Guillain-Barré Syndrome in Adults in a Decade: The Largest, Single-Center, Cross-Sectional Study From the Kingdom of Saudi Arabia

BACKGROUND

Guillain-Barré Syndrome (GBS) is the most common cause of acute, usually post-infectious, peripheral neuropathy resulting in a symmetrical, ascending paralysis. We evaluated the clinical and neurophysiological features, treatment, and outcomes of patients with GBS in our center.

METHODS

A retrospective chart review on patients with GBS admitted to King Abdulaziz Medical City, Riyadh, Saudi Arabia, from January 2011 to December 2020. Data were analyzed using JMP statistical software version 15 pro.

RESULTS

A total of 86 patients who met the criteria were included, 55 (64%) were males, with a mean age of 49.5+/-17.5 years. Antecedent infection was reported in 53 (61.6%), 51 (62.2%) presented within one week of symptoms onset. Ascending weakness was seen in 55 (70.5%), while 70 (81.4%) had areflexia. Acute motor axonal neuropathy (AMAN) was the commonest electrophysiological type of GBS in 41 (51.9%) patients. Albuminocytologic dissociation was seen in 48 (57%) who had lumbar puncture. Nearly half, 41 (47.7%) were admitted to the intensive care unit (ICU). Seventy (81.3%) were treated with intravenous immunoglobulin. There was no significant difference in the clinical presentation, management, ICU requirement, and discharge disposition between males and females. Females were more likely to have a higher disability at discharge (p=0.01). Patients younger than 60 years were more likely to require ICU admission (p=<0.01).

CONCLUSION

Our patients with GBS were slightly older than previously reported from the region. AMAN was the commonest type of GBS. Younger patients were more likely to need ICU admission, whereas females were more likely to have a more severe disability.

A case of fatal acute bacterial meningoencephalitis with extremely high cerebrospinal fluid white blood cell count

Acute bacterial meningoencephalitis is still prevalent despite the widespread vaccination and still fatal despite the advances in antimicrobial therapy. Identifying patients at risk, lowering the threshold of clinical diagnosis and early treatment of such a curable disease will save patients' lives.

The Management and Outcome of Stroke Patients Admitted on Weekdays Compared to Weekends at the King Abdulaziz Medical City, Riyadh, Saudi Arabia

Background and Purpose

Stroke is an unexpected medical emergency that can result in significant disability. The weekend effect suggests that individuals with acute medical problems are not treated the same way on weekends as they are on weekdays. There is no previous published study about weekend effect on stroke patients from Saudi Arabia.

Methods

This was an IRB approved, retrospective, cohort study. All stroke patients admitted between January 2017 and December 2018 were included. Ten standards of care were chosen to assess compliance with standardized care. Seven measures were chosen for acute management of stroke.

Results

A total of 731 patients were included, 68.5% were males; 493 (67%) were admitted during weekdays and 238 (33%) on weekends. There was no difference for age (P = .32), gender (P = .32), nationality (P = .62), stroke subtype (P = .27) and stroke severity (P = .69) on weekday or weekend admission. In two-third patients, more than 70% of stroke orders were utilized, with no difference in thrombolysis rate (P = .81). There was no difference in recurrent stroke (P = .86), mortality or discharge disposition (P = .34) between the patients. The patients admitted during weekdays had less complications (38 vs 46%; P = .04).

Conclusions

There was no difference in the quality of care provided to stroke patients admitted during weekdays or weekends. There was no difference in the use of acute intervention on weekends and weekdays. Patients had similar outcomes and discharge disposition whether admitted on weekdays or weekends, except that those admitted on weekends had a significantly greater overall number of complications.

Early seizures in stroke – frequency, risk factors, and effect on patient outcomes in a tertiary center in Saudi Arabia

Objectives:

To determine the frequency, risk factors, and outcomes of Early seizure (ES) after stroke in a Saudi cohort.

Methods:

A retrospective study was conducted in King Abdulaziz Medical City, Riyadh, KSA. All stroke patients whether they had first or recurrent stroke were included from February 2016 to December 2017. Data were analyzed using the SAS software version 9.4.

Results:

Out of 665 patients, 456 (68.6%) were males and 564 (85.2%) were Saudis; the cohort’s mean age was 60.6±12.6 years. Fifty-one (7.7%) patients had ES, which were more common in women (p=0.0123). Loss of consciousness (p=0.0402) and confusion (<0.0007) were associated with ES, whereas unilateral weakness (p=0.001) and unilateral numbness (p=0.0317) at presentation decreased the risk of ES. Vascular risk factors did not differ between patients with and without ES. Hemorrhagic stroke was associated with ES (p=0.0054), whereas patients with small vessel disease were less likely to develop ES (p=0.0013). Patients with ES had more severe stroke (NIHSS >5) (p=0.0139), more ICU admissions (49% vs. 26.2%; p=0.0005), longer length of hospital stay (44.9 days vs. 24.9 days; p=0.0018), higher rates of stroke-related complications (e.g. recurrent stroke, pulmonary embolism, hospital acquired infections, and need for tracheostomy and gastrostomy tube placement) (p≤0.0001), and were likely to be more severely disabled defined as mRS 3–5 at discharge (47.7% vs. 40.8%; p=0.0055) or to die in hospital (11.8% vs. 4.6%; p≤0.0001).

Conclusion:

The ES after stroke were common in our cohort. Increased stroke severity and confusion were independent predictors of ES. The ES were associated with higher rates of in-hospital complications, longer length of hospital stay, and worse outcomes at discharge.

Stroke at Moderate and High Altitude

Syed, Maryam J., Ismail A. Khatri, Wasim Alamgir, and Mohammad Wasay. Stroke at moderate and high altitude. High Alt Med Biol. 23:1-7, 2022. Background: Stroke at high altitude is an understudied area in stroke research. With improvements in road infrastructure, access to high-altitude areas for recreation and living purposes has risen. Subsequently, it has been anticipated that due to normal physiological changes to high altitude the incidence of stroke is also likely to increase in these regions. Methods: We searched PubMed for available literature about stroke at high altitude. Cross-referencing was done from available articles and through other scientific search engines. Relevant case series and case reports were included in this review of the topic. Results: Only one review article, eight case series (including review of literature), and seven case reports were identified that could be included in this review. Most of the available data come from moderate and high altitude. Conclusions: There is limited available literature about stroke at high and extreme altitudes. Stroke at high altitude is likely to become an important subset of stroke population. Currently, there is inadequate knowledge about the incidence and prevalence, mechanisms, and stroke outcomes. Cerebral venous thrombosis is more common than arterial stroke. Stroke is probably secondary to conventional risk factors, polycythemia, and other coagulopathies. A case-control study may identify the at-risk population for stroke at moderate and high altitudes.

Decompressive craniectomy is a life-saving procedure in malignant MCA infarction

Objectives:

To investigate the indications, timings, and outcomes of decompressive craniectomy (DC) performed for malignant middle cerebral artery (MCA) infarctions at our tertiary care center.

Methods:

This retrospective case series involved patients who underwent DC for malignant MCA infarction at King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, between January 2012 and December 2018. Demographic, clinical, and radiological data were collected, and stroke- and surgery-related complications and discharge outcomes were assessed.

Results:

Eighteen patients (mean age: 50±10 years), of whom 13 (72%) were men, underwent DC during the study period. Of the patients, 9 (50%) had severe stroke (NIHSS 16–25), 10 (56%) had right MCA infarction, and 11 (61%) received either intravenous thrombolysis or endovascular thrombectomy or their combination. Indications for surgery included clinical deterioration as seen in 16 (89%) patients, ipsilateral pupillary dilatation as seen in 11 (61%) patients, and signs of raised intracranial pressure in 6 (33%) patients. Surgery was performed within 48 h in 14 (78%) patients. The mean Intensive Care Unit stay was 15±7 days. Seven (39%) patients were discharged home and 3 (17%) were transferred to an inpatient rehabilitation unit, and 2 (11%) patients died. All patients had stroke-related complications; one (6%) patient developed cerebrospinal fluid leak, 3 (17%) had sunken skin flap syndrome and wound infection each, and 2 (11%) developed epidural hematoma.

Conclusion:

The DC was life-saving in the our patients with malignant MCA infarction. Most of the patients had surgery within 48 hours. More than one-third of the patients were discharged home, while mortality occurred in only 2 patients. Moreover, stroke- and surgery-related complications were common in our cohort.

Patterns and outcomes of stroke thrombolysis in a large tertiary care hospital in Riyadh, Saudi Arabia

Objectives:

To present the experience on stroke thrombolysis of a tertiary care center in Riyadh, KSA.

Methods:

Cross-sectional, observational study of patients thrombolyzed between January 2012 and December 2018.

Results:

Thrombolysis was performed in 148 patients (mean age: 58.2±14.5 years), 94 (63.5%) of them were men. The median onset-to-door time was 81 minutes, and 25% of the patients arrived within 1 hour. The median National Institute of Health Stroke Scale score upon admission was 13. Hypertension (68.9%), diabetes (56.1%), and dyslipidemia (40.5%) were the most common risk factors for stroke. The most common mechanism of stroke was cardioembolism (43.2%), which was associated with a more severe presentation (p=0.031). Intravenous thrombolysis alone was given to 98 patients (66.2%); the rest received intravenous tissue plasminogen activator plus endovascular therapy or endovascular therapy alone. The median door-to-needle (DTN) time was 70.5 min, with a significant improvement from 2012 (111.6 minutes) to 2018 (69.9 minutes) (p<0.001). Among the patients, 53 (35.8%) showed a good outcome (with a modified Rankin score of 0–2) whereas 14 (9.5%) died. Symptomatic intracranial hemorrhage (sICH) was seen in 8.1%. All vascular risk factors were more common in patients aged >60 years, except smoking, which was more common in the younger age group (p=0.007).

Conclusion:

In our cohort, the utilization of thrombolysis and the DTN time improved over time. One-thirds of the patients received endovascular treatment. Moreover, the frequency of the vascular risk factors was high. Compared with the published findings, our results showed that cardioembolic strokes were the most frequent and had severe presentation and were likely the cause of the slight increase in mortality and sICH.

Social Anxiety and Obsessive-Compulsive Disorder Are Common Among Persons With Multiple Sclerosis at King Abdulaziz Medical City, Riyadh

Background

Multiple sclerosis (MS) is associated with a physical disability and disturbed psychosocial functioning in young people. Many psychological and psychiatric comorbidities have been reported in MS.

Objective

To determine the frequency of social anxiety disorder (SAD) and obsessive-compulsive disorder (OCD) among MS patients and their relation to MS severity.

Methods

A cross-sectional survey was conducted in an adult MS cohort. Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) and Social Phobia Inventory (SPIN) were used to determine the presence and severity of OCD and SAD. The Statistical Package for the Social Sciences (SPSS) version 22 (IBM Corp., Armonk, NY) was used for statistical analysis. The Mann-Whitney U test and logistic regression were used to assess the association of the two diseases with the severity of MS.

Results

A total of 145 persons with MS (pwMS) were studied. The mean age was 33.5 (±8.5) years; the mean duration of MS was 7.2 (± 5.1) years. The majority (74.1%) were women; 57.3% were married; 63% had a college education; 50% belonged to the higher middle-class socioeconomic strata. Relapsing-remitting multiple sclerosis was the most common type of MS (92.2%). The mean Expanded Disability Status Scale (EDSS) score was 2.24 (±2.19). SAD was reported by 26.9%, and OCD was reported by 31% of the cohort. PwMS with walking difficulty but not wheelchair-bound had a statistically significant increased risk of SAD (p = 0.036). There was no direct association between MS-related disability and OCD. However, pwMS with SAD were more likely to have concomitant OCD (t=4.68, p-value <0.001, 95% CI: 0.47-1.16). Increasing disability was associated with higher chances of developing social anxiety and, in turn, OCD (t=3.39, p-value <0.001, 95% CI: 0.66-2.52).

Conclusions

Social anxiety and obsessive-compulsive disorders were present in nearly one-third of pwMS. Impaired walking but not wheelchair dependence was associated with social anxiety. PwMS with SAD were more likely to have obsessive-compulsive disorder.

The association of diabetes with ischemic stroke and transient ischemic attacks in a tertiary center in Saudi Arabia

BACKGROUND

Diabetes mellitus increases stroke risk 1.5 to 3 fold, particularly ischemic stroke. There is limited literature on the impact of diabetes on stroke patients in Saudi Arabia.

OBJECTIVES

Determine the association of diabetes on the presentation, subtypes, in-hospital complications and outcomes of ischemic stroke and transient ischemic attacks (TIA).

DESIGN

IRB approved, retrospective chart review.

SETTING

Tertiary care center.

PATIENTS AND METHODS

All adult patients with ischemic stroke or TIA aged 18 years or older admitted from January 2016 to December 2017 were included.

MAIN OUTCOME MEASURES

Stroke severity at presentation, stroke-related complications, discharge disposition and discharge modified Rankin Scale (mRS) in relation to diabetes.

SAMPLE SIZE

802 patients.

RESULTS

Among 802 cases, 584 (72.8%) had diabetes; the majority (63.1%) were males. The mean age was younger in the non-diabetic stroke group (54.6 [15.5] years vs. 63.3 [9.9], P<.001). Hypertension (83.6% vs 49.1%, P<.001), dyslipidemia (38.9% vs. 28.9%, P=.009), prior stroke (27.7% vs. 19.3% P=.014), and ischemic heart disease (20.4% vs. 7.8%, P<.001) were more common in diabetic patients whereas smoking was more common (19.3% vs. 11.1%, P=.003) in the non-diabetic patients. The commonest subtype of stroke was large artery disease followed by small vessel disease. Both were more common in diabetic vs. non-diabetic patients (55.8% vs. 44%, P=.003), and (16.6% vs. 11%, P=.05) respectively. Diabetic stroke patients were more likely to have lacunar stroke (16.4% versus 9.2%, P=.009). TIAs occurred more commonly in the non-diabetic group (26.1% vs. 13.7%, P<.001). Non-diabetic patients had a better outcome (mRS score of 0-2) at discharge (62.4% vs. 45.9%, P=.002).

CONCLUSIONS

Almost three-fourth stroke patients were diabetic in our cohort. Diabetic stroke patients were older, had multiple vascular comorbid conditions, presented late to the hospital, and were likely to have more disability at the time of discharge. Large vessel atherosclerosis as well as lacunar infarctions were more common in diabetic stroke patients.

LIMITATIONS

Missing data about time of presentation in few patients, missing modified Rankin Scale score at discharge.

CONFLICT OF INTEREST

None.

Common Carotid Artery Occlusion in a Young Patient: Can Large-Vessel Stroke Be the Initial Clinical Manifestation of Coronavirus Disease 2019?

Background

The occurrence of large-vessel occlusion in young patients with coronavirus disease 2019 (COVID-19) infection has been exceedingly rare. An extensive review of reported studies revealed a few reported cases. In the present report, we have described the clinical presentation, radiological findings, and outcome of large-vessel occlusion in a young patient with COVID-19 and reviewed the pertinent reported data on this condition.

Case Description

A 31-year-old woman was in her usual state of health until she had presented with a 3-day history of right-sided weakness, slurred speech, and decreased vision. The patient had been taken to several hospitals where she had been treated conservatively with analgesics and discharged. Shortly thereafter, her weakness had become progressive. She had become severely dysarthric and unresponsive. On arrival to the emergency department, her physical examination revealed that she was stuporous, with a Glasgow coma scale of 10 (eye response, 3; verbal response, 2; motor response, 5). The National Institutes of Health Stroke Scale score was 19 on presentation. Brain computed tomography and computed tomography venography revealed an occluded left internal carotid artery and left middle cerebral artery with subacute left middle cerebral artery territory infarction and midline shift. Computed tomography angiography revealed complete occlusion of the left common carotid artery. An emergent decompressive craniectomy was successfully performed. The patient was shifted to the intensive care unit. She was later found to be positive for COVID-19.

Conclusions

Although rare, patients with COVID-19 can present with large-vessel occlusion. Prompt identification of COVID-19–related coagulopathy is essential to assess young patients with clinical manifestations of infarction.

Brainstem hemorrhage is uncommon and is associated with high morbidity, mortality, and prolonged hospitalization

OBJECTIVE

To determine the frequency, risk factors, and outcomes of patients with brainstem hemorrhage in stroke center at King Abdulaziz Medical City, Riyadh.

METHODS

A retrospective, observational cohort study including all patients with brainstem hemorrhage from January 2014 to December 2017. The clinical presentation, location of hemorrhage, complications and clinical outcomes were analyzed.

RESULTS

Of 1921 stroke patients, 219 had hemorrhagic stroke (11.4%), of whom only 10 (4.6%) had brainstem hemorrhage, comprising 0.5% of all stroke patients. All patients were men; mean age was 58.5 years. Most frequent presenting symptoms were headache (70%), unilateral weakness (60%), and loss of consciousness (50%). All patients had hemorrhage in pons, 5 had concomitant cerebellar hemorrhage (50%), one had medullary hemorrhage, and one midbrain hemorrhage (10% each). Mean ICU stay was 17 days; mean hospital stay was 58 days. At the time of discharge, three (30%) had mRS of 0-2, 5 (50%) had mRS of 3-5, whereas 2 (20%) had died. Glasgow coma scale (GCS) of >8 at presentation was associated with a good outcome at three months (p=0.03). Presentation within six hours of symptom onset (p=0.233), hypertension on presentation (p=0.233), and age less than 60 years (p=0.065) did not affect discharge outcomes.

CONCLUSION

Brainstem hemorrhage occurred in 0.5% of all stroke patients. It was associated with high morbidity and mortality. Low Glasgow Coma Scale at presentation was associated with poor outcomes.

Frequency, risk factors, and outcomes in patients with significant carotid artery disease admitted to King Abdulaziz Medical City, Riyadh with Ischemic Stroke

OBJECTIVE

To determine the frequency, risk factors, and outcomes of significant carotid artery disease (CAD) in patients with ischemic stroke.

METHODS

The frequency of significant CAD in patients admitted to the Stroke Unit between January 2014 and December 2015 was determined from radiological data. Outcomes were determined clinically and radiologically.

RESULTS

Among 435 patients, 273 were men (62.8%), with a mean age of 57.4+/-12.2 years. Significant CAD was found in 48 vessels in 40 (9.2%) patients, of which 30 patients were symptomatic. Nine of these patients were treated with carotid artery stenting, one underwent carotid endarterectomy, and 3 underwent an urgent thrombectomy, without stenting. Seventeen symptomatic patients were not treated for the following reasons: patient/family refusal (n=2), contraindications (n=5), and complete occlusion (n=10). One (7.7%) of the 13 treated patients had an ipsilateral stroke on follow up, one (7.7%) had contralateral transient ischemic attack (TIA), 9 (69.2%) had no recurrence, and no clinical data were available for 2 patients. Among the 17 untreated patients, one (5.9%) had an ipsilateral stroke, 7 (41.2%) had no recurrence, and 9 (52.9%) were lost to follow up.

CONCLUSION

Significant carotid artery disease is uncommon in our cohort found in less than 10% of patients. Vascular risk factors are more or less similar between patients with or without CAD except obesity which appears to have inverse relation with CAD. A small number of patients received carotid intervention with no recurrence of stroke at limited follow up.

An overview of complications affecting the Central Nervous System following bariatric surgery

Bariatric surgery has been considered as an effective treatment for morbid obesity. Apart from procedures related complications, a broad spectrum of neurological disorders affecting any part of neuraxis has been reported following BS. Central nervous system complications, although less common than peripheral nervous system complications, carry significant morbidity and potential mortality. Encephalopathy, behavioral and psychiatric disorders, myelopathy and optic neuropathy are the most frequently reported CNS complications. Early detection and prompt management may improve or completely reverse these neurological complications. It is essential that the treating physicians must be aware of their clinical manifestations and management, so early diagnosis and treatment can prevent patients from suffering significant neurological deficits and even death. This review discusses the clinical manifestations of these complications in detail which will help concerned physician in earlier recognition and hence prevent the delay in specific treatment.

Renal dysfunction as a predictor of acute stroke outcomes

Objectives:

To explore if renal dysfunction in terms of estimated glomerular filtration rate (eGFR) can be considered a risk factor for stroke outcomes.

Methods:

The study population consisted of adults diagnosed with acute stroke admitted to the King Abdulaziz Medical City, Riyadh, Kingdom of Saudi Arabia between 2012 and 2015. Data was collected by chart review. The Modification of Diet in Renal Disease equation was used to estimate GFR. Patients were classified into 2 eGFR categories: eGFR >60 (normal) and eGFR ≤60 (low).

Results:

A total of 727 patients were studied of whom 596 (82%) had normal eGFR and 131 (18%) had low eGFR. There were more males (68.5%). Ischemic strokes were more prevalent (87.2%). Urinary tract infections were more likely to occur in the low eGFR group (OR=2.047, 95% CI=1.024 – 4.093). They were also significantly more likely to die during admission (OR=3.772, 95% CI=1.609 – 8.844). There was a statistically significant degree of disability reflected by higher mRS (p=0.010) as well as higher post-stroke National Institute of Health Stroke Score scores in the low eGFR group (p=0.011).

Conclusion:

Estimated glomerular filtration rate is a possible predictor of stroke severity, disability and mortality.

Novel LMNA mutations in patients with Emery-Dreifuss muscular dystrophy and functional characterization of four LMNA mutations

Mutations in LMNA cause a variety of diseases affecting striated muscle including autosomal Emery-Dreifuss muscular dystrophy (EDMD), LMNA-associated congenital muscular dystrophy (L-CMD), and limb-girdle muscular dystrophy type 1B (LGMD1B). Here, we describe novel and recurrent LMNA mutations identified in 50 patients from the United States and Canada, which is the first report of the distribution of LMNA mutations from a large cohort outside Europe. This augments the number of LMNA mutations known to cause EDMD by 16.5%, equating to an increase of 5.9% in the total known LMNA mutations. Eight patients presented with either p.R249W/Q or p.E358K mutations and an early onset EDMD phenotype: two mutations recently associated with L-CMD. Importantly, 15 mutations are novel and include eight missense mutations (p.R189P, p.F206L, p.S268P, p.S295P, p.E361K, p.G449D, p.L454P, and p.W467R), three splice site mutations (c.IVS4 + 1G>A, c.IVS6 - 2A>G, and c.IVS8 + 1G>A), one duplication/in frame insertion (p.R190dup), one deletion (p.Q355del), and two silent mutations (p.R119R and p.K270K). Analysis of 4 of our lamin A mutations showed that some caused nuclear deformations and lamin B redistribution in a mutation specific manner. Together, this study significantly augments the number of EDMD patients on the database and describes 15 novel mutations that underlie EDMD, which will contribute to establishing genotype-phenotype correlations.

Cerebral vasospasm in intracerebral hemorrhage-case report

BACKGROUND

Cerebral vasospasm is commonly seen in subarachnoid hemorrhage. However the vasospasm in spontaneous intracerebral hemorrhage without subarachnoid extension has not been described.

REPORT

We report a patient who developed intracerebral hemorrhage associated with cerebral vasospasm demonstrated by conventional angiography. The vasospasm involved the superior and inferior divisions of the middle cerebral artery on the side of intracerebral hemorrhage. The vasospasm resolved in six days as documented by a repeat angiography.

CONCLUSION

Cerebral vasospasm can be rarely seen in patients with intracerebral hemorrhage. Further elaboration is required to understand the pathophysiology and subsequent impact on outcome in such patients.

Low bone mineral density in spinal muscular atrophy

BACKGROUND AND PURPOSE

Pathological fractures are common in pediatric neuromuscular disorders. Dual-energy x-ray absorptiometry has become the most accepted technique for the measurement of bone mineral density (BMD) in adults and children. Limited data are available on BMD in pediatric neuromuscular diseases except Duchenne muscular dystrophy.

METHODS

We retrospectively analyzed the results of all dual-energy x-ray absorptiometry scans done in a period of 23 months at a tertiary care pediatric neuromuscular center. BMD was performed on spine region L1-4. Osteopenia was classified as mild if the Z scores were between 0 and -1.5, moderate if Z scores were between -1.5 and -2.5, and severe if Z scores were > -2.5 standard deviation scores.

RESULTS

Eighty-four dual-energy x-ray absorptiometry scans were performed on 79 patients between the ages of 4 months and 18 years with the mean age of 8 years. Z scores were used to compare their BMDs. BMD was lowest in patients with spinal muscular atrophy (SMA) with Z score of -2.25 +/- 0.31 standard deviation scores. The Z score for patients with Duchenne muscular dystrophy was -1.72 +/- 0.1. The BMD in nonambulatory patients with SMA was significantly decreased compared with ambulatory patients with SMA (P < 0.05).

CONCLUSIONS

We conclude that osteopenia is common in children with neuromuscular disorders. Patients with SMA have the lowest BMD.

A non-randomized study of safety and efficacy of heparin for DVT prophylaxis in intracerebral haemorrhage

OBJECTIVE

To evaluate the safety and efficacy of subcutaneous heparin for deep venous thrombosis (DVT) prophylaxis in patients with intracerebral haemorrhage (ICH) during acute phase in comparison to elastic stockings.

METHODS

The diagnosis of ICH was based on imaging (CT or MRI) and DVT was based on Doppler ultrasound.

RESULTS

A total of 458 patients were identified over a period of 5 years (1997-2001). Median age was 59 years (range:12-99 years). Two hundred (44%) patients received heparin (heparin group) in addition to elastic stockings and 258 (56%) patients were only given elastic stockings (stockings group). These two groups were not randomized. Heparin was administered subcutaneously (SQ) in doses of 2500-5000 international units twice daily. Two groups were matched for age (p = 0.5), sex (p = 0.28), presence of diabetes mellitus (p = 0.14), cigarette smoking (p = 0.045) and presence of hydrocephalus or midline shift on CT/MRI (p= 0.87). One patient developed DVT in control group while none developed DVT in heparin group (p = 0.18). One patient had worsening of ICH on repeat CT scan in Heparin group. This worsening was non fatal. Systemic haemorrhagic complications (non fatal) were seen in 7 (14%) patients receiving heparin. Twenty five patients (12%) in heparin group and 52 (20%) in control group died (p = 0.02).

CONCLUSION

Subcutaneous heparin in doses of 2500-5000 units twice daily during acute phase in patients with ICH may be safe for DVT prophylaxis. It was not superior to elastic stockings in a non-randomized comparison to prevent DVT.

Intraarterial thrombolysis with reteplase in acute ischaemic stroke in a Pakistani center

Acute ischaemic stroke is a major cause of neurological morbidity and mortality across the globe. Recent advances in past two decades have made complete reversal of life threatening stroke a reality. The judicious use of intravenous and intraarterial thrombolysis in acute ischaemic stroke has saved countless lives. The use of thrombolytic therapy in Pakistan in acute stroke is still miniscule. Very limited literature is available from Pakistan on the use of intravenous thrombolysis. Intraarterial thrombolysis has been used only in few patients and there are no published reports of that from Pakistan. We present the case of a young man who came within 1 hour of stroke onset with a large right middle cerebral artery infarct resulting in severe neurological deficit. An urgent cerebral angiography showed complete occlusion of right internal carotid artery at its bifurcation. Successful intraarterial thrombolysis was performed with excellent clinical outcome. To our knowledge this is the first report of use of intraarterial thrombolysis in acute stroke from Pakistan.

Salvage decompressive craniectomy in malignant MCA infarcts--results of local experience at Shifa International Hospital, Islamabad, Pakistan

Malignant infarctions of the middle cerebral artery (MCA) have high mortality. Recent studies showed decreased mortality with good functional outcome in young people with decompressive surgery. We report prospective, non-randomized case series of live patients in whom successful life saving decompressive craniectomy was performed. All five were males. Mean age was 59.2 +/- 13 years. Four had right MCA infarction while I had left MCA infarction. Ipsilateral temporoparietal craniectomy with duraplasty was performed in mean time of 76 +/- 27 hours after onset of symptoms. Four (80%) patients were discharged to home in awake, alert, conversant, hemiparetic state. One patient developed status epilepticus, and was transferred to another facility in intubated. sedated state. Three month follow-up on three patients showed moderate improvement in neurological status. Early craniectomy was life saving in all of our patients. Neurosurgical intervention should be considered early in large MCA infarcts, especially in young patients.

Carotid artery stenting in high risk patients--results of first twelve patients at Shifa International Hospital, Islamabad, Pakistan

OBJECTIVE

Carotid artery stenting (CAS) is emerging as an alternative procedure to carotid endarterectomy. It is mostly performed in patients with high surgical risk. Many centers in Pakistan have started CAS. We present results of 1st twelve patients who underwent carotid artery stenting at Shifa International Hospital, Islamabad.

METHODS

Our carotid intervention team is comprised of a vascular neurologist, interventional cardiologist and interventional radiologist. Based on high risk criteria/patient choice, patients are recruited for CAS. Carotid artery stenting using standard technique with embolic protection device is performed.

RESULTS

Twelve carotid artery stenting procedures were done between August 2006 and March 2008. One patient had TIA before stent deployment and was excluded from final analysis. Of the other 11 patients, ten were males, with mean age of 68.2 +/- 11.3 years (median age 71). Ten were symptomatic; one asymptomatic with complete occlusion of contralateral internal carotid artery. High-risk criteria were present in all: complete contralateral occlusion (2 patients); age greater than 70 years (7 patients); severe coronary artery disease (7 patients) and previous ipsilateral endarterectomy (1 patient). The stenosis ranged between 60-95%. Embolic protection device was used in nine (82%). Five (46%) patients developed hypotension requiring intravenous vasopressors. One of them developed persistent hypotension despite maximum pressor support and died. None developed neurological deterioration, acute renal failure, or haematomas/ pseudoaneurysm formation. One-year follow-up is available on two patients with patent stent and no neurological events.

CONCLUSION

Hypotension is a common and potentially lethal complication of carotid artery stenting. Our results suggest that a multidisciplinary team approach with availability of specialized care can provide results comparable to internationally acceptable outcomes.

Multiple sclerosis in Pakistan

We describe retrospective data from the largest series of patients (n=142) with multiple sclerosis (MS) from Pakistan. Mean age at onset was 27 years, with a female to male ratio of 1.45:1. The disease onset was polysymptomatic in 75% patients. Motor weakness was the most common onset symptom (70%), followed by sensory symptoms (45%). Optico-spinal type of MS was seen in only 3% of patients The courzse was relapsing-remitting (RR) in 81%, primary progressive (PP) in 21%, and secondary progressive (SP) in 4% of patients. Almost three-fourths of the patients were moderately (45%) or severely (31%) disabled at the time of evaluation. Two-thirds of patients with severe disability had a mean disease duration of only 5.2 years. In conclusion, MS is not uncommon in Pakistan, and many patients were found to have severe disability despite short disease duration. Multiple Sclerosis 2007; 13: 668-669. http://msj.sagepub.com

A case of Hirayama disease in Pakistan

We report a case of Hirayama disease in a 23 year old male presenting with weakness of right hand and forearm. The weakness started gradually, progressed over a period of 12 months and stabilized. Few months after the onset of right-sided weakness, he noticed weakness in the left hand and forearm which increased over a period of 3 months before stabilizing. Neurological examination demonstrated moderate to severe atrophy of distal upper extremity muscles, preserved reflexes and normal sensory findings. Electrophysiological studies revealed neurogenic changes in the muscles innervated by lower cervical spinal cord. Magnetic resonance imaging showed atrophy of mid-cervical cord with high signal intensity in the anterior horn cell region. These examination and investigation findings were compatible with the diagnosis of juvenile muscular atrophy of distal upper extremities (JMADUE) also known as Hirayama disease.

Unusual causes of cerebral venous thrombosis

Cerebral venous thrombosis is a relatively uncommon condition afflicting mostly young adults. Thrombosis of cerebral veins or sinuses results in variable and nonspecific clinical features, including headache, lethargy, motor or sensory deficits, seizures, neck stiffness and sometimes fever. A multitude of conditions have been attributed as risk factors for CVT. The more common conditions include hereditary thrombophilia, pregnancy and purperium, postoperative state, intracranial and local infections and the use of oral contraceptives. Frequently, the cause of CVT is multifactorial, and in less than twenty percent of cases no clear risk factor is identified. In this review, we have focused on relatively rare and unusual causes of cerebral venous thrombosis. Many of the conditions described have very few reported cases and the causal relationship is not well established.

MS in Asian countries

This paper reviews all available English language literature on MS from Asian countries published between 1970 and 2005. Although limited data are available, the review reveals that western Asia--including the Middle East--has the highest prevalence of MS across the continent, and that MS in Asia largely resembles conventional MS in western countries. Opticospinal MS (a distinct clinical entity from conventional MS) is more common in eastern Asian regions. Larger epidemiological and genetic studies, with more complete ascertainment in various Asian populations, are needed so that we can understand the diversity of Asian MS.

Catheter-based aortography fails to identify aortic atherosclerotic lesions detected on transesophageal echocardiography

BACKGROUND AND PURPOSE

Transesophageal echocardiography is used to detect the aortic arch pathology during diagnostic workup of ischemic stroke events. Conventional angiography is increasingly used in diagnosing and treating atherosclerotic vascular lesions in patients with ischemic stroke. Although catheter-based aortography can be performed with cerebral angiography, there is limited information about the utility of aortography in identifying atherosclerotic abnormalities of the aortic arch.

METHODS

A retrospective chart review was performed to identify patients who underwent aortography as part of their angio-graphic study and transesophageal echocardiography. Both studies were reviewed independently in the absence of knowledge of the results of the other study. The findings of these aortograms were correlated with the findings of transesophageal echocardiography.

RESULTS

A total of 34 patients underwent both aortography and echocardiography. Of a total of 34 trans esophageal echocardiograms, 29 showed abnormal findings in the aorta (85%) and 5 appeared normal (15%). These aortic abnormalities included mild to moderate atherosclerosis in 18 cases (52%), moderate to severe atherosclerosis in 4 cases (12%), and severe atherosclerosis in 7 cases (21%). None of these abnormalities were detected by aortography. No disease was visualized in the origin of the supraaortic arteries.

CONCLUSIONS

Aortic arch atherosclerosis is common in patients with ischemic stroke; however, aortograms acquired during conventional angiography fail to identify abnormalities detected on transesophageal echocardiogram.

Epidemiology of epilepsy in Pakistan: review of literature

OBJECTIVE

To review literature pertinent to the epidemiology of epilepsy in developing countries with special reference to Pakistan.

METHODS

All the studies published in medical journals related to epilepsy in Pakistan were systematically reviewed. Important findings from various studies are summarized.

RESULTS

Overall prevalence of epilepsy in Pakistan is estimated to be 9.99 per 1000 population. Highest prevalence is seen in people younger than 30 years of age. A slight decrease in prevalence is noted between the ages of 40 and 59. Higher prevalence is observed in rural population. Etiology of epilepsy is more commonly identified in pediatric population. Epilepsy was considered idiopathic in 21 to 76% cases. Only 27.5% epileptic persons in urban areas and 1.9% in the rural areas were treated with AEDs. The burden of epilepsy is not fully evaluated and understood. Generalized seizures were the most common seizure type noted. Knowledge about epilepsy and its care is extremely low.

CONCLUSION

Epilepsy is a common medical problem in Paksitan, more prevalent is rural population. The majority of people with epilepsy are treated inadequately or inappropriately.

Characteristics of rodent intestinal mucin Muc3 and alterations in a mouse model of human cystic fibrosis

Human mucin MUC3 and rodent Muc3 are widely assumed to represent secretory mucins expressed in columnar and goblet cells of the intestine. Using a 3'-oligonucleotide probe and in situ hybridization, we observed expression of rat Muc3 mostly in columnar cells. Two antibodies specific for COOH-terminal epitopes of Muc3 localized to apical membranes and cytoplasm of columnar cells. An antibody to the tandem repeat (TR) sequence (TTTPDV)3, however, localized to both columnar and goblet cells. On CsCl gradients, Muc3 appeared in both light- and heavy-density fractions. The lighter species was immunoreactive with all three antibodies, whereas the heavier species reacted only with anti-TR antibody. Thus Muc3 is expressed in two forms, a full-length membrane-associated form found in columnar cells (light density) and a carboxyl-truncated soluble form present in goblet cells (heavy density). In a mouse model of human cystic fibrosis, both soluble Muc3 and goblet cell Muc2 were increased in amount and hypersecreted. Thus Muc2 and Muc3 contribute to the excess intestinal luminal mucus of cystic fibrosis mice.

Susceptibility of the cysteine-rich N-terminal and C-terminal ends of rat intestinal mucin muc 2 to proteolytic cleavage

The present study reveals that partial proteolytic degradation of rat Muc 2 mucin can occur rapidly even in the presence of a battery of proteinase inhibitors. During the initial steps of purification from homogenates of intestinal scrapings, degradation was rapid, causing release of the entire 118 kDa C-terminal glycopeptide and, as shown by N-terminal sequencing, a large (200 kDa) N-terminal glycopeptide fragment. Degradation could be prevented by adding 6 M guanidinium chloride provided that its presence was maintained throughout every step of purification. Even after purification, however, the mucin was still vulnerable to partial proteolysis unless it was stored in guanidinium chloride at -20 degrees C. These findings imply that a potent proteinase contaminant remains tightly bound to the mucin through every step of purification, or else that the mucin has autocatalytic properties. Because the C- and N-terminal regions of secretory mucins are required for their assembly into linear mucin polymers that form functional gels, our findings emphasize that extreme care is required to purify structurally intact mucin molecules. They also imply that the specific degradation steps described here are likely to occur rapidly after mucins are secreted into the intestinal lumen and come into contact with the products of sloughed cells.

Evidence that a peptide corresponding to the rat Muc2 C-terminus undergoes disulphide-mediated dimerization

We have investigated the possibility that the intestinal mucin rat Muc2 forms dimers during biosynthesis via intermolecular disulphide bridging of its C-terminal domains. Since the cysteine alignment of RMuc2 (and other secretory mucins) is similar to that of human von Willebrand factor, a similar C-tail to C-tail dimerization may occur in mucins. The C-terminal domain of RMuc2 (534 amino acids) was expressed in COS-1 cells, and the products monitored by SDS/PAGE and western blotting with three antibodies to different regions of the C-terminal domain. In cells, the expressed domain was glycosylated and formed disulphide-dependent dimers centred at approximately 150 kDa. The domain dimer, but not its precursor monomer, was secreted into the culture medium. The dimers in the media however, appeared to be 12-15-kDa heavier (i.e. had a slower mobility) than in cell lysates. Initial N-glycosylation, dimerization and secretion were inhibited by addition of tunicamycin to incubations, whereas benzyl-alpha-GalNAc did not interfere with these processes. However benzyl-alpha-GalNAc resulted in a decrease in the apparent size of secreted dimers, such that they now had the same mobility on gels as dimers normally seen in cell lysates (i.e. 150 kDa). A similar change in dimer size was observed after incubating untreated media samples with N-acetylneuraminidase. This suggests that benzyl-alpha-GalNAc caused inhibition of sialylation of cell dimers just before they were secreted. In summary, the C-terminal domain of RMuc2 can form disulphide-dependent dimers, and N-glycosylation is required for dimerization and subsequent secretion. A late sialylation event appears to precede the secretion of mucin domain dimers.

The carboxyl-terminal sequence of rat intestinal mucin RMuc3 contains a putative transmembrane region and two EGF-like motifs

A 3' RACE technique was used to establish the nucleotide sequence encoding the C-terminal 379 amino acids of rat intestinal Muc3. Unlike the C-terminus of Muc2 and many secretory mucins, Muc3 contains two EGF motifs and a putative transmembrane domain. The mRNA for rat Muc3 is 7.5-8.0 kb.

Cloning of the cDNA for a rat intestinal Na+/dicarboxylate cotransporter reveals partial sequence homology with a rat intestinal mucin

In this report we present the full-length cDNA and deduced 587 amino acid sequence of a putative rat intestinal Na+/dicarboxylate cotransporter. It shows sequence and structural similarity to a rabbit renal Na+/dicarboxylate cotransporter. An unexpected fining was the presence of a C-terminal transmembrane region that is homologous with an 87 amino acid hydrophobic region of a rat intestinal mucin, M2. Mucin-related sequences in transporter proteins have not been described before.

Intestinal mucins inhibit rotavirus replication in an oligosaccharide-dependent manner

Rotaviruses are important causes of infant morbidity and mortality worldwide. It has been previously shown that mucinous glycoproteins can inhibit rotavirus replication. However, the structure-function relationships of this inhibition have not been completely elucidated. Mucins were purified from epithelial scrapings of rat and human intestine by CsCl density-gradient ultracentrifugation and tested for the inhibition of rotavirus replication in MA-104 cells. Native human and rat intestinal mucins inhibited the replication of human and animal rotaviruses at low concentrations. Antiviral activity was most prominent in the densely glycosylated part of the rat and human mucins. Activity was retained after thiol reduction and alkylation, chloroform methanol partition, and partial removal of oligosaccharides. However, total deglycosylation of the mucins destroyed antiviral activity. Intestinal mucins from humans and other animals are potent inhibitors of rotavirus replication, and this inhibition is dependent on specific mucin-viral interactions.

Suggestive evidence for two different mucin genes in rat intestine

In the present report we describe the isolation and sequence of a partial cDNA (M2-798) for a rat intestinal mucin designated M2. A rat intestinal lambda ZAP II cDNA library was screened using a polyclonal antiserum which was prepared against deglycosylated high-molecular-mass glycopeptides of the purified mucin. Mucin cDNA clones were found to contain tandem repeats of 18 nt which encoded a threonine- and proline-rich peptide having a consensus sequence of TTTPDV. This is the same sequence reported recently by Gum, Hicks, Lagace, Byrd, Toribara, Siddiki, Fearney, Lamport and Kim [(1991) J. Biol. Chem. 266, 22733-22738] for a rat intestinal cDNA called RMUC 176. A novel feature present in the cDNA M2-798 is a 246 nt unique region at the 3' end which encodes a hydrophobic sequence of 82 amino acids. RNA blots probed with M2-798 cDNA produced a single hybridization band between 7.5 and 9.0 kb in rat small intestine and colon. An identical hybridization pattern was obtained with a PCR-generated cDNA probe corresponding solely to the unique hydrophobic region of M2-798, demonstrating that this region is encoded by the authentic M2 mRNA. Our data suggest that the unique region of M2 has the potential to be either a transmembrane region, or a domain which mediates hydrophobic interactions of the mucin with other molecules. Since we have previously reported another rat intestinal cDNA which encodes the C-terminus of a mucin-like peptide (MLP) [Xu, Wang, Huan, Cutz, Forstner and Forstner (1992) Biochem. J. 286, 335-338], we wished to discover whether M2 was encoded by the same gene. RNA blotting experiments with probes specific for M2 and MLP showed different mRNAs for each. The message for M2 (7.5-8.5 kb) was smaller than that for MLP (> 9.5 kb) and, unlike MLP, gave no signal in human colonic LS174T cells. The results of DNA blots probed with M2-798 and an MLP-probe suggest that M2 and MLP are likely to be single-copy genes. It would appear therefore that normal rat intestine, like human intestine, may express two different mucin genes.

cDNA for the carboxyl-terminal region of a rat intestinal mucin-like peptide

When subjected to thiol reduction, purified intestinal mucins have been shown to undergo a decrease in molecular mass and to liberate a 118-kDa glycopeptide (Roberton, A. M., Mantle, M., Fahim, R. E. F., Specian, R., Bennick, A., Kawagishi, S., Sherman, P., and Forstner, J. F. (1989) Biochem. J. 261, 637-647). The latter has been called a putative "link" component because it is assumed to be important for disulfide bond-mediated mucin polymerization. Controversy exists as to whether the putative link is an integral mucin component or a separate mucin-associated glycopeptide. In the present study both NH2-terminal and internal amino acid sequences of the 118-kDa glycopeptide of rat intestinal mucin were used to generate opposing oligonucleotide primers for polymerase chain reaction. A specific 1.2-kilobase (kb) product was obtained, from which a 0.5-kb HindIII fragment was used as a probe to screen a lambda ZAP II cDNA library of rat intestine. A 2.6-kb cDNA (designated MLP 2677) was sequenced and revealed an open reading frame of 2.5 kb encoding 837 amino acids. The deduced amino acid sequence showed that the putative link peptide is equivalent to the carboxyl-terminal 689 amino acids of a larger peptide. Northern blots revealed a mRNA size of approximately 9 kb. Computer searches revealed no sequence homology with other proteins, but similarities were seen in the alignment of cysteine residues in the link and in several domains of human von Willebrand factor, as well as cysteine-rich areas of bovine and porcine submaxillary mucins and a frog skin mucin designated FIM-B.1. In keeping with earlier demonstrations of the presence of mannose in the 118-kDa glycopeptide, there were several (13) consensus sequences for attachment of N-linked oligosaccharides within the link domain. Further sequencing of MLP 2677 in a direction 5' to the codon specifying the NH2-terminal proline of the link has revealed a coding region for 148 amino acids, including a unique 75-amino acid domain rich in cysteine and proline, and a region containing 4.5-variable tandem repeats (each 11-12 amino acids) rich in serine, threonine, and proline. The presence of mucin-like tandem repeats suggests that the entire cysteine-rich link peptide represents the carboxyl-terminal region (75.5 kDa) of a mucin-like peptide (MLP). The latter is estimated to have a molecular mass of approximately 300 kDa.