Some studies have reported that the rate of syringomyelia increases as the degree of tonsillar herniation increases.6,9 As a possible explanation for syringomyelia development, other studies14,15 have addressed crowding of the SAS at the foramen magnum caused by tonsillar decent. In a study by Doruk et al15, the measured cervicomedullary compression ratio, defined as the ratio of the area occupied by the cerebellar tonsils to the area of the foramen magnum, was significantly correlated with the development of syringomyelia. This ratio could reflect the severity of blockage of the SAS at the CVJ and further supports the previously described mechanisms of syringomyelia development.9Extradural abnormalities at the CVJ are associated with CM1.15 Such pathologies include a small posterior cranial fossa, platybasia, basilar invagination, and short clivus.3,6,8,9 Several studies have examined the presence of CVJ abnormities in CM1 patients with and without syringomyelia.13,16-21 However, the presence of associated syringomyelia within the context of CM1 with and without CVJ abnormalities was inadequately highlighted. For instance, in one study,13 syringomyelia existed in 64% of CM1 patients with a short clivus, compared to 36% of CM1 patients without a short clivus. In order to further understand the relationship between the presence of one or more CVJ abnormalities and syringomyelia in CM1, the current study was conducted. Such knowledge will likely enhance the understanding of CVJ relationship with CM1 and may aid in the management of syringomyelia in such patients.     

Extrahepatic pseudocyst in an adult

Ventriculoperitoneal (VP) shunts are commonly used in neurosurgical procedures to treat hydrocephalus. Although shunt-associated abdominal complications are well documented, extrahepatic pseudocysts are a rare shunt complication in adult patients. Therefore, we herein report the case of a 54-year-old male patient who presented with a bulging mass around the previous surgical site at the right upper quadrant of the abdomen. He had a 4-year history of VP shunt surgery for posthemorrhagic hydrocephalus. A computed tomographic scan revealed a large extrahepatic pseudocsyt. Our case represented a rare entity of extrahepatic pseudocyst in adult patients underwent VP shunt surgery. The clinical presentation, diagnostic tools, and treatment methods were discussed.

Ventriculoperitoneal (VP) shunts are commonly used in neurosurgical procedures to divert excess cerebrospinal fluid (CSF) from the ventricular system into the abdominal cavity, which is indicated for hydrocephalus related to congenital hydrocephalus, trauma, hemorrhage, neoplasms, infection, and various other conditions.1 Several abdominal complications are common in patients undergoing VP shunts, including pseudocysts, infection, and hollow organ perforation.2, 3 Catheter migrations may occur into the abdominal cavity including abdominal wall, small bowel, large bowel, gall bladder, liver, stomach, vagina, fallopian tube, urinary bladder, or scrotum.4-6 Abdominal pseudocysts occur in less than 10% of all patients receiving VP shunts and occur primarily in pediatric populations.7Hepatic pseudocyst secondary to shunt operation is a rare entity, which is classified as intra-axial and extra-axial types.8 The intra-axial hepatic pseudocysts commonly demonstrate that the tip of the shunt can be dislodged into the liver parenchyma.9 By penetrating the Glisson’s capsule, the distal tube cause subcapsular pseudocyst formation in patients with extra-axial hepatic pseudocysts.3 However, extrahepatic pseudocysts are rare shunt complications in adult patients, and only several cases have been reported in the relevant literature.10-15 Therefore, we herein report the development of extrahepatic pseudocysts following VP shunt surgery in a 54-year-old male patient. The clinical presentation, diagnostic tools, and treatment methods are also discussed to manage this rare complication.     

Corpus callosum index correlates with brain volumetry and disability in multiple sclerosis patients

Objectives:To analyze the correlation between corpus callosum index (CCI), brain volumetry, and disability in multiple sclerosis (MS) patients. The brain volumetry consists of the corpus callosum, cortical gray matter, subcortical gray matter, and white matter volumes.Methods:This was a retrospective cross-sectional study from October 2018 to February 2019 of 30 patients with MS aged 20 to 61 years old. Brain volumetry was performed using FreeSurfer© software. The CCI were measured manually using conventional best mid-sagittal T1W brain MRI. The anterior, posterior, and medium segments were measured and divided to its greatest anteroposterior diameter. Higher CCI values indicated greater corpus callosum volumes. Clinical evaluation was comprised of MS subtype, age of onset, relapse frequency and Expanded Disability Status Scale (EDSS).Results:Thirty MS patients with median of age 22 years were included. Relapsing-remitting (RRMS) subtype were 73.3%. Very significant correlations were shown between the CCI and corpus callosum volume (CCV) (r=0.79; p<0.0001) and cerebral white matter volume (r=0.81; p<0.0001). Significant correlations were shown between the CCI and cortical gray matter volume (r=0.64; p<0.0001) and subcortical gray matter volume (r=0.69; p<0.0001). The CCI was positively correlated with age of onset and inversely with EDSS. The CCV and CCI were smaller in secondary progressive MS (SPMS).Conclusion:The CCI is easy and fast to obtain in conventional MRI and significantly correlated with brain volumetry, age of onset and disability in MS patients.

Multiple sclerosis (MS) is one of the most common neurological diseases of the central nervous system and has various clinical manifestations, affecting the sensory, motor, cerebellar, brainstem, and autonomic systems.1–4 The MS progression will lead to disability that can affect the quality of life. In 2013, the prevalence of MS was 33 per 100,000 globally, an increase from approximately 30 per 100,000 in 2008.5 Regarding the cognitive impairment, it has been found in a study by Rao et al6 a 45% frequency of cognitive impairment in MS patients. Furthermore, it has been found in several studies that the decline in visual and verbal episodic memory as well as decelerated cognitive processing speed are the most frequent cognitive domains impaired in multiple sclerosis.7 Between these 2 domains, it has been shown that memory impairment were slightly more common than those with memory impairment and processing speed impairment in 128 patients with relapsing-remitting MS (RRMS).8 In our previous study, we found impairments in the Symbol Digit Modality test (up to 50%), California Verbal Learning test-II (27.5%), and Brief Visuospatial Memory test-revised (32.5%) in MS patients.9Brain volume in MS patients were found to be significantly smaller compared to healthy subjects and associated with the progression of disability.10 Brain atrophy in MS can occur by 3 mechanisms: volume loss within the lesion itself, retrograde degeneration, and Wallerian degeneration in the remote area of the fiber pathway.4,11,12 Brain atrophy can be seen in earliest stages of MS (clinically isolated syndrome).13 Gray matter atrophy begins early in the course of the disease and is correlated with the progression of disability, especially motor and cognitive disability.14–16 Measuring brain atrophy has been proposed as one of several treatment monitoring parameters for MS.17The corpus callosum is one of the main white matter pathways and affected by the progress of chronic diseases, including MS.1,3,4 Corpus callosum damage is correlated with cognitive impairment and motor disability in MS patients. Corpus callosum atrophy could be a clinically relevant marker of cognitive impairment.18–20Brain volumetry using magnetic resonance imaging (MRI) is a useful, noninvasive tool in assessing subcortical morphometric changes as well as evaluating the regional neurological impact of psychopathology, such as dementia, psychiatric disorders, and normal aging.21 Some software packages have been developed for measuring brain tissue volume using MRI with semi-automatic segmentation, such as FreeSurfer© (The General Hospital Corporation, Boston MA, USA), FIRST (FMRIB’s Integrated Registration and Segmentation Tool), FSL (FMRIB’s Software Library), and SPM (Statistical Parametric Mapping).22With this background, the objective of this study was to determine the correlation between the corpus callosum index (CCI) measurements and the corpus callosum, cortical gray matter, subcortical gray, and cerebral white matter volumes determined through brain MRI volumetry and clinical characteristics in MS patients.     

Incidence,risk factors,clinical presentation,and outcomes of hemorrhagic transformation in patients with ischemic stroke admitted to a tertiary hospital in Kingdom of Saudi Arabia

Objectives:To describe the incidence rate, clinical presentation, relevant risk factors, and outcome of hemorrhagic transformation (HT) among ischemic stroke patients.Methods:This retrospective study analyzed HT in patients with ischemic stroke admitted to King Abdullah Medical City from August 2011 to April 2019. Data were analyzed using SPSS. Patients characteristics, procedures, treatments, and outcomes were reported.Results:There were 504 ischemic stroke patients. The HT was detected in 38 patients (8%). The median age was 66.5 (54.3 -77.5) years, and 24 (63%) were males. HT was classified as hemorrhagic infarction (HI) in 22 patients (58%) while 16 patients (42%) were parenchymal hematoma (PH). The most common risk factors noted were: hypertension (74%), diabetes mellitus (DM) (66%), hyperlipidemia (63%) and ischemic heart disease (IHD) (61%). Nine patients (23.6%) developed HT after receiving thrombolytic therapy. Only one patient (3%) died of HT patients.Conclusion:HT accounted for (8%) of all ischemic stroke patients. Old age, DM, hypertension, and hyperlipidemia are frequently encountered with stroke patients who developed HT. Follow up CT brain could be of value and could identify HT early to get better outcomes.

Hemorrhagic transformation (HT) which is a spectrum of hemorrhage related to brain ischemia.1 The HT is a primary complications of acute ischemic stroke (AIS).2 Ischemia makes the cerebral vasculature fragile and more reliable to cause HT after AIS.3–5 HT increases both morbidity and mortality rate in the ischemic stroke patients.2 The HT affects the outcomes with potential severe short- and long-term effects.6 The incidence of HT is between 10–40% and depends on many factors.1,7,8 Most of HT occurs within 2 weeks of an ischemic stroke.5 Previous studies considered old age, hypertension (HTN), diabetes mellitus (DM), large infarct (>2 cm), reperfusion time, lower platelet count and treatment with thrombotic- or anticoagulant-therapies as risk factors.9–12 The most effective treatment for AIS according to previous studies is recombinant tissue plasminogen activator (r-tPA),13 however, it appears to increase the risk of symptomatic or asymptomatic HT.1 Previous studies also suggest that the outcome of HT patients be strongly associated with HT type hemorrhagic infarction (HI) (Petechiae) or parenchymal hematoma (PH) (a space-occupying lesion), PH was a significant predictor of both mortality and neurological deterioration.14 Thus, it is critical to understand HT and its characteristics especially in our population. This retrospective study was designed to describe the incidence rate, clinical presentation, and relevant risk factors of HT among ischemic stroke patients. Identifying such knowledge could improve the outcome and decrease the risk of HT in AIS patients.     

Guillain–Barre syndrome: demographics,clinical features,and outcome in a single tertiary care hospital,Oman

Objectives:Guillain–Barre syndrome (GBS) is an acute autoimmune-mediated peripheral nervous system disease. Different studies from various geographical regions have reported considerable variability regarding its epidemiology, clinical features, and outcome. Our study aimed to document demographics, clinical features, and outcomes among GBS patients admitted to a single tertiary care hospital in Muscat, Oman.Methods:A retrospective data analysis of 44 GBS patients, who were admitted during a two-year period from January 2016 to December 2018 at Khoula hospital, was carried out. Demographics, antecedent illness, duration of symptoms, muscle power graded by the Medical Research Council scale (MRCs), sensory & autonomic involvements, nerve conduction study results, CSF study, need for ventilation, condition at discharge and subsequent follow-up status were obtained.Results:Ninety-one percent of the patients were Omanis, with male predominant 63.6% and the average age was 42.69 years. Quadriparesis was the predominant presenting complaint (61.3%) and AIDP was the commonest variant (52%). All patients received a single cycle of IVIg and (13.6%) patients admitted to the ICU for mechanical ventilation. The study showed good outcome and recovery in 18 months follow up.Conclusion:The clinical presentation of GBS in the majority of patients in Oman is similar to those reported in previous studies, and most patients had favorable prognoses. Our results can be used as baseline data for understanding the characteristics of GBS in Oman and, consequently, for better management.

Guillain–Barre syndrome (GBS), also known as Landry’s paralysis, is an acute immune-mediated polyradiculoneuropathy;1,2,3 with males are about 1.5 times more affected than females, and an overall incidence rate of 1–2 per 100,000 population per year worldwide.4,5 The syndrome is characterized by an acute or subacute progressive generalized muscle weakness of upper and lower limbs with relative or complete areflexia, and limb paraesthesia.1 The typical pattern starts with typically ascending flaccid paralysis, which progresses over a few days to a few weeks. Patients may also develop cranial nerves involvement, usually as a facial or pharyngeal weakness. In addition, autonomic dysfunction is common in the disease, which manifests as postural hypotension, loss of vasomotor control (causing wide fluctuation in blood pressure), and a variety of cardiac arrhythmias. Ventilator assistance is required when respiratory failure and oropharyngeal weakness develop in the course of the disease, which has been reported to be required in approximately one-third of hospitalized patients; these data indicate that early management is vitally important for GBS.1,3Proceeding infections (such as infections with Campylobacter jejuni, Cytomegalovirus, Epstein–Barr virus, Mycoplasma pneumonia, and HIV)2,4,5,6,7 may activate the immune response, owing to molecular mimicry, to cross-react with the peripheral nerve’s components (the myelin and/or the axon) resulting in the endoneural inflammation of spinal nerve roots, nerve’s distal segments, and at potential nerve entrapments sites.2 Some triggering factors (e.g., immunization, trauma, bone marrow transplantation, and surgery) may also affect the pathogenesis of GBS .6–8Seasonal variability is reported for GBS, which can reflect seasonal changes in the peaks of the predisposing factors, such as infections, although GBS may occur during any season.9,10 Seasonal occurrence has been reported to peak during the summer season in Asian countries.11,12The GBS is believed to include a variety of acute neuropathies with underlying immune-mediated pathogenic mechanisms rather than a single disease; therefore, GBS recognized variants are considered as syndromes [including acute inflammatory demyelinating polyneuropathy (AIDP), acute motor axonal neuropathy (AMAN), acute motor-sensory axonal neuropathy (AMSAN), and Miller–Fisher syndrome]. The most prevalent form of GBS reported is AIDP which is responsible for 70–90% of cases.5,6 In addition to history and clinical examination, confirming the diagnosis of GBS may include cerebrospinal fluid (CSF) analysis and electroneurodiagnostic testing, both of which can be normal in the early phase of the disease.3,4Therapeutic plasma exchange (TPE) and intravenous immunoglobulin (IVIg) are used effectively for adult and pediatric patients with GBS; and if these treatments are administered during the first few weeks of the disease along with a efficient supportive care, they can minimize mortality and improve the outcome of the disease.13,14 Physical therapy is considered as an essential part of the supportive management for decreasing complications’ incidence, such as respiratory complications and deep venous thrombosis (DVT), as well as for pain management and to enhance early mobilization.15The understanding of clinical presentation and epidemiology of GBS in each population can help us better understand the pathogenesis of the disease, its risk factors, and prognosis.16 Moreover, the evaluation of GBS outcome may be effective for planning an appropriate therapeutic strategy and for determining disease-related morbidity and mortality. The results of different studies from various geographical regions have reported considerable variability regarding the epidemiology, clinical features, and outcomes of GBS.17,18 Therefore, our study aims to assess the presentation, clinical findings, demographics, seasonal variations, and outcomes among patients with GBS in a tertiary care institute in Muscat, Oman.     

Farming,well water consumption,rural living,and pesticide exposure in early life as the risk factors for Parkinson disease in Iğdır province

Objectives:To investigate potential risk factors for Parkinson’s disease (PD) in elderly individuals rural living in Turkey.Methods:In total, 72 consecutive elderly Parkinson disease patients referred to the Neurology Clinic, Iğdir State Hospital, Iğdır, Turkey were included in the study. A structured questionnaire comprising questions on history of pastoral living, pit water consumption, and exposure to ionizing radiation and pesticides was administered to the patients. The patients were divided into 2 groups on the basis of water consumption: well water consumption group and city network consumption group.Results:Of 72 patients with PD, 49 (68.1%) exposed to well water while 23 (31.9%) did not exposed to well water. The average duration of well water consumption was 20 (standard deviation 6) years (p<0.01) in group 1. Nitrate, sulfate and heavy metal levels were significantly higher in well water than in city network water (p<0.05).Conclusion:Consumption of well water containing heavy metals and nitrates in early life may contribute to the etiology of Parkinson disease in elderly individuals in Iğdır province of Turkey

Parkinson disease (PD) is a major cause of morbidity in senior individuals. The major pathophysiology of this disorder entails death of dopaminergic neurons and degeneration of neuronal projections to the basal ganglia. The etiology of the disease is multifactorial, and interactions between genetic and environmental factors play a critical role in the development of the disorder.1 Reportedly, well water consumption, farming, smoking, pesticides, rural living, diet, and coffee and alcohol consumption as well as ionizing radiation, head trauma, and infections are the potential environmental risk factors for PD.2–4 Studies1,2,3,4 have reported controversial results, but for the most part, they have confirmed the association between environmental factors and PD.2 In most of the studies, smoking has been found to be negatively associated with PD.3In rural areas, particularly among farmers, consumption of well water contaminated with nitrates, phosphates, and heavy metals that are components of chemical fertilizers and pesticides is a potentially important risk factor for informed consent was obtained from all the patients. A structured questionnaire comprising 10 questions was administered to PD patients and controls to obtain information about place of birth, residence, occupation, history of head trauma, family history of PD and essential tremor, rural living, history of well water consumption, PD.2,3 Iğdır province is a rural area in eastern Turkey where agriculture is the main source of income. PD is very common in Iğdır province, and Metsamor nuclear reactor is located at a distance of approximately 16 km from this province.4 We aimed to investigate farming, well water consumption, rural living, and pesticide exposure as potential risk factors for PD in elderly individuals of Iğdır province through a case-control study and through chemical analysis of the well water for nitrate, phosphate, and heavy metal levels.     

The comorbidity of headaches in pediatric epilepsy patients: How common and what types?

Objectives:To estimate the prevalence and characteristics of headache in pediatric epileptic patients.Methods:This cross-sectional study was performed over 6 months period from January 2018 to June 2018 at King Abdullah Specialist Children Hospital, King Abdulaziz Medical City, Riyadh, Kingdom of Saudi Arabia using a structured questionnaire in pediatric patients with epilepsy.Results:There were 142 patients enrolled (males, 57.7%; average age, 10.7±3.1 years) with idiopathic epilepsy (n=115, 81%) or symptomatic epilepsy (n=27, 19%). Additionally, patients had focal epilepsy (n=102, 72%) or generalized epilepsy (n=40, 28%), and among them, 11 had absence epilepsy. Overall, 65 (45.7%) patients had headaches compared with 3/153 (2%) in the control group (p < 0.0001). Among the 65 patients with headaches, 29 (44.6%) had migraine-type, 12 (18.4%) had tension-type, and 24 (36.9%) had unclassified headache. There was no significant difference in age, gender, type of epilepsy syndrome, and antiepileptic used except in patients with or without headache. For migraine patients, there was a lower headache prevalence in the subgroup treated with valproic acid compared with other treatments.Conclusion:Headache, predominantly migraine, is a common problem in pediatric epileptic patients and choosing valproic acid when possible can be important in preventing migraine in these patients.

Epilepsy and headache are chronic paroxysmal disorders that affect adult and pediatric patients1 with episodic manifestations. Headache or (cephalalgia) is defined as a feeling of pain in the region of the head or neck. Primary headaches include migraines, tension-type headache, and cluster headache. Epileptic seizure is a brief episode of signs or symptoms caused by abnormal excessive synchronized neuronal activity.2 Epilepsy is defined as a condition where the patient has an enduring tendency to have recurrent unprovoked seizures.2 These two disorders coexist in some patients.3 There are few studies on the comorbidity of headaches in children with epilepsy.4-6 Other studies reported a significant association between migraine and epilepsy.1,7-9 Additionally, the genetic predisposition for both entities was reported in some forms of channelopathy,10 and others found more prevalence of migraine headache in specific diseases in pediatric like benign epilepsy with centrotemporal spikes and juvenile myoclonic epilepsy.11 Seizure-associated headache is common, with an incidence of 42–51% in adult epileptic patients.12 However, for pediatric patients, it is often neglected by parents and physicians because of other neurological manifestations of the seizure such as loss of consciousness and motor components,13 and approximately 36% of the parents were reported to be unaware that their children experienced headache.14 It is our experience that headache is a common problem in up to 50% of epilepsy patients but we do not know exactly the prevalence, in addition to what type of headache is most commonly found in epileptic pediatric patients. Because of few reports on this topic have conflicting results, the objective of this study was to evaluate the prevalence and characteristics of headache in children with epilepsy who were seen at one center in Saudi Arabia.     

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

Objectives: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<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.

Epilepsy is one of the most common neurological disorders in Saudi Arabia, with an estimated prevalence of 6.54 per 1000 individuals.1 It is estimated that 20-40% of newly diagnosed patients are expected to fail seizure control with medical treatment.2 Refractory epilepsy is commonly defined as the failure to achieve freedom from seizures despite two or more antiepileptic drugs (AEDs).3 Patients with drug-resistant epilepsy (DRE) have a lower quality of life and face more social difficulties than patients with controlled epilepsy.4-6 More than half of the economic burden of epilepsy is accounted for by patients with refractory epilepsy.7 Epilepsy surgery is the best evidence-based treatment option for these patients with drug resistant focal epilepsy.8,9 The current guidelines for patient referral to epilepsy surgery were published in 2003 by the American Academy of Neurology.9 The benefits of epilepsy surgery may not only reduce the frequency of seizures but might also lower mortality and improve the quality of life.10 Despite its proven efficacy and favorable outcome, the average referral delay of an epilepsy surgery candidate is more than 20 years.11 This delay is predominately attributed to non-adherence to referral guidelines, which results from a lack of awareness and familiarity with them.12 Another factor that contributes to the delay is patients’ misbeliefs regarding the surgery’s risks and benefits, which are highly influenced by physicians’ lack of knowledge.13 Epilepsy surgery was introduced to Saudi Arabia in 1998.14 Several epilepsy surgery centers have subsequently been established across the country. A survey in 2013 showed that 56% of health-care professionals in Saudi Arabia were not aware that surgery was a treatment option for patients with epilepsy.15 Our aims in this study were 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.     

Prevalence and risk factors of myasthenia gravis recurrence post-thymectomy

Objectives:To evaluate the prevalence and the factors associated with recurrence of myasthenia gravis following thymectomy.Methods:Six electronic databases which reported on recurrence of myasthenia gravis following thymectomy and/or its risk factors from 1985 to 2018 were searched. Summary prevalence and risk values obtained based on the random effect models were reported.Results:Seventy (70) papers containing 7,287 individuals with myasthenia gravis who received thymectomy as part of their management were retrieved. The patients had a mean follow-up of 4.65 years post-thymectomy. The prevalence of myasthenia gravis recurrence post-thymectomy was 18.0% (95% CI 14.7–22.0%; 1865/7287). Evident heterogeneity was observed (I²=93.6%; p<0.001). Recurrence rate was insignificantly higher in male compared with female patients (31.3 vs. 23.8%; p=0.104). Pooled recurrence rates for thymomatous (33.3%) was higher than the rate among non-thymomatous (20.8%) myasthenia gravis patients (Q=4.19, p=0.041). Risk factors for recurrence include older age, male sex, disease severity, having thymomatous myasthenia gravis, longer duration of the myasthenia gravis before surgery, and having an ectopic thymic tissue.Conclusion:A fifth of individuals with myasthenia gravis experience recurrence after thymectomy. Closer monitoring should be given to at-risk patients and further studies are needed to understand interventions to address these risks.

Myasthenia gravis (MG) a rare clinical condition characterized by autoimmune abnormalities is also the commonest neuromuscular junction (NMJ) disorder.1 Its pathophysiology involves the production of abnormal antibodies which binds to nicotinic acetylcholine receptors at the NMJ of skeletal muscles leading to alteration and damage of the NMJ.1-2 The disease is common in young women, however, another peak in incidence may occur at the 6th or 7th decade of life mainly in men in some population; and it may exhibits no sex preference in others.2 Clinically, patients with MG develop varying levels of skeletal muscle weakness affecting the ocular, bulbar, oculo-bulbar system, respiratory system, and the extremities.1 The pattern and course of MG is complex, varying from early remission to acute exacerbation and even death.3Previous research has revealed a strong relation between MG and disorders affecting the thymus. About 40 to 70% of individuals with MG have thymic follicular hyperplasia, and 10 to 21% of them have thymoma.4-6 Also, 20-47% of individuals having a thymoma have already developed or will develop MG.6-7 Findings from the literature indicate that 40 to 90% of individuals with MG attained remission following thymectomy compared with 10 to 20% among individuals with MG treated with medications without any surgery.6,8 Also, a recent randomised controlled trial demonstrated that thymectomy for individuals with nonthymomatous MG demonstrated better treatment outcomes during a three-year period compared with pharmacological therapy alone.9 Thus, guidelines now recommend thymectomy as a key treatment approach for MG.10A number of systematic reviews and/or meta-analyses among individuals with MG have been carried out. Some of these reviews explored the differences in outcomes between thymectomy and conservative management of MG,11,12 others compared surgical approaches of thymectomy,13-15 or potential prognostic factors for remission among individuals with MG irrespective of histological type following thymectomy.3,16 None assessed recurrence of MG following thymectomy or its risk factors. The identification of patient factors which are associated with recurrence of MG following thymectomy is crucial for the development of targeted interventions to address challenges associated with the care of individuals with MG. This systematic review and meta-analysis aimed to estimate the post-thymectomy recurrence rates and to investigate the factors associated with recurrence of MG following thymectomy in individuals with MG.     

Efficacy of routine post-operative head computed tomography on cranial surgery patients outcome

Objectives:To identify the role of routine postoperative head CT in changing postoperative management after elective craniotomies.Methods:We conducted a retrospective study on adult patients who underwent cranial surgery. Exclusion criteria includes cranial CTs done postoperatively for urgent clinical indications, pediatric patients, CSF diversion procedures and sedated patients. Patients were placed into “positive” group if the physical assessment changed from the baseline in the form of clinical deterioration, and the “negative” group if the exam did not change. The data then were analyzed to identify which patients needed further medical or surgical management based on CT findings only with “negative” physical examination.Results:Total of 222 were included in the study. 151 patients had negative physical examination. Only 8 out of 151 patients had positive CT findings. Two patients out of 222 (0.9%) had a negative physical exam and positive CT findings that required additional action that wouldn’t be done urgently without routine postoperative brain CT. Only one patient out of 222 (0.4%) who was re-operated urgently based CT findings only and negative physical examination.Conclusion:Routine postoperative routine brain CT did not alter the course of medical management, even in the presence of significant radiological findings.

Neurosurgical patients have high early postoperative complications in comparison with other surgical domains.1 Postoperative brain CT is done routinely after cranial procedures to predict the possibility of early complications, including hemorrhage and significant brain edema.2 Other less urgent indications are the gross assessment of the extent of resection and ventricular catheter placement in cerebrospinal fluid diversion procedures.3 Imaging studies in our institute are done routinely for the postoperative cranial surgeries, even in the absence of clinical indication or postoperative complications; thus, raising suspicion about the role and efficacy of routine postoperative imaging.In this study, the aim is to determine the necessity of postoperative head CT scan in cranial surgeries to identify early complications, and its role in patient care, outcomes, and costs, with a review of the literature.     

Electrophysiologic severity of carpal tunnel syndrome in diabetic patients of the Saudi population

Objectives:To study the frequency of multiple vascular risk factors and electrophysiological severity of carpal tunnel syndrome (CTS) in Saudi diabetic patients.Methods:This retrospective cross-sectional study was conducted in Neurology Department, King Fahd Hospital of University, Al-Khobar, Kingdom of Saudi Arabia from April 2017 to March 2018 and included 200 patients with CTS. Body parameters, such as blood pressure (BP), weight, height, and body mass index (BMI), along with laboratory and median nerve electrophysiological parameters, of diabetic and non-diabetic patients were compared, and a p-value<0.05 was considered significant.Results:Frequency of hypertension (HTN) and obesity was significantly higher in diabetic patients (p<0.05). Mean median nerve sensory amplitude (MNSA) was lower in diabetic patients (p<0.05).Non-recordable nerves, as well as bilateral and extremely severe CTS (p<0.05), were more frequently seen in diabetic patients. Age, BMI, systolic BP, low serum high density lipoprotein (HDL), high triglycerides, high fasting blood sugar, and high glycated hemoglobin (Hba1c) levels, known to affect the electrophysiological severity of CTS, had a statistically significant association with diabetes.Conclusion:Diabetes mellitus (DM) and obesity are the most commonly identified risk factors of CTS. Dyslipidemia, HTN and obesity are more frequently seen in diabetic patients with CTS. These concurrent risk factors are confounding the electrophysiological severity of CTS in these patients. Further larger-scale studies with the control of confounding factors are recommended.

Carpal tunnel syndrome (CTS) is known to have a frequent nerve entrapment syndrome and encompasses 45% of non-traumatic nerve lesions.1,2 Carpal tunnel syndrome can result in various problems, including pain and paresthesia in the median nerve distribution, swelling, and in severe cases weakness of the thumb and lateral 3 fingers.3 It affects the daily life activities, such as holding and gripping things by hand, brushing teeth, and driving.4 Carpal tunnel syndrome can be associated with any risk factor that causes pressure on the median nerve inthe wrist, including coexisting comorbidities and working conditions of the individuals.5 Some common conditions that can lead to CTS includes obesity, DM, oral contraceptives, smoking, corticosteroid use, pregnancy, hypothyroidism, rheumatoid arthritis, osteoarthritis, and wrist fracture.6The prevalence of CTS in diabetic patients is 14% without diabetic neuropathy and 30% with diabetic neuropathy.7 Literature has shown a high incidence of CTS in pre-diabetic states.8 Some researchers have also found a relationship between duration of diabetes, Hba1c, and micro vascular complications.9 Although type 2 diabetes is more frequently diagnosed among CTS patients, some studies had reported that the association between diabetes and CTS represents a confusion bias, most likely due to the strong relationship between obesity and type 2 diabetes.10 It has been shown that age, BMI, and other vascular risk factors, including metabolic syndrome, could affect the electrophysiological severity of CTS. Elevated low density lipoprotein (LDL) cholesterol and hyperglycemia were reported as independent risk factors for CTS in some studies.8,11,12 Similarly, obesity, elevated triglycerides, elevated LDL cholesterol and hypertension were shown to be strongly associated with CTS.13 In the study conducted by Balci et al,14 75% of the CTS patients were found to have metabolic syndrome, and the electrophysiological parameters (median nerve sensory onset latency, sensory conduction velocity, sensory amplitude, distal motor latency, motor conduction velocity, and motor amplitude) were worse in patients with metabolic syndrome. Gül et al,15 similarly showed that severity of CTS was even more severe in patients with metabolic syndrome than in those with diabetes.The aim of the present study was to study the frequency of multiple vascular risk factors, such as HTN, dyslipidemia and obesity in CTS patients, and to compare the electrophysiological severity of CTS in Saudi diabetic and non diabetic patients. This population is facing a high burden of multiple vascular risk factors, which are also affecting the severity of CTS.     

The potential role of nutritional components in improving brain function among patients with Alzheimer’s disease: a meta-analysis of RCT studies

Objectives:To find out the potential role of nutritional components in improving brain function among patients with Alzheimer’s disease (AD).Methods:The correlation between nutrition and cerebral function in cases of AD has been the focus of 19 prospective randomised controlled trials (RCTs) with a combined research sample of 2297 patients. These RCTs are subject to systematic review and meta-analysis in the current paper.Results:Findings showed that chain-free secondary saturated fatty acids (SFA) and trans fatty acids (TFA) occurred in higher concentrations in AD patients’ brains than in controls. Furthermore, neuroinflammation was caused by remodelling of the lipid membrane and AD patients’ cognitive function was impacted by alterations in tyrosine, tryptophan, purine, and tocopherol pathway metabolomics. Moreover, in cases of mild-to-moderate AD, reduction in functionality was induced by administration of alpha-tocopherol for more than 12 months. Consumption of Souvenaid helps in synaptic synthesis, which enhances functional connectivity. Furthermore, consumption of the B vitamins folate, cobalamin and pyridoxine at dosages of 0.8 mg, 0.5 mg and 20 mg per day, respectively, over a period of one year resulted in lower plasma tHcy levels and brain atrophy.Conclusion:Chain-free SFA and TFA occur in greater amounts in the brains of individuals with AD than in those without AD.

Life expectancy has recently increased enormously throughout the world, owing to development in medical sciences. As a result, the ageing population has expanded quickly, causing a phenomenal rise in the prevalence of late-life cognitive diseases like AD and vascular dementia (VaD).1-3 Besides impacting cognition in ageing individuals, causing the brain to become atrophied and disrupting learning, cognitive, reasoning and communication capabilities, such conditions are also a significant burden from a social and economic perspective.4 Dementia occurs in 5-8% of people older than 65, 15-20% of those older than 75 and 25-50% of those older than 85 years of age.5 Age, gender, head trauma and CVD risk factors (e. g. cardiac disease, diabetes, high blood pressure, depression, high cholesterol, sedentarism, smoking, alcohol drinking) are among the known sporadic AD risk factors that are not of genetic origin.6-8The creation of medication capable of deferring AD onset by disrupting and mitigating Aβ synthesis has been the aim of a number of clinical research trials and empirical work and has attracted ample annual investment from pharmaceutical companies. Even though such medication is yet to be formulated, drugs for symptom management do exist.9 Thus, the approach toward drug development for AD, as well as the therapeutic role of nutrition in preventing AD, need to be reconsidered.Evidence has been produced that AD risk and progression are diminished by diet-related components like antioxidants,10,11 vitamins,12-14 polyphenols,15,16 and omega-3 fatty acids.17,18 By contrast, saturated fatty acids19 and simple carbohydrates20 are considered to increase likelihood of AD development.21 The RCTs carried out in the period 2010-2018 were reviewed in this paper to investigate whether AD patients’ cognitive function can be enhanced based on nutritional constituents. To this end, a meta-analysis was conducted to establish the extent to which cerebral function in AD cases was influenced by nutrition-based treatments. Furthermore, subgroup meta-analyses were also carried out to determine conformance to nutrition plans, proportion of deaths due to general causes and AD, respectively, body weight (BW), lean body mass (LBW), life expectancy, quality of life (QoL), and development of additional neurodegenerative diseases.     

Visual evoked potentials follow-up in idiopathic intracranial hypertension

Objectives:To demonstrate the importance of visual evoked potential (VEP) in determining the severity and prognosis of the disease and in monitoring the clinical course in patients with idiopathic intracranial hypertension (IIH).Methods:This is a prospective cross-sectional study conducted covering the period between March 2014 and January 2015. The study included 32 patients recently diagnosed with IIH and 30 healthy volunteers. The initial VEP values of the IIH patients were compared to the VEP values of the healthy control group. Furthermore, the initial VEP values of the IIH patients were compared with their VEP values after one month of treatment.Results:The mean age of the IIH patients was 37.8±12.02 years. Of the IIH patients, 27 (84%) were females and 5 (16%) were males. There was a statistically significant association of the initial VEP values with the visual field findings (p=0.011) and visual acuity (p=0.040). Moreover, a statistically significant difference was found between the control group and IIH patients in terms of right (p<0.001) and left P100 values (p<0.001). While 18 (56%) of the initial VEPs of IIH patients were pathological, 14 (44%) of the second VEPs were pathological, and this difference was not statistically significant (p=0.125).Conclusion:A relationship between the VEP P100 values and the severity of the disease was detected, while the importance of monitoring VEP values in the follow-up of IIH patients was not demonstrated.

Idiopathic intracranial hypertension can be defined as raised intracranial pressure with a normal cerebrospinal fluid (CSF).1,2 The overall incidence of IIH is 2.4/100,000; however, the incidence is 22/100,000 in obese women.3 Indeed, the female gender and a high body mass index (BMI) are important risk factors for the disease and female patients account for 90% of the cases.4,5The visual field is commonly affected in IIH patients.6 Although the visual field is currently the most sensitive method to monitor visual disturbances during the course of the disease, its specificity and sensitivity is not 100%.6,7 However, an early diagnosis, determination of the disease severity, and follow-up of the patients with IIH are critical as IIH can cause serious and irreversible visual field defects and even vision loss during the course of the disease.7-9The number of patients with IIH is on the rise globally as the number of patients with obesity increases day by day.10 There is a paucity of precisely sensitive and objective indicators of the disease for monitoring relapses and remission.11,12 Moreover, no sensitive and objective methods have been established yet to determine the disease severity in order to decide whether surgery should be performed in these patients.12-14Despite the potential of IIH to cause visual morbidity, only a limited number of studies are available in the literature to predict the potential impact of IIH on the vision.13 The findings obtained by VEP reflect the functions of the visual pathways extending from the retina to the occipital cortex. The test is particularly sensitive to demonstrate conduction disturbances in the anterior (pre-chiasmatic) visual pathway.15,16 A few studies have shown abnormal findings in VEP tests in patients with IIH, indicating the importance of VEP in the evaluation of the visual functions.17 In the literature, we found only one study evaluating the value of VEP values in the follow-up of patients with IIH.17This study aimed to demonstrate the importance of VEP testing in determining the severity and prognosis of the disease and in monitoring the clinical course of the patients with IIH as the number of studies evaluating this subject is limited in the literature.     

Inflammatory bowel disease and restless leg syndrome

Objectives:Inflammatory bowel disease (IBD) has been associated with restless leg syndrome (RLS). This study aims to explore the prevalence, clinical predictors, and severity of RLS in IBD patients compared to controls.Methods:We conducted a case-control study between January and December of 2019 comparing IBD patients with controls. Assessment of RLS was performed using the previously validated diagnostic restless leg syndrome questionnaire (RLSQ). Logistic regression analyses were applied to investigate associations between patient demographics and clinical features and RLS diagnosis.Results:A total of 218 IBD patients and 211 healthy controls were incorporated after excluding 6 patients with positional discomfort and 4 patients with habitual foot tapping. The mean age was 30.2±11.7 and 64% were females. The prevalence of RLS was 16/218 (7.34%) and 17/211 (8.06%) among cases and controls, respectively. Based on the RLSQ severity score, 6/16 (37.5%), 4/16 (25%) and 1/16 (6.3%) of the IBD patients with RLS had mild, moderate and severe RLS; respectively. The odds of IBD were lower among patients with confirmed RLS (OR=0.90, 95% CI=0.44-1.84, p = 0.78). In the logistic regression analysis, only vitamin B12 deficiency (OR=10.20, 95% CI=1.40-74.10, p = 0.022) was associated with RLS diagnosis among IBD patients.Conclusion:No difference was found in the prevalence of RLS between IBD patients and non-IBD controls. Vitamin B12 deficiency was associated with RLS diagnosis among patients with IBD.

Inflammatory bowel disease (IBD) is a family of chronic inflammatory disorders that cause inflammation of the gastrointestinal tract. It comprises two main conditions: ulcerative colitis (UC) and Crohn’s disease (CD). Approximately 30% of IBD patients suffer from extra-intestinal manifestations (EIMs), which can involve the rheumatologic, musculo-cutaneous, and hepato-biliary systems.1,2 Anemia is a common manifestation of IBD that can be attributed to iron, folate (folic acid), or vitamin B12 deficiencies.3Patients with IBD may develop neurological symptoms as part of the disease itself or through secondary complications, such as anemia. Perhaps one of its most distressing neurological manifestations is restless leg syndrome (RLS), which is a movement disorder characterized by an uncomfortable sensation in the legs which engenders restlessness temporarily relieved by movement. This discomfort takes place most commonly during night and when resting, and often disturbs sleep.4 Iron deficiency anemia (IDA) has been strongly associated with RLS.5,6 The RLS can be primary, i.e., idiopathic, or secondary, and is believed to be caused by both genetic and environmental factors.7 The most common secondary causes of RLS include iron deficiency and kidney disease; other causes include cardiovascular disease, arterial hypertension, diabetes, liver cirrhosis, migraine, Parkinson’s disease, and pregnancy.7-9 In a previous study conducted in Saudi Arabia, the prevalence of RLS among IBD patients was estimated to be 21.5%, compared to 9.7% in controls.10 Another study reported a 10% prevalence rate of RLS in North America and Europe, which is much higher than the prevalence rate reported by studies from Asian countries (0.6-1.8%).9 In contrast to many findings in Asian countries, the prevalence of RLS has been reported to increase with age in Europe, North America, and Saudi Arabia,10,11 and women have a higher prevalence of RLS compared to men.11,12 Moreover, it has been suggested that patients with RLS have poorer health and quality of life.11 This study describes the prevalence, clinical predictors, and severity of RLS in IBD patients compared with healthy controls.