Pediatric intracranial hypertension: Experience from 2 Tertiary Centers

Objectives:To review the experience of 2 tertiary centers in Saudi Arabia with intracranial hypertension (IH) in the pediatric population.Methods:We retrospectively reviewed and analyzed pediatric patients diagnosed with IH from June 2002 to May 2017 in 2 institutes.Results:We identified 53 patients (30 females and 23 males) with a mean age of 7 years at the time of presentation. Among them, 41 patients were younger than 12 years, and 12 were older. Obese and overweight patients constituted 27.00% (n = 14) of all cases, 8 (66.7%) of whom were older than 12 years. The most common presenting feature was papilledema followed by headache. Vitamin D deficiency, which constituted the most common associated condition, was identified in 12 (22.6%) patients. Acetazolamide was the treatment option in 98.11% of patients, and only 5.7% underwent surgical interventions. The length of follow-up ranged from 6 months to 8 years.Conclusion:Intracranial hypertension is rare in children and commonly seen in overweight females older than 12 years similar to adults. Patients younger than 12 years tend to develop secondary IH. More studies are needed to characterize the clinical presentation and guide the management plan.

Intracranial hypertension (IH) is rarely reported in children. It is characterized by increased intracranial pressure (ICP) without any evidence of underlying brain pathology, structural abnormalities, hydrocephalus, or any abnormal meningeal enhancement.1 The incidence of IH differs from region to region due to variations in the prevalence of obesity and other secondary causes. The annual incidence of IH in children is 0.9 per 100,000 in the United States,2 0.5 per 100,000 in Germany,3 0.6 per 100,000 in Nova Scotia and Prince Edward Island in Eastern Canada,4 and 1.2 per 100,000 in Croatia.5 A study carried out in Oman estimated the incidence of IH to be 1.9 per 100,000 in children below 15 years of age; with it being higher in female children.6 The present study aimed to review the clinical presentation, possible aetiological factors, diagnosis, management, and outcomes in children with IH in 2 tertiary institutes in Saudi Arabia.     

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.     

Hemorrhagic colloid cyst

Colloid cysts are cystic lesions that are usually located in the anterior portion of the third ventricle near the foramen of Monro. Rarely, hemorrhagic cysts can lead to acute obstructive hydrocephalus or sudden death. We herein report 2 cases and a review literature. We examine a 47-year old male who presented with progressive headache and a 55-year old male who presented with progressive memory disturbance and unsteady gait. Both cases demonstrated typical imaging features of hemorrhagic colloid cyst, and were histopathologically confirmed. Total excision was achieved in both cases with good outcomes. Hemorrhagic colloid cysts are rare; however, bleeding tendencies should be carefully considered in patients with these cysts. The degree of rapidity with which clinical deterioration occurs may play a major role in the preferred treatment approach and subsequent outcomes.

Colloid cysts are benign, thin-walled, cystic lesions that arise from the brain’s endodermal embryonic remnants, and they are usually located in the anterior portion of the third ventricle near the foramen of Monro; these cysts contain colloid material.1 The clinical presentation of these cysts ranges from incidental findings on brain images to sudden death. The clinical presentation of these cysts is largely dependent on the mass’ effect on the foramen of Monro.1 Rarely, hemorrhagic cysts can lead to acute obstructive hydrocephalus or sudden death.2,5 We herein report 2 cases of hemorrhagic colloid cysts.     

Susceptibility of ABO blood group to COVID-19 infections: clinico-hematological,radiological, and complications analysis

In the wake of the COVID-19 pandemic, research indicates that the COVID-19 disease susceptibility varies among individuals depending on their ABO blood groups. Researchers globally commenced investigating potential methods to stratify cases according to prognosis depending on several clinical parameters. Since there is evidence of a link between ABO blood groups and disease susceptibility, it could be argued that there is a link between blood groups and disease manifestation and progression. The current study investigates whether clinical manifestation, laboratory, and imaging findings vary among ABO blood groups of hospitalized confirmed COVID-19 patients.This retrospective cohort study was conducted between March 1, 2020 and March 31, 2021 in King Faisal Specialist Hospital and Research Centre Riyadh and Jeddah, Saudi Arabia. Demographic information, clinical information, laboratory findings, and imaging investigations were extracted from the data warehouse for all confirmed COVID-19 patients.A total of 285 admitted patients were included in the study. Of these, 81 (28.4%) were blood group A, 43 (15.1%) were blood group B, 11 (3.9%) were blood group AB, and 150 (52.6%) were blood group O. This was almost consistent with the distribution of blood groups among the Saudi Arabia community. The majority of the study participants (79.6% [n = 227]) were asymptomatic. The upper respiratory tract infection (P = .014) and shortness of breath showed statistically significant differences between the ABO blood group (P = .009). Moreover, the incidence of the symptoms was highly observed in blood group O followed by A then B except for pharyngeal exudate observed in blood group A. The one-way ANOVA test indicated that among the studied hematological parameters, glucose (P = .004), absolute lymphocyte count (P = .001), and IgA (P = .036) showed statistically significant differences between the means of the ABO blood group. The differences in both X-ray and computed tomography scan findings were statistically nonsignificant among the ABO age group. Only 86 (30.3%) patients were admitted to an intensive care unit, and the majority of them were blood groups O 28.7% (n = 43) and A 37.0% (n = 30). However, the differences in complications’ outcomes were statistically nonsignificant among the ABO age group.ABO blood groups among hospitalized COVID-19 patients are not associated with clinical, hematological, radiological, and complications abnormality.     

Telepsychiatry: knowledge,effectiveness, and willingness; assessments of psychiatrists in Saudi Arabia

Objectives:To assess psychiatrists’ knowledge and perception regarding telepsychiatry and evaluate their willingness to adopt telepsychiatry clinical practice in Saudi Arabia.Methods:A cross-sectional study was conducted among psychiatrists working in Saudi Arabia from November 2020 through May 2021. A self-administered questionnaire comprising socio-demographic data, factors related to knowledge, perception, willingness, barriers, and the effectiveness of telepsychiatry, was distributed via. online platform. Data were tabulated and cleaned in MS Excel, and all statistical analyses were performed using SPSS v26.Results:There were 328 psychiatrists enrolled in the group with an average age of 25–35 years (48.8%). The group comprised mainly Saudis (83.5%); male participants outnumbered females (70.4% to 29.6%). Overall, the psychiatrists’ telepsychiatry knowledge level was poor (51.8%), while (48.2%) of the respondents showed good knowledge. However, nearly all respondents exhibited good perception (80.8%), with only 19.2% classified as poor. In addition, older individuals, consultants, clinicians with 11–15 years of experience, clinicians interacting with patients via email, and those who frequently received patient questions regarding online communication indicated increased knowledge.Conclusion:Although perception was positive regarding telepsychiatry, psychiatrists’ knowledge on the subject was deemed insufficient. Psychiatrists’ knowledge depended on their age, position, years of experience, frequent interaction with patients through an online platform, and clients that provided their online contact details.

The earliest telemedicine trials were in the 1950s when Norfolk State Hospital and Nebraska Psychiatric Institute used closed-circuit television to provide patient consultations. Telemedicine has various branches; it includes telepsychiatry, which offers psychiatric care through any form of telecommunication, such as video conferencing. ¹ Telecommunication provided for both psychiatrists and their patients a convenient, easy, and fast tool to connect both parties for accessible psychiatric evaluations, various forms of therapy such as individual, group, family therapy, medication management, and essential information on their diseases; most importantly it saved both time and effort for both psychiatrists and their patients. ^2,3 It can also be utilized for non-clinical applications, such as organizational learning, in addition to infinite services. ⁴ Telepsychiatry can be applied in situations where patients stay in rural areas or move from distant areas become difficult; also, in follow-ups or medication refills. ⁵ Many patients reported their satisfaction with telecommunications. ³ Telepsychiatry, similar to any technology, faces barriers or limitations in its use; therefore, considerable research has been conducted to identify these barriers. ^2-13 Barriers such as technical, interpersonal challenges hindering their use of Telepsychiatry, lack of cost-effectiveness, the opposing view among psychiatrists; as many psychiatrists find it challenging to accept Telepsychiatry, and they are reluctant to accept the effectiveness of this service delivery and think that system workflow integration should be improved. In addition, psychiatrists dislike their inability to take physical steps to ensure patients’ comfort. ^2-7 Furthermore, Telepsychiatry is the most active telemedicine application functioning as a feasible alternative for current mental health services, improved care services, and early treatment. Regardless of the benefits mentioned previously; psychiatrists are less satisfied with it because the quality of audio-visual technology impacts the reliability of teleconsultation. in addition, there were a few limitations when addressing satisfaction, such as the lack of return to clinics (RTCs), small sample sizes, and no apparent difference in satisfaction between Telepsychiatry and face-to-face consultation. For that reason, substantial research has been conducted to identify this satisfaction limitation as it is still unknown whether opposing is due to the program or technology. User acceptance or Patients and cultural factors presented a primary barrier or challenges in implementation, as many Saudi psychiatrists are skeptical of Telepsychiatry’s outcomes, and clinicians are unsatisfied with the service, affecting their willingness to utilize telemedicine. The second barrier is consumer acceptance, impacting patients’ willingness to be treated by telemedicine. Other obstacles are the lack of qualified experts to implement the technology, essential Information and Communications Technology (ICT) infrastructure, and acceptable strategies and plans for implementing telemedicine in Saudi Arabia. In addition, some health providers lack ICT skills and cannot apply the innovation. ^6-13 Thus, there are scattered current data investigating psychiatrists’ satisfaction with Telepsychiatry in Saudi Arabia. Therefore, this study aims to fill the research gap in this area.The earliest telemedicine trials were in the 1950s when Norfolk State Hospital and Nebraska Psychiatric Institute used closed-circuit television to provide patient consultations. Telemedicine has various branches; it includes Telepsychiatry, which offers psychiatric care through any form of telecommunication, such as video conferencing. ¹ Telecommunication provided for both psychiatrists and their patients a convenient, easy, and fast tool to connect both parties for accessible psychiatric evaluations, various forms of therapy such as individual, group, family therapy, medication management, and essential information on their diseases; most importantly it saved both time and effort for both psychiatrists and their patients. ^2,3 It can also be utilized for non-clinical applications, such as organizational learning, in addition to infinite services. ⁴ Telepsychiatry can be applied in situations where patients stay in rural areas or move from distant areas become difficult; also, in follow-ups or medication refills. ⁵ Many patients reported their satisfaction with telecommunications. ³ Telepsychiatry, similar to any technology, faces barriers or limitations in its use; therefore, considerable research has been conducted to identify these barriers. ^2-13 Barriers such as technical, interpersonal challenges hindering their use of Telepsychiatry, lack of cost-effectiveness, the opposing view among psychiatrists; as many psychiatrists find it challenging to accept Telepsychiatry, and they are reluctant to accept the effectiveness of this service delivery and think that system workflow integration should be improved. In addition, psychiatrists dislike their inability to take physical steps to ensure patients’ comfort. ^2-7 Furthermore, Telepsychiatry is the most active telemedicine application functioning as a feasible alternative for current mental health services, improved care services, and early treatment. Regardless of the benefits mentioned previously; psychiatrists are less satisfied with it because the quality of audio-visual technology impacts the reliability of teleconsultation. in addition, there were a few limitations when addressing satisfaction, such as the lack of return to clinics (RTCs), small sample sizes, and no apparent difference in satisfaction between Telepsychiatry and face-to-face consultation. For that reason, substantial research has been conducted to identify this satisfaction limitation as it is still unknown whether opposing is due to the program or technology. User acceptance or patients and cultural factors presented a primary barrier or challenges in implementation, as many Saudi psychiatrists are skeptical of Telepsychiatry’s outcomes, and clinicians are unsatisfied with the service, affecting their willingness to utilize telemedicine. The second barrier is consumer acceptance, impacting patients’ willingness to be treated by telemedicine. Other obstacles are the lack of qualified experts to implement the technology, essential Information and Communications Technology (ICT) infrastructure, and acceptable strategies and plans for implementing telemedicine in Saudi Arabia. In addition, some health providers lack ICT skills and cannot apply the innovation. ^6-13 Thus, there are scattered current data investigating psychiatrists’ satisfaction with Telepsychiatry in Saudi Arabia. Therefore, this study aims to fill the research gap in this area.Table 1- The psychiatrists’ socio-demographic characteristics. n=328

Treatment of reticulated acropigmentation of Kitamura with Q-switched alexandrite laser

Background Reticulated acropigmentation of Kitamura (RAPK) is a pigmentary disorder of autosomal dominant inheritance, occurring predominantly within the Japanese population, for which no successful treatment has been described. Objective The objective was to describe a 23‐year‐old Saudi woman with reticulated acropigmentation of Kitamura (RAPK), who was successfully treated with a 75‐nm Q‐switched alexandrite laser. Method To report a 23‐year‐old Saudi woman with reticulated acropigmentation of kitamura (RAPK) who was treated with two sessions of the Q‐switched alexandrite laser, six weeks apart with no recurrence after two years. Results Cutaneous pigmentation of reticulated acropigmentation of kitamura (RAPK) almost resolved completely in two laser sessions. Side effects were limited to transient post inflammatory hypopigmentation. Conclusion Cutaneous pigmentation of reticulated acropigmentation of kitamura (RAPK) can be effectively treated by Q‐switched alexandrite (755‐nm) laser, which shows a promising result, and it can be considered as treatment option, although further studies are required to confirm the effectiveness of this treatment modality with other Q‐switched laser; e.g. Q‐switched ND:YAG or Q‐switch Ruby.     

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.