Diabetes and Stroke: More than just accelerated atherosclerosis?

Editoria

Peri-ictal Water Drinking in an Omani Patient with Bilateral Mesial Temporal Sclerosis

Peri-ictal water drinking (PIWD) is a rare vegetative manifestation of temporal lobe epilepsy without a definite lateralization value. We report a case of PIWD in a 22-year-old Omani man with post-concussion syndrome and epilepsy presented to a tertiary care hospital in Muscat, Oman in 2021 for evaluation of paroxysmal events. His behaviour of PIWD was misinterpreted by his family until characterized in the epilepsy-monitoring unit as a manifestation of epilepsy that was treated medically. To our knowledge, this is the second reported case in our region. Keywords: Peri-ictal water drinking, Ictal Spitting, Epilepsy, Autonomic

Eating Epilepsy in Oman : A case series and report on the efficacy of temporal lobectomy

Eating epilepsy (EE), where seizures are triggered by eating, is rare and has not been reported in the Gulf region. In EE, the ictal semiology includes partial or generalised seizures. Focal brain changes on imaging, if present, are often confined to the temporal lobe or perisylvian region. Therapeutic options, especially in those patients who are refractory to pharmacotherapy, have not been well-established. We report a series of five patients with EE from Oman, a country located in the eastern part of the Arabian Gulf region, and highlight the usefulness of temporal lobectomy in one patient who had medically-intractable EE. Surgical intervention could be considered as a potential therapeutic option in carefully selected patients with medically-intractable seizures

The Yield of Cardiac Investigations in Patients Presenting with an Acute Ischemic Stroke: A single tertiary centre experience

Objectives: Strokes are a major source of morbidity and mortality. The Aim of this study was to evaluate the effectiveness of routine cardiac investigations in identifying a cardioembolic aetiology for ischemic strokes. Methods: This was a retrospective study of patients who had presented with a stroke to our institution between January and December 2019. Results: A total 183 patients (mean age 66.2+13.5 years, 109 or 59.6% male) were included in the final analysis. The common risk factors were hypertension (74.9%) diabetes (61.7%), and hyperlipidaemia (54.6%). The Middle cerebral artery (MCA) was the commonest artery affected (44 or 24%). On admission, 14(7.6%) patients were in atrial fibrillation with the rest being in sinus rhythm. On 24-hour ECG holter monitoring, no abnormalities were noted in 135 patients. Atrial fibrillation was seen in 15(8.1%) patients (inclusive of the 14 who had AF on resting ECG). 32 (17.4%) patients had evidence of non-sustained atrial arrhythmia and 9(4.9%) had non sustained ventricular tachycardia. Thirty patients(16.3%) were also noted to have frequent supraventricular ectopics (>30/hour) while 5(2.7%) patients had a high ventricular ectopic burden (>10% burden). No significant abnormalities were noted in the echocardiograms of the patients, but 10 out of 132 (7.5%) patients had a positive bubble echo. Twenty-four (13.1%) patients had enlarged left atria. Conclusion: The overall diagnostic yield of abnormalities from routine cardiac testing for patients with stroke appears to be low. Targeted screening of patients with crytogenic stroke as suggested by newer guidelines is recommended. Keywords: Cerebrovascular Accidents; Echocardiography; Atrial Fibrillation; Oman

“Different Strokes”: A management dilemma

Stroke is a common medical emergency resulting from numerous pathophysiological mechanisms and with varied clinical manifestations; as such, the diagnosis of stroke requires diligent clinical assessment. When different stroke syndromes occur in the same patient, it may cause a dilemma in terms of diagnosis and management. This continuing medical education article describes an interesting patient with recurrent neurological events, highlighting the complex pathophysiological processes associated with cerebrovascular syndromes. It offers readers the opportunity to apply their own basic neuroscience knowledge and clinical skills to solve the challenges encountered during the course of diagnosing and treating this patient. Specifically, the article aims to familiarise readers with an approach to diagnosing brainstem strokes and the diverse manifestations of a common stroke syndrome. Keywords: Stroke; Lacunar Stroke; Cerebral Hemorrhage; Cerebral Small Vessel Disease; Continuing Medical Education

Atherosclerotic Carotid Artery Disease: Where to from the Emergency Room? A University Hospital Experience

Objective: Stroke is the second leading cause of death worldwide, with 5.5 million deaths attributed to this cause in 2016. Vascular intervention, including carotid endarterectomy and carotid artery stenting, play a major role in stroke prevention, especially if intervention is performed early after onset of symptoms. The aim of the paper was to define the role of vascular surgeons in ischemic stroke and hence improve referral patterns by drawing an algorithm for the referral process which could reduce time to intervention and optimize patient benefit from intervention. Methods: This retrospective study reviewed the symptomatic and asymptomatic patients with atherosclerotic disease of the carotid artery referred to the vascular surgery unit of our institution from April 2018 to March 2020, to examine factors influencing recognition of suitable candidates for intervention. Results: A total of 38 patients with ischemic stroke were recognized as having carotid artery stenosis and were referred to the vascular surgery service during the study period. Only 6 met the criteria for carotid endarterectomy; 4 underwent the procedure. Conclusions: Choice of patients for carotid endarterectomy involves multiple steps, with potential for missed opportunities. By involving a multidisciplinary team approach, the recommended protocol aims to lead to early and appropriate referral to a vascular surgeon or interventional radiologist resulting in increased and optimised intervention in stroke prevention. Keywords: Stroke, TIA, carotid, symptomatic, asymptomatic, referral, vascular, surgery, endarterectomy, stenting, referral

Frequency of Dimethyl Fumarate Induced Lymphopaenia Among Omani Patients with Multiple Sclerosis

Objectives: Dimethyl fumarate (DMF) is known to cause lymphopenia in treated multiple sclerosis (MS) patients. There is a dearth of research on DMF therapy in the Arab world, especially in Oman. This study aimed to analyse the prevalence of lymphopenia among Omani MS patients and the reasons for discontinuing DMF. Methods: In this retrospective study, we reviewed the medical records of Omani MS patients who were treated using DMF at two tertiary hospitals in Muscat from the period 2017 February to 2023 February. Their demographic, clinical, and laboratory data were retrieved and analysed. Absolute lymphocyte count (ALC) values at baseline and at the last follow up, as well as the reasons for discontinuing DMF were collected. Descriptive and inferential statistical techniques were used for data analysis. Binary-logistic regression analysis was used to identify the risk factors for DMF-induced lymphopenia. Results: The study included a total of 64 MS patients and the majority (40; 63%) were female. The DMF therapy was started at mean age of 33 7.7 years. After administration of DMF, 14 (21.9%) patients developed 1–3 grades lymphopenia with the following breakup: grade-1: 5/64 (7.81%) patients; grade-2: 8/64 (12.5%) patients; grade-3: 1/64 (1.6%) patient. DMF was discontinued in 23 (36.0%) patients, mainly in response to adverse events or confirmed pregnancy. Female sex was the only significant predictor of DMF-induced lymphopenia (p = 0.037). Conclusion: Most Omani MS patients had mild lymphopenia (grades 1–2), like other regional and international reports. Early adverse events and pregnancy were the main reasons provided for discontinuing DMF therapy. Keywords: Multiple Sclerosis; Dimethyl Fumarate; Absolute Lymphocyte Count; Lymphopenia; Oma

Spectrum of Cerebral Venous Thrombosis in Oman

Objectives: Cerebral venous thrombosis (CVT) can have varied and life-threatening manifestations. This study aimed to examine the spectrum of its clinical presentations and outcomes in a tertiary hospital in Oman. Methods: This retrospective study was conducted at the Sultan Qaboos University Hospital, Muscat, Oman, between January 2009 and December 2017. The medical records of all patients with CVT were reviewed to determine demographic characteristics, clinical features and patient outcomes. Results: A total of 30 patients had CVT. The mean age was 36.8 ± 11 years and the male-to-female ratio was 2:3. Common manifestations included headache (83%), altered sensorium (50%), seizures (43%) and hemiparesis (33%). Underlying risk factors were present in 16 patients (53%). Computed tomography or magnetic resonance imaging of the brain was abnormal in all patients, with indications of infarcts (40%) and major sinus thrombosis (100%). There were five cases (20%) of deep CVT. The patients were treated with low-molecular-weight heparin, mannitol and anticonvulsants. The majority (77%) had no residual neurological deficits at follow-up. Conclusion: These findings indicate that CVT is a relatively uncommon yet treatable disorder in Oman. A high index of suspicion, early diagnosis, prompt anticoagulation treatment and critical care may enhance favourable patient outcomes. Keywords: Venous Thrombosis; Cerebral Thrombosis; Cranial Venous Sinuses; Neurological Manifestations; Patient Outcome Assessment; Oman

Post COVID-19 Guillain-Barré-Syndrome (GBS): A case report from Oman

Guillain-Barré-Syndrome (GBS) is one of the reported neurological manifestations linked to a severe acute respiratory syndrome caused by coronavirus 2 (SARS-CoV-2)(COVID-19). We are presenting a case of a 72-years-old male patient who attended Sultan Qaboos University Hospital with a history of progressive bilateral limbs weakness and numbness. After exclusion of other possible causes, a diagnosis of GBS induced by COVID-19 was made. He received Intravenous Immunoglobulin (IVIG) 0.4g/kg/day for 5 days.  This diagnosis is in line with a rare complication of COVID-19. This case highlights the characteristics and the course of GBS following COVID-19 infection. Further studies are needed to characterize the manifestations and the course of various neuromuscular disorders in relation to COVID-19 infection. Keywords: COVID-19, Guillain-Barré-Syndrome (GBS), IVIG, Oma

Risk Factors for Ischaemic Stroke in an Omani Community: A case-control study

Objectives: Stroke is recognised as the third most common cause of mortality and it has an increasing incidence in developing countries. Recognition and control of risk factors are of prime importance in the prevention of stroke. This study aimed to examine the characteristics of ischaemic stroke (IS) patients in Oman and quantify its various risk factors using a case-control model. Methods: This case-control study was conducted from January 2012 to March 2013 at Sultan Qaboos University Hospital and Royal Hospital, Muscat. Adult Omani patients with IS who were admitted to either hospital were compared to age- and gender-matched controls. Demographic factors and frequency of various conventional risk factors were documented. Univariate and stepwise multivariate logistic regression analyses were performed to evaluate the risk factors associated with IS. Results: A total of 255 patients and age-and gender-matched controls were included in this study. The mean age was 62.2 ± 13.2 years and 63.14% were male. Most cases (89.02%) were above 45 years of age. Cardio-embolism (31.76%) was the commonest mechanism of IS. Stepwise multiple logistic regression model revealed that family history of stroke was the strongest independent risk factor, followed by hypertension and high-density lipoprotein levels (odds ratio: 10.10, 5.17 and 3.34, respectively; P <0.01 each). Conclusion: Cardio-embolism was the predominant mechanism of IS in this study. Family history of stroke, hypertension and reduced high-density lipoprotein were the leading independent risk factors. Strong emphasis on screening for risk factors, control of hypertension and lifestyle modification for those with a family history of stroke would be expected to emerge as the major stroke-preventive measures in Oman. Keywords: Ischemic Stroke; Risk Factors; Case-Control Study; Oman