Stroke in Saudi Arabia: a review of the recent literature

Health-Related Quality of Life Among Patients With Stroke: A Cross-Sectional Study

PURPOSE

To assess levels and predictive factors of health-related quality of life (HRQOL) among stroke patients.

METHODS

The study employed a cross-sectional predictive correlational design. Levels of HRQOL were assessed using the Stroke-Specific Quality of Life (SS-QOL) scale, and the Hospital Anxiety and Depression Scale was employed to assess psychological aspects among 209 Saudi stroke patients. The analysis included demographic and medical variables to comprehensively explore influencing factors.

RESULTS

A two-step hierarchical multiple regression analysis was performed. The overall SS-QOL summary score (49 items) showed a mean score of 94.4 (SD = 8.1), indicating poor functioning. Nine predictor variables were found to significantly predict HRQOL levels, including age (β = -0.212, p ≤ .001), female (β = -5.33, p ≤ .001), unmarried (β = 2.48, p ≤ .001), low gross monthly income (GMI) (β = -9.02, p ≤ .001), medium GMI (β = -8.36, p ≤ .001), having a medical history of hypertension (β = 2.7, p ≤ .01), time since stroke (β = 3.26 p ≤ .001), and being a probable case of anxiety (β = -4.29, p ≤ .001) and/or depression (β = -2.75, p ≤ .001). These variables collectively explained ~76% of the variance in HRQOL scores (adjusted R2 = .762, F (16,192) = 42.6, p ≤ .001).

CONCLUSIONS

Stroke patients exhibited poor HRQOL levels influenced by various factors. Clinicians should consider these predictors and intervene early to enhance HRQOL among patients at risk, emphasizing the importance of optimizing patient outcomes.

Knowledge levels of stroke among hypertensive and diabetic patients in a tertiary hospital

BACKGROUND

Strokes represent a major global health challenge, as they now affect up to 15 million people annually, with increasing mortality rates accompanying growing prevalence. In Saudi Arabia, hypertension (HTN) and diabetes mellitus (DM) have been identified as major contributors to stroke risk, with a combination of HTN and DM significantly magnifying the risk of strokes. While there have been global improvements in stroke prevention, recently knowledge levels vary significantly worldwide, and multiple studies in Saudi Arabia show inconsistent awareness levels.

OBJECTIVES

This study seeks to develop insights for the development of tailored prevention programs that align with Saudi Vision 2030 in terms of enhancing quality of life. Thus, the aim of the study is to assess knowledge levels of stroke risk factors, warning signs, symptoms, and prevention methods among high-risk groups (HTN and DM patients) at King Saud University Medical City (KSUMC).

METHODS

This was an analytical cross-sectional study conducted among 422 participants from June 2022 to January 2023, using a validated Arabic questionnaire taken, with permission, from previous studies. All HTN and T2DM patients in the waiting areas of the outpatient clinics at KSUMC, Riyadh were included as part of the random sampling, though patients below 20-years-old and those with other endocrine disorders were then excluded.

RESULTS

The majority of participants were male (64.5 %). The analysis showed that 66.1 % of participants had "poor total knowledge" of stroke factors. Half of the participants (50.5 %) had "poor knowledge" about stroke risk factors, though the most commonly identified risk factor was "hypertension". Additionally, the findings showed that 46.4 % of participants had "poor knowledge" of stroke warning signs and symptoms, with the most commonly identified warning sign being "difficulty in speaking." Nearly half of participants (46.4 %) had "good knowledge" of stroke prevention methods; however, "regular exercise" was the most commonly identified prevention method.

CONCLUSION

Although the participants displayed decent knowledge of stroke prevention methods, several notable deficits in overall knowledge of stroke factors emerged. In particular, knowledge of stroke risk factors and warning signs and symptoms among participants was inadequate. This implies that healthcare providers should seek to launch campaigns addressing stroke knowledge mainly among high-risk groups, potentially distributing brochures about stroke knowledge in the relevant clinics and seeking to provide a range of educational content by means of social media.

Demographic Characteristics and Functional Outcome in Posterior Circulation Strokes

INTRODUCTION

The constantly increasing incidence of stroke in Saudi Arabia substantiates an urgent need to elucidate underlying risk factors and etiologies. In terms of improving outcomes, the predictors of functional outcomes need to be identified as well. As posterior circulation strokes (PCS) have not been studied in detail, the current study aimed to identify the risk factors, etiology, and predictors of outcome in PCS.

METHODS

This retrospective study included the data for 138 patients with PCS. Demographics, risk factors, clinical signs/symptoms, etiology, and outcome at discharge and 3-month follow-up were recorded. Factors associated with outcomes were identified, and the difference was ascertained using Chi-square, odds ratios, and 95% confidence intervals.

RESULTS

The mean participant age was 58 ± 14.8 years with 73% being males. The mean arrival time was 26.5 ± 31.6 h; with a mean National Institute of Health Stroke scale (NIHSS) score of 7.2 ± 5.6. Motor deficit and dysarthria were the most common presentations. Twenty percent of patients received intravenous recombinant tissue plasminogen activator, whereas endovascular thrombectomy was performed in 9 (6.5%). Follow-up outcome at 3 months was available in 113 (81.8%). Male sex, baseline modified Rankin scale of <2, low baseline NIHSS, and stable or improvement in baseline NIHSS during 24 h of admission were documented as predictors of a good outcome, whereas history of atrial fibrillation and prior stroke, high NIHSS at admission and worsening of symptoms during 24 h of admission, as well as bilateral body involvement were associated with poor outcome.

CONCLUSION

The functional outcomes and the predictors of functional outcomes did not differ from the previously published literature; however, significant differences were observed in the risk factors and etiological profile in our population. These differences are of potential interest to the researchers and clinicians, as they carry important therapeutic and prognostic implications and need to be verified through large prospective studies.

Factors Associated with Mental Illness in a Primary Healthcare Setting in the Kingdom of Saudi Arabia: A Case-Control Study

BACKGROUND/OBJECTIVES

Mental health conditions are a leading cause of morbidity and mortality worldwide, with a 13% rise within the last decade. This study aimed to investigate the factors associated with mental illness in patients presenting to a primary healthcare center in the Kingdom of Saudi Arabia (KSA).

METHODS

Data were extracted from the electronic health records of 46 primary care centers in Riyadh, Saudi Arabia from March 2022 to March 2023. A total of 2418 age-matched mental health cases and controls were evaluated. Descriptive and logistic regression analyses were performed to examine the distribution and association of relevant risk factors. A total of 1209 cases were age-matched to 1209 controls presenting to a primary clinic.

RESULTS

The odds of mental illness in females were 2.2 times that of males. Clinical conditions associated with mental illness were stroke, diabetes, and obesity. Neurodegenerative disorders were also associated with mental illness.

CONCLUSIONS

Primary clinics in the KSA can serve as focal points in removing the barriers to mental healthcare. There is an urgent need to spread awareness, remove the stigma, and provide appropriate care and referrals for mental health conditions in the KSA.

Knowledge of symptoms, risk factors, and treatment centers of stroke among the general population of Al-Ahsa, Saudi Arabia

Background

In Saudi Arabia, stroke is a significant cause of illness and mortality progressively becoming more serious. Studies have indicated that modifiable cardiovascular risk factors are responsible for a significant portion of the burden caused by stroke, which could be targeted through public awareness.

Objective

We evaluated the level of knowledge about stroke among the general population of the Al-Ahsa, Saudi Arabia. Furthermore, association between stroke level of knowledge and sample characteristics was analyzed.

Methods

This was a cross-sectional study conducted from February 22, 2023, to March 22, 2023, using a convenience sampling technique. An electronic Google Forms survey was distributed through social media, to reach the maximum number of participants.

Results

This study included a total of 500 participants from Al-Ahsa, Saudi Arabia. Forty-three percentage of participants were male, while 57% were females. Most participants were of a younger age, where 66.6% were 18-39 years. The most recognized stroke symptom, risk factor, and stroke treatment center were dizziness/vertigo (91%), hypertension (97%), and King Fahad Hospital, respectively. Those with higher education possessed a greater level of stroke-related knowledge than other demographic groupings.

Conclusion

The general public of Al-Ahsa demonstrated a high level of knowledge about stroke symptoms (82.6%), risk factors (90%), and treatment facilities (80%). However, it was evident that the general public failed to recognize the proper course of action in the event of a stroke.

Primordial and Primary Prevention of Ischemic Stroke in Saudi Arabia: A Combination Approach and Evolving Concepts

Ischemic stroke is a considerable public health hazard and a significant cause of disability and mortality in Saudi Arabia. Primary prevention strategies in the country are currently limited. With the health sector transformation program that depends on the principles of value-based care and applying the new model of care in disease prevention, aggressive and serious steps for primary stroke prevention are expected to be implemented. This article reviews primordial and primary prevention of ischemic stroke in Saudi Arabia and suggests a combination approach and framework for implementation. We provide a pragmatic solution to implement primordial and primary stroke prevention in Saudi Arabia and specify the roles of the government, health professionals, policymakers, and the entire population. Currently, there are several key priorities for primordial and primary stroke prevention in Saudi Arabia that should target people at different levels of risk. These include an emphasis on a comprehensive approach that includes both individual and population-based strategies and establishing partnerships across health-care providers to share responsibility for developing and implementing both strategies. This is an urgent call for action to initiate different strategies suggested by experts for primary stroke prevention in Saudi Arabia.

The Association between Sleep Quality and Depressive Symptoms among Stroke Survivors and Caregivers

BACKGROUND

Stroke is a serious health problem that can lead to the development of depressive symptoms, sleep disturbances, and functional dependence in stroke survivors. The change in stroke survivors' quality of life results in negative health outcomes for stroke survivors and caregivers. This study aims to investigate the association between sleep quality and depressive symptoms among stroke survivors and caregivers in Saudi Arabia.

METHODS

A cross-sectional design was used to collect data from 100 stroke survivors and 80 caregivers using the patient health questionnaire and Pittsburgh Sleep Quality Index.

RESULTS

43% of the stroke survivors reported depressive symptoms and 65% had poor sleep quality; 21% of the caregivers reported depressive symptoms and 46% reported poor sleep quality. A strong association between sleep quality and depressive symptoms was detected for the stroke survivors and caregivers: (r = 0.885, p < 0.001); (r = 0.669, p < 0.001), respectively. A strong association was found between caregivers' depressive symptoms and patient post-stroke depressive symptoms (r = 0.502, p < 0.001). A moderate association was found between stroke survivors' sleep quality and caregivers' sleep quality (r = 0.407, p < 0.001). There was a moderate association between stroke survivors' depressive symptoms and caregivers' sleep quality (r = 0.456, p < 0.001). Moreover, there was a moderate association between stroke survivors' sleep quality and caregivers' depressive symptoms (r = 0.492, p < 0.001).

CONCLUSION

Poor sleep quality and depressive symptoms are common among stroke survivors and caregivers. This study found an association between the two variables. Therefore, depressive symptoms and sleep disturbances in stroke survivors and caregivers should receive more attention. Future research should focus on an interventional study to enhance sleep quality and decrease the risk of depressive symptoms.

Evaluation of Contralateral Limb Cross Education and High-Frequency Repetitive Transcranial Magnetic Stimulation on Functional Indices of the Affected Upper Limb in Subacute Phase of Stroke

Background

Stroke is one of the causes of long-term morbidity. Despite rehabilitation strategies, most survivors live with motor deficits in the upper limbs.

Objectives

The aim of the study was to compare the effect of contralateral cross education (CE) and high-frequency repetitive magnetic stimulation (HF-rTMS) on the function of upper extremity in subacute phase of stroke.

Methods

Forty patients were randomly assigned into 4 groups. Group "A" received physical therapy (PT) for 10 sessions, 3 times per week. Group "B" received PT and HF-rTMS as follows: stimulation of 20 Hz for 5 s, intertrain interval for 50 s, 20 trains, 2000 pulses at 90% resting motor threshold, and conventional PT. Group "C" was treated with CE and PT. In group "D," HF-rTMS, CE, and PT were administered.

Results

Significant differences were found in the Fugl-Meyer scale between "A" and "C" (P = 0.01), "A" and "D" (P = 0.02), and "B" and "C" groups (P = 0.01). In the box-block test, there were significant differences between "A" and "B" (P = 0.01), "A" and "C" (P < 0.001), "B" and "D" (P = 0.001), and "B" and "C" groups (P = 0.01). Statistical differences were observed in grip strength between "A" and "B" (P = 0.01) and "A" and "C" groups (P = 0.02).

Conclusions

It is suggested that clinicians select the therapeutic methods in line with their expected goal. When the goal is to improve upper extremity function, CE+PT could be more effective than HF-rTMS+PT. Also, CE+PT and HF-rTMS+PT were more effective than CE+HF-rTMS+PT at improving grip strength. Therefore, combining several methods would not always lead to better results.

Differentiation of Epileptic Brain Abnormalities among Neurological Patients at Taif Region Using MRI

This study was conducted to assess the prevalence of epilepsy among different age groups and gender of neurological patients in the Taif region and define the most common brain lesion, affecting epileptic patients living in the Taif city using MRI. Data from 150 patients who were clinically diagnosed with epilepsy and had brain MRIs were analyzed using SPSS. Statistical significance was considered when the p value is 0.05. The percentage of epilepsy was generally higher in males than in females in the Taif city, and seizures were different between the studied age groups. However, epilepsy was more pronounced in females than in males at certain age groups. Moreover, white matter lesions were most commonly found in the studied group (27.7%), followed by focal lesions, edema, and stroke with equal percentages (16.9%) and less commonly with congenital diseases (12%) and atrophic changes (9.6%). Epilepsy was more pronounced in females than in males at certain age groups. White matter lesions were identified as the most common lesion, presenting in epilepsy patients in the Taif city.

Association of Genetic and Allelic Variants of Von Willebrand Factor (VWF), Glutathione S-Transferase and Tumor Necrosis Factor Alpha with Ischemic Stroke Susceptibility and Progression in the Saudi Population

Stroke is a key cerebrovascular disease and important cause of death and disability worldwide, including in the kingdom of Saudi Arabia (KSA). It has a large economic burden and serious socioeconomic impacts on patients, their families and the community. The incidence of ischemic stroke is probably increased by the interaction of GSTT1 and GSTM1 null genotypes with high blood pressure, diabetes and cigarette smoking. The roles of VWF, GSTs and TNF-alpha gene variations in the induction of stroke are still uncertain and require further examination. In the current study, we studied the associations of SNPs in the genes VWF, GSTs and TNF-alpha with stroke in the Saudi population. Genotyping was performed using the ARMS -PCR for TNF-alpha, AS-PCR for VWF and multiplex PCR for GSTs. The study included 210 study subjects: 100 stroke cases and 110 healthy controls. We obtained significant distributions of VWF rs61748511 T > C, TNF-alpha rs1800629 G > A and GST rs4025935 and rs71748309 genotypes between stroke cases and the healthy controls (p < 0.05). The results also indicated that the TNF-alpha A allele was associated with risk of stroke with odd ratio (OR) = 2.22 and risk ratio = RR 2.47, p < 0.05. Similarly, the VWF-TC genotype and C allele were strongly linked with stroke with OR = 8.12 and RR 4.7, p < 0.05. In addition, GSTT1 and GSTT1 null genotype was strongly associated with stroke predisposition with OR = 8.30 and RR = 2.25, p < 0.0001. We conclude that there is a possible strong association between the VWF-T  > C, TNF-alpha G > A, GSTT1 gene variants and ischemic stroke susceptibility in the Saudi population. However, future well-designed and large-scale case-control studies on protein-protein interactions and protein functional studies are required to verify these findings and examine the effects of these SNPs on these proteins.

Epidemiological Features of Neurological Disorders in North Africa and the Middle East from 1990 to 2019: Results from the Global Burden of Disease Study 2019

BACKGROUND

The burden of neurological disorders increases with population growth and aging and nearly three-quarters of the global burden of neurological disorders has been reported in low- and middle-income countries. Therefore, this study aimed to report the epidemiological features and the burden of neurological disorders in North Africa and the Middle East (NAME) countries.

METHODS

The study population included 21 countries in the NAME region with a population of more than 600 million. The Global Burden of Disease (GBD) 2019 database was used. In GBD 2019, neurological disorders are classified into 7 diseases and injuries. Incidence rates, prevalence rates, death rates, disability adjusted life years (DALYs) rates by age-standardized rate (ASR) per 100000 people were measured. Also, the attributed burden to high body mass index (BMI), high fasting plasma glucose, smoking, and alcohol use were reported.

RESULTS

The highest incidence rates of neurological disorders in 2019 were in Iran 11293.27 (95% UI, 10132.62-12499.59) and Egypt 10257.33 (95% UI, 9189.37-11341.16), respectively, and the highest mortality 41.12 (95% UI, 17.68-92.44) and DALYs 1503.0 (95% UI, 853.8-2492.15) rates were in Afghanistan. In NAME region, the incidence and prevalence rate of neurological disorders increased by 0.84% (10006.37 to 10090.79) and 1.36% (33711.72 to 34170.57) respectively, while the mortality and DALYs rate decreased by 2.75% (34.11 to 33.17) and 3.92% (1438.48 to 1382.14) between 1990 and 2019. The highest decrement of the neurological disorders-related DALYs with a 10.10% decrement pertained to Afghanistan (1671.86 to 1503). The highest increment of the neurological disorders-related DALYs with a 1.89% increment pertained to Morocco (1330.69 to 1355.83). The highest attributed DALYs to alcohol use pertained to Turkey 9.8 (95% UI, 4.23-18.05). The highest attributed DALYs to high BMI 112.23 (95% UI, 29.3-285.75) and high fasting plasma glucose 100.36 (95% UI, 18.79-302.85) pertained to Qatar. The highest attributed DALYs to smoking pertained to Lebanon 106.34 (95% UI, 37.65-253.87). Most DALYs were associated with those aged 75 years and more.

CONCLUSION

Despite progressive reduction in death due to neurological disorders in the NAME region in recent decades, there was a considerable and increasing number of people affected by different neurological disorders. As populations age, societies will face more challenges regarding prevention, detection, treatment, and rehabilitation.

Al-Rawi M. Evaluation of knowledge of risk factors and warning signs of stroke - An observational study among future health care professionals

Background and objective

The role of healthcare professionals in society is unique since they are providers of health information and medication counseling to patients. Hence, this study aimed to evaluate Knowledge of Risk Factors and Warning Signs of Stroke among undergraduate health care Students (UHCS) at King Saud University (KSU), Riyadh, Saudi Arabia.

Methodology

An online cross-sectional study was conducted among UHCS at KSU, Riyadh, Saudi Arabia from September to November 2022, using self-administered 34-item questionnaires divided into five sections to assess participants' knowledge of stroke risk factors, warning signs, and management and source of information about the stroke. The Statistical Package for the Social Sciences version 26 was used to analyze the data (SPSS).

Results

Of the 300 questionnaires distributed, 205 students completed the questionnaires, giving a response rate of 68.3%. Of whom 63 (30.7%) were pharmacy, 81 (39.5%) were nursing and 61 (29.8%) were emergency medical services (EMS) Students. One hundred and eighty-two (88.8%) of the students agreed that stroke affects bodily movement. With regards to risk factors, students identified high blood pressure 182 (88.8%), followed by heart disease 175 (85.4%), advanced age 164 (80%), previous Stroke history 158(77.1%), and lack of physical activity 156 (76.1%). Difficulty in speaking or slurred speech 164 (80%), dizziness, and loss of balance 163 (79.5%) were identified as the warning signs of stroke. In this study, 41.3 % of the pharmacy students reported a good level of knowledge than nursing and EMS students. However, 32.2% (N = 66) of the healthcare undergraduates reported good knowledge. The knowledge score was significantly associated with the year of study, and educational degree (p = 0.0001). Furthermore, there were no differences between parents working in healthcare settings (p = 0.99).

Conclusion

In conclusion, the knowledge of stroke among healthcare students at King Saud University varied. The reported knowledge gap mostly relates to stroke risk factors and warning signs. Therefore, increasing public awareness of potential risk factors and stroke warning signs needs to receive more attention.

Hyperlipidemia and Hypertension Are Associated With Intracerebral Hemorrhage Incidence: A Retrospective Study

Introduction Stroke places a huge burden on the socioeconomic systems. Hemorrhagic stroke (HS) is the second most common type of stroke and the second leading cause of disability and death. The updated data on the prevalence of intracerebral hemorrhage (ICH) stroke and related physiological risk factors in Saudi Arabia were limited. The aim of this study was to identify the prevalence of ICH stroke and the related physiological risk factors. Methods This was a retrospective, hospital-based, and chart review study that utilized the BESTCare system at King Abdulaziz Medical City (KAMC), Riyadh, Saudi Arabia. Patients who attended the neurology department (inpatient/outpatient) between 2015 and 2020 were studied. The statistical tool JMP (JMP Inc., Cary, NC, USA) was used for data entry and analysis. Results Patient data (N = 1,870, 58.6 ± 13.87 years old) were screened for comorbidities, hypertension (66.1%), diabetes mellitus (DM) (57.7%), hyperlipidemia (28.4%), and history of an old stroke (22.3%). Ischemic stroke (IS) was more dominant than ICH stroke with ratios of 94.5% (n = 1767) versus 5.5% (n = 103), respectively. The prevalence of ICH stroke among the patients (n = 103) was 10.6%, 20.3%, 24.2%, and 28.1% in the age groups of <40, 41-50, 51-60, and 61-70 years old, respectively. There was a significant gender effect on the distribution of both IS and ICH (p = 0.003). ICH strokes were more prevalent in males than in females. Body mass index (BMI) has no significant effect on the prevalence of IS and ICH stroke (p = 0.081). ICH stroke was significantly associated with DM (p = 0.032), hypertension (p = 0.01), and hyperlipidemia (p = 0.002). Regression analyses show that only hypertension (positive association) and hyperlipidemia (negative association) were significantly associated with the incidence of ICH stroke. Conclusion IS was more prevalent than ICH stroke. ICH strokes were more prevalent in males than in females. Also, hypertension was the most common factor leading to ICH stroke, unlike hyperlipidemia, which was revealed to be protective against ICH stroke.

Time Window for Acute Stroke Treatment: Current Practice in King Abdullah Medical City Specialist Hospital in Makkah, Saudi Arabia

Introduction

Stroke has become one of the most severe causes of long-term neurological impairment and disability and is considered one of the leading causes of mortality worldwide. This study aimed to determine time delays in stroke patients from symptoms onset to treatment with tissue plasminogen activator (tPA) initiation in King Abdullah Medical City Specialist Hospital, Makkah, Saudi Arabia.

Patients and methods

We reviewed 81 patients who suffered from acute stroke. The data were collected from patients’ electronic and paper files. Patients were divided into two main categories based on interval time from recognition of symptoms to tPA treatment. Patients were divided into early treatment, if the duration was less than or equal to 120 minutes, and delayed treatment, if the interval time was more than 120 minutes.

Results

Nearly two-thirds (64.2%) were males, and more than half (5.6%) were in the older age group (>65 years). Patients who underwent thrombectomy were 7.4%. The mean value of the National Institutes of Health Stroke Scale (NIHSS) score was 10.7 (SD: 7.14). The mean time from symptoms onset to arrival at the hospital was 82.4 (SD: 44.1) minutes, while the total time from recognition of symptoms to tPA treatment was 154 (SD: 50.8) minutes. The prevalence of patients with delayed treatment was 72.8%, and the rest were assumed to have early treatment (27.2%). None of the socio-demographic variables were predicted to influence delayed treatment.

Conclusion

A significant number of patients were delayed in treatment. Patients' socio-demographic data and NIHSS scores seem to have no significant effect on delayed treatment. Further research is needed to establish the delay in time for pre-hospital and in-hospital treatment of stroke patients.

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

Aims:

The authors aimed to assess the ischemic stroke risk factors and scales.

Materials & methods:

A retrospective cohort study was conducted on patients with acute ischemic stroke (from January 2017 to December 2018). The scores of the National Institutes of Health Stroke Scale (NIHSS) at admission and discharge and of the modified Rankin Scale (mRS) and Barthel Index (BI) scale post-month of the stroke were collected.

Results:

Out of 376 patients, 359 were included, with a mean (standard deviation) age of 67.8 (12.2) years and male predominance (56.2%). Hyperlipidemia and hypertension were the most prevalent comorbidities (91.1% and 80.5%, respectively). The NIHSS, BI and mRS scores were worse among women, with no significant effects for comorbidities. The NIHSS scores at admission and discharge were significantly correlated with the post-month BI and mRS scores.

Conclusion:

The study findings suggest a complex interplay of gender, strict control and prevention of the modifiable stroke risk factors, as well as the association of neurological deficits' intensity with the functional outcomes.

This study aimed to explore the demographics, the clinical risk factors and the scores of the National Institutes of Health Stroke Scale (NIHSS), modified Rankin Scale (mRS) and Barthel Index (BI) scale at different points of time among the survivors of acute ischemic stroke at a tertiary hospital in Jordan. Also, the study aimed to investigate the differences in the scales' scores by the patients' characteristics and the correlations between these scales. Out of 376 screened patients, 359 were included. Their mean (standard deviation) age was 67.8 (12.2) years, and 56.2% were men. Compared with male participants, women scored significantly worse on the NIHSS at admission (7.61 [5.51] vs 9.47 [6.64]; p = 0.048), NIHSS at discharge (5.57 [4.72] vs 7.40 [5.88]; p = 0.028) and BI scale 1 month post-event (78.68 [28.33] vs 66.03 [35.86]; p = 0.011). The mean (standard deviation) mRS score post-month of stroke was lower in men (2.4 [1.7]) than in women (2.9 [1.9]), with a lack of statistical significance (p = 0.097). Thus, despite the male predominance in the cohort, women tended to have a more severe stroke, worse neurological impairment and poorer functional outcomes. Hyperlipidemia had the highest prevalence, sensitivity, positive predictive value and negative predictive value rates, followed by hypertension. No statistically significant differences existed in the comorbidities' NIHSS, BI scale and mRS scores. Strong and significant correlations were observed between the scores of NIHSS at admission and discharge and the BI scale and mRS scores at 1 month post-event. Thus, the authors concluded that neurological deficit severity has a potential role in predicting functioning outcomes and vice versa.

Secondary Cerebellar Cortex Injury in Albino Male Rats after MCAO: A Histological and Biochemical Study

The present study focused on secondary injury following the middle cerebral artery (MCA) occlusion in rats not linked to the MCA’s feeding zone. This entity has been very rarely studied. Additionally, this study investigated the rates of expression of five fundamental angiogenic biomarkers called endoglin, vascular endothelial growth factors-A (VEGF-A), endothelin-1 (ET-1), 2granulocyte colony-stimulating factor (G-CSF), and angiopoietin-using the MCA occlusion (MCAO) model. The random allocation of twelve adult male albino rats was in two groups. As a sham control group, six rats were used. This group was subjected to a sham operation without MCAO. The MCAO group consisted of six rats that were subjected to MCAO operation. After three days, the rats were sacrificed. The cerebellar specimens were immediately processed for light microscopic examination. An angiogenic biomarkers multiplex assay from multiplex was used to assess endoglin levels, VEGF-A, ET-1, angiopoietin-2, and G-CSF in serum samples. Hematoxylin and eosin-stained sections showed that the cerebellar cortex of rats of the MCAO group was more affected than the sham control group. Furthermore, Nissl stain and immunohistochemical analysis revealed an apparent increase in the number of positive immunoreactive in the cerebellar cortex and an evident decrease in Nissl granules in Purkinje cells of the MCAO rats, in contrast to the control rats. In addition, there was a significant increase in angiogenic factors VEGF-A, ET-1, angiopoietin-2, and endoglin. Interestingly, there was an increase in the G-CSF but a non-significant in the MCAO rats compared to the control rats. Furthermore, there was a significant correlation between the angiopoietin-2 and ET-1, and between G-CSF and ET-1. VEGF-A also exhibited significant positive correlations with the G-CSF serum level parameter, Endoglin, and ET-1. Rats subjected to MCAO are a suitable model to study secondary injury away from MCA’s feeding zone. Additionally, valuable insights into the association and interaction between altered angiogenic factors and acute ischemic stroke induced by MCAO in rats.

Demographic characteristics and types of stroke in Southwestern Saudi Arabia, and the potential demand of neuro endovascular specialists

OBJECTIVES

To identify demographic characteristics, and types of stroke in Southwestern (Aseer) Region, Saudi Arabia.

METHODS

This study is a retrospective and hospital-based. The data of all stroke patients (n=562) admitted to the tertiary care hospital in the province, Aseer Central Hospital (ACH) within the period from January 2016 until December 2017 are included.

RESULTS

The mean ± SD of stoke patients' age was 62.6 ± 17.0 years. Male patients were more than female patients (62.6% and 37.4%, respectively). The majority (93.2%) were Saudi, while 91.5% had below university education and 6.4% were smokers. Interestingly, only 2% of patients had a family history of stroke, while 68.1% were diabetic, 80.4% were hypertensive, 91.6% had high serum cholesterol level, and 10.7% had history of transient ischemic attacks (TIA). Despite the lack of awareness, and leading to delay in reaching health care facility, 58.1% of stroke patients, were arriving to emergency department (ED) in less than 24 hours (potential endovascular therapeutic window).

CONCLUSIONS

In Aseer Region, Saudi Arabia, stroke affects mainly those who are older, less educated, diabetic, hypertensive, with hypercholesterolemia and previous history of TIA. Associated factors for stroke differ significantly according to their nationality.

Assessment of the stroke-specific quality-of-life scale in KFHU, Khobar: A prospective cross-sectional study

Objectives:

To assess the overall and domain-specific quality of life (QOL) in post-stroke patients using the stroke-specific quality of life (SS-QOL) scale and to identify variables that may affect the QOL after stroke.

Methods:

A prospective cross-sectional study, included 80 stroke patients, was conducted in the Neurology department at King Fahad Hospital of the University (KFHU), Khobar, Saudi Arabia, from December 2019 to February 2020. Stroke patients were interviewed using the Arabic version of the SS-QOL questionnaire and modified Rankin scale (mRS).

Results:

The overall quality of life in the surveyed participants was at the level of 3.72 points, which is above the average recognized in the middle of the scale that ranges from 1 to 5. The overall quality of life was not significantly correlated with sex, age, type of stroke, recurrence of stroke, and time since stroke (p>0.05). Hypertension and atrial fibrillation were the only comorbidities that were determined to be significantly associated with the overall quality of life at the level of (3.53), and (2.97) respectively (p<0.05). There was a statistically significant correlation between the mRS score and the overall quality of life (p<0.05).

Conclusion:

Performing a comprehensive assessment of the overall QOL in post-stroke patients will result in better health outcomes, particularly in terms of quality of functioning in psycho-social aspects.

Influence of Spiritual Coping and Social Support on the Mental Health and Quality of Life of the Saudi Informal Caregivers of Patients with Stroke

The research explored the influence of spiritual coping and social support on mental health and quality of life (QOL) of informal caregivers of stroke survivors in Saudi Arabia. The respondents were frequently using religious coping strategies than existential coping strategies. The respondents received higher support from significant others and lowest support from friends. The majority of the respondents had mild to moderate depression, while more than one-third had mild to severe anxiety. Psychological health received the highest QOL, while physical health received the poorest QOL. Spiritual coping and social support significantly influenced the informal caregivers' mental health and QOL.

Prevalence of Balance Impairment and Factors Associated with Balance among Patients with Stroke. A Cross Sectional Retrospective Case Control Study

Stroke is a major cause of disability worldwide, and balance impairments are common disabling factors in patients with stroke, leading to falls. Thus, the study objectives were as follows: (i) To find the prevalence of balance impairment among patients with stroke. (ii) To find out the factors associated with balance impairment in patients with stroke. This cross-sectional retrospective case control study involved eighty-one post stroke patients with a mean age of 58.36 ± 14.06, recruited from six hospitals, who underwent an assessment of balance, walking speed, depression and isometric strength of the ankle and knee. These patients were later categorized into subjects with good balance (<45) in the Berg balance scale (BBS) and those with poor balance (≥45), as cases and controls, to assess the factors associated with balance impairment using binary logistic regression. The prevalence of balance impairment among patients with stroke was 48.1%. The reduction in power of knee flexors (OR = 0.858), knee extensors (OR = 0.880) and ankle dorsiflexors (OR = 0.820) was found to be significantly associated with balance impairment, along with speed (OR = 1.187 (95% CI = 1.100, 1.280)), depression (OR = 1.331 (95% CI = 1.055-1.679)) and activities of daily living (OR = 0.313 (95% CI = 0.150-0.650)). In summary, around half of the patients with stroke exhibited balance impairments, with females being more prone.

Burden of stroke in the Kingdom of Saudi Arabia: A soaring epidemic

Stroke is a key cerebrovascular disease that is related to high morbidity and mortality in the globe. The Kingdom of Saudi Arabia (KSA) is not an exception where stroke is fast developing into a serious challenge due to the high mortality rate. Additionally, stroke presents a tremendous economic burden and has a devastating effect on the quality of lives of individuals. The number of stroke cases are increasing yearly, thus posing a major challenge to the health care system. Therefore, it is crucial to implement primary and secondary prevention strategies in the KSA. Nevertheless, as compared with developed countries, information on the prevalence, socio-demographic properties and prevention of stroke remains scarce that could be attributed to the shortage of research conducted in this specified region. The review is written to address the various aspects of stroke in the KSA, based on current literatures search using PubMed, Scopus, Web of Science and Google Scholar databases, to identify studies published since inception to Dec 2020.

Public Awareness of Ischemic Stroke in Medina city, Kingdom of Saudi Arabia

Objectives:

To assess social awareness of ischemic stroke amongst Saudi citizens in Medina city.

Methods:

In a cross-sectional study conducted between February and September 2019, we used a validated questionnaire to conduct face-to-face interviews and collect data, at 4 shopping malls and 5 supermarkets in Medina city, KSA.

Results:

Five hundred and nineteen participants completed the questionnaire. Of the respondents, 57.4% correctly defined stroke, 42.6% correctly chose ≥2 stroke signs and made ≤one mistake, 23.1% knew of blood clot-dissolving drugs, 32.8% correctly identified ≥ 4 risk factors with ≤ one mistake, 85.93% knew that going to the Emergency Room (ER) was the correct action, and 35.84% identified ≥ 3 post-discharge requirements, with ≤one mistake. Most participants (65.77%) cited internet and social media as information sources. In the univariate comparison, older age (p<0.001) and family history of stroke (p=0.001) better predicted stroke knowledge. In a multivariate logistic regression, the only predictor for stroke recognition was the educational level. The gender and family history were predictors for stroke signs knowledge. Educational level and the family history of stroke were predictors for risk factors knowledge respectively.

Conclusion:

We observed a significant stroke knowledge deficit in our Saudi cohort, thus there is a need to increase public awareness about stroke risk factors, warning signs and emphasizing prevention approaches.

Dilemma in the foreign lands during COVID-19: An outlook of expat health care professionals with a take on a social perspective

BACKGROUND

The World Health Organization (WHO) has declared novel coronavirus (COVID-19) infection a global pandemic due to the fast transmission of this disease worldwide. To prevent and slow the transmission of this contagious illness, the public health officials of many affected countries scrambled to introduce measures aimed at controlling its spread. As a result, unprecedented interventions/measures, including strict contact tracing, quarantine of entire towns/cities, closing of borders and travel restrictions, have been implemented by most of the affected countries including the Kingdom of Saudi Arabia.

OBJECTIVES

The aim of this paper is to share health care professionals' perspectives who are experiencing COVID19 firsthand in a foreign land. In addition, the role of the Saudi governance to combat the current situation is also discussed.

DISCUSSION

Personal and previous experiences as related to Middle East respiratory syndrome coronavirus (MERS-CoV) by the authors has been compared to the current situation and how it affected our thoughts and management. A review of the evidence-based literature was conducted to investigate the demographics of the region; and to understand the awareness of the various tools that are available and how they were utilized in the present situation of pandemic.

CONCLUSIONS

Saudi Arabia has been challenged during the pandemic as are other countries.

The Effect of the COVID-19 Pandemic on Emergency Department Visits for Neurological Diseases in Saudi Arabia

Introduction COVID-19 has been a gravitating topic in the past months, yet much information about this new virus is to be unraveled. The uncertainties about the virus and its effects have affected a lot of daily life activities. One of these affected activities is emergency department (ED) visits and how this disease might have changed people's perspective on when to go to an emergency. This study aims to assess the effect of the COVID-19 pandemic on emergency department visits for neurological conditions. Methods A retrospective record review study was conducted at King Abdul-Aziz University Hospital (KAUH) during the month of July 2020. The study included visits of patients with common neurological conditions (headache, seizures, and weakness), during December 2019 - May 2020 at KAUH. Information obtained from the medical records included demographic data, date of visit, the reason for the visit, history of a similar episode, number of ED visits during the past year, priority given at the ED, length of hospitalization, diagnosis of COVID-19 at KAUH, known chronic diseases, and whether brain imaging was performed with which kind of imaging. Descriptive analysis was conducted to assess the impact of the pandemic on ED visits and statistical analysis (chi-square test) was performed on ED visit data to assess for significance. Results There was a 24% reduction in the number of visits for common neurological symptoms (during the pandemic) time period in comparison to (pre-pandemic). However, some other variables have also shown an increase (during the pandemic) time period. Most notably, brain CT scans, which underwent an 11.3% increase during the pandemic time period (p=0.005). Some variables have shown no significant change, for example, the relationship between the time period and the reason for the visit (p=0.305). Conclusion Multiple factors most likely contributed to the decrease in emergency department visits recorded in this study. One of the main reasons is the fear of catching COVID-19 infection by just vising the hospitals. Considering these findings, it is predominant to raise awareness when patients do need to go to the emergency department due to an acute neurological condition regardless of any pandemic.

Association of affected lower limb flexor muscle strength with swing phase duration and gait speed in elderly post-stroke patients

BACKGROUND

Although several studies have shown an association of muscle weakness with gait speed (GS), no study has explored the relationship of muscle strength with swing phase duration and GS after stroke among the elderly in Saudi Arabia.

OBJECTIVE

To examine the association of affected ankle dorsiflexor and hip flexor muscle strength with swing phase duration and GS in the elderly with different stroke chronicity.

METHODS

In this cross-sectional study, we included a total of 60 post-stroke patients aged ≥55 years who were admitted in neurorehabilitation units between May 2017 and August 2018. Linear regression was employed to examine the association of muscle strength (measured using a handheld dynamometer) with swing phase duration and GS (both measured using the computerized Zebris-Mat).

RESULTS

The chronicity of the stroke was negatively associated (p < 0.05) with swing phase duration. The ankle dorsiflexor muscle strength was significantly associated with GS (β= 0.656, p = 0.041). In contrast, hip flexor muscle strength was significantly associated with GS (β= 0.574, p < 0.0001) even after adjusting for stroke chronicity (β= 0.561, p < 0.0001).

CONCLUSIONS

Stroke chronicity was the predictor that reduced swing phase duration. The ankle dorsiflexor muscle strength was associated with GS. However, the hip flexor muscle strength was associated with GS even after adjusting for stroke chronicity.

Stroke in the adult Qatari population (Q-stroke) a hospital-based retrospective cohort study

BACKGROUND

Studies assessing the burden of stroke in Qataris are limited. We aim to study stroke in the Qatari population.

METHODS

A retrospective review was undertaken of all Qatari adults presenting with stroke to Hamad Medical Corporation over a 5-year period. Descriptive statistics were used to summarize demographic and all other clinical characteristics of the patients. The primary outcome was the incidence of stroke in the Qatari patients. Comparison was made between the sexes.

RESULTS

862 patients were included, with 58.9% being male. The average incidence of stroke over the 5-year period was 92.04 per 100,000 adult Qatari population. The mean age of the cohort was 64.3±14.4 years, (range 19-105 years). The mean age of first ever cerebrovascular event was 63.2±14.5 years. The diagnosis was ischemic stroke in (73.7%), transient ischemic attack in (13.8%), intracerebral hemorrhage (ICH) in (11.6%), subarachnoid hemorrhage in (0.7%) and (0.2%) cerebral venous sinus thrombosis. Small vessel disease was the most common cause of ischemic stroke accounting for (46.5%), followed by large artery atherosclerosis (24.5%). Hypertension (82.7%) and diabetes (71.6%) were particularly prevalent in this cohort. Females were older (65.8±14.1 vs 63.4±14.5 years), had more hypertension and diabetes and more disability or death at 90 days (p<0.05) compared to Qatari males.

CONCLUSION

Stroke occurs at a significantly lower age in Qataris compared to the western population. This study has uncovered sex differences that need to be studied further.

Causes of morbidity and mortality among patients admitted in a tertiary hospital in southern Nigeria: A 6 year evaluation

BACKGROUND

Data on morbidity and mortality are essential in assessing disease burden, monitoring and evaluation of health policies. The aim of this study is to describe the causes of morbidity and mortality in the wards of University of Calabar Teaching Hospital (UCTH).

METHODS

The study took a retrospective approach evaluating causes of morbidity and mortality from 2012-2017. Causes of death were documented based on International Classification of Disease 10 (ICD-10). Data were retrieved from health records department, UCTH.

RESULTS

Overall, 2,198 deaths were recorded out of the 49,287 admissions during the study period giving a mortality rate of 4.5% comprising 1,152 (52.4%) males and 1,046 (47.6%) females. A greater number of males were admitted via accident and emergency. Age group 15-45 years had the highest number of admissions (57.9%) and deaths (37.7%), while age group >65 years recorded the highest number of deaths per admission (9.7% mortality rate). The broad leading causes of death were infectious and parasitic disease and diseases of the circulatory system (cardiovascular diseases) accounting for 22.7% and 15.8% of all deaths, respectively. However, diseases of the circulatory system recorded the highest number of deaths per admission (13.7% mortality rate). Overall, infectious diseases were the chief cause of mortality in adults while conditions originating from perinatal period were the major cause of death in children. Septicemia (6.0%), stroke (4.2%), liver diseases (4.1%), tuberculosis (3.7%), diabetes (3.6%) and HIV/AIDS (3.4%) were the specific leading cases of deaths. Sepsis, chronic diseases of the tonsil and adenoids and malaria were the specific leading causes of death in children, while sepsis, stroke and liver diseases were the leading cause of death in adults.

CONCLUSION

Most causes of deaths in this study are preventable. This study revealed double burden of communicable and non-communicable diseases.

Quality of life and social support: Perspectives of Saudi Arabian stroke survivors

Given that stroke is an indispensable health burden in Saudi Arabia and around the world, great importance has been attached on studies of social support and other factors that could improve the quality of life of stroke survivors. Perceptions of quality of life and social support may vary depending on patients' cultural and societal background. This research assessed the quality of life and social support of community-dwelling Saudis who survived stroke. A quantitative study was performed among 123 Saudi stroke survivors. Questionnaire-guided interviews measuring social support and quality of life were performed, and the multivariate effects of predictor variables on the four domains of quality of life were determined through multivariate multiple regression analysis. Among the dimensions of social support, support from family members had the highest average, whereas support from friends had the lowest. The environmental domain of quality of life was perceived to be the best aspect, whereas physical health was perceived to be the poorest. Multivariate analysis revealed that age, gender, employment status, monthly family income, type of community, education, type of stroke, side of stroke and support from significant others had multivariate influences on the domains of quality of life. Several sociodemographic and disease-related variables and social support influence patients' quality of life. The study adds critical knowledge as to how Arab stroke survivors perceive their quality of life and social support. Ensuring that stroke survivors receive adequate social support is imperative because it can improve their quality of life.

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.

Occupational Therapy Goal Achievement for People with Stroke: A Retrospective Study

Methods

A cross-sectional retrospective study design was used. People with stroke receiving rehabilitation services at King Abdulaziz Medical City (KAMC) were the target of this study. Data about the extent of achieving occupational therapy goals were collected using the Goal Attainment Scaling (GAS).

Results

Of the 100 medical records of people with stroke included in this study, only 30% of the goals were functional. Only 54% of the goals were achieved. No association was found between the number of achieved goals and variables such as age, gender, type of stroke, and stroke hemisphere/side.

Conclusion

People with stroke included in this study have not shown significant progress toward achieving their therapy goals. As for clinical practice, this study could guide therapists in the future to improve the process of achieving their patients' goals.

A comparison between warfarin and apixaban: A patient's perspective

BACKGROUND

Novel oral anticoagulants (NOACs) were developed as alternatives to warfarin. However, the patients' preference regarding warfarin or the NOACs has not been established. Quality-of-life (QOL) surveys are a well-established method for determining the patients' preference for a treatment route.

AIMS

This study compared the patients' perspectives on treatment with warfarin versus apixaban using the QOL measures.

SETTINGS AND DESIGN

This cross-sectional study was conducted in 2019 for patients treated with either warfarin or apixaban at King Abdulaziz Medical City, Riyadh, Kingdom of Saudi Arabia.

METHODS

We used a series of descriptive statistics to examine the differences in sociodemographic characteristics among patients. A propensity score-matching approach was employed to reduce the effect of confounding variables that often influence treatment selection. Greedy matching approach was used to analyze the QOL.

RESULTS

A total of 388 patients were identified, of which 124 were matched between the two groups (62 patients in each group). Most of the patients were female, married, below the sufficiency level, educated, and nonsmokers. The patients using warfarin had a significantly better health state (M = 69.64, standard deviation [SD] = 16.52) than those using apixaban (M = 66.33, SD = 23.17), P = 0.011.

CONCLUSIONS

Future studies should explore why patients using apixaban showed lower QOL scores and improve health-care providers' awareness of these issues.

Scoping review of acute stroke care management and rehabilitation in low and middle-income countries

BACKGROUND

Stroke is a major public health concern, affecting millions of people worldwide. Care of the condition however, remain inconsistent in developing countries. The purpose of this scoping review was to document evidence of stroke care and service delivery in low and middle-income countries to better inform development of a context-fit stroke model of care.

METHODS

An interpretative scoping literature review based on Arksey and O'Malley's five-stage-process was executed. The following databases searched for literature published between 2010 and 2017; Cochrane Library, Credo Reference, Health Source: Nursing/Academic Edition, Science Direct, BioMed Central, Cumulative Index to Nursing and Allied Health Literature (CINNAHL), Academic Search Complete, and Google Scholar. Single combined search terms included acute stroke, stroke care, stroke rehabilitation, developing countries, low and middle-income countries.

RESULTS

A total of 177 references were identified. Twenty of them, published between 2010 and 2017, were included in the review. Applying the Donebedian Model of quality of care, seven dimensions of stroke-care structure, six dimensions of stroke care processes, and six dimensions of stroke care outcomes were identified. Structure of stroke care included availability of a stroke unit, an accident and emergency department, a multidisciplinary team, stroke specialists, neuroimaging, medication, and health care policies. Stroke care processes that emerged were assessment and diagnosis, referrals, intravenous thrombolysis, rehabilitation, and primary and secondary prevention strategies. Stroke-care outcomes included quality of stroke-care practice, functional independence level, length of stay, mortality, living at home, and institutionalization.

CONCLUSIONS

There is lack of uniformity in the way stroke care is advanced in low and middle-income countries. This is reflected in the unsatisfactory stroke care structure, processes, and outcomes. There is a need for stroke care settings to adopt quality improvement strategies. Health ministry and governments need to decisively face stroke burden by setting policies that advance improved care of patients with stroke. Stroke Units and Recombinant Tissue Plasminogen Activator (rtPA) administration could be considered as both a structural and process necessity towards improvement of outcomes of patients with stroke in the LMICs.

Mediating role of self-efficacy in the relationship between family social support and hypertension self-care behaviours: A cross-sectional study of Saudi men with hypertension

BACKGROUND

Self-efficacy and family social support are significantly associated with hypertension self-care behaviours. However, little is known about their mechanism in Saudi Arabia. This cross-sectional study aimed to examine the relationships among family social support, self-efficacy, and self-care behaviours among men with hypertension in Saudi Arabia.

METHODS

Data were collected from May to August of 2018. The Hypertension Self-Care Profile and the Perceived Social Support from Friends and Family scales were used to measure the study variables. Multiple linear regression was used to analyse the relationships between the variables, and the Baron and Kenny test was used to assess if self-efficacy mediated the relationship between family social support and hypertension self-care behaviours.

RESULTS

Respondents (N = 158) from the Jizan and Al-Sharqia regions of Saudi Arabia completed the survey. Family social support and self-efficacy were significantly associated with hypertension self-care behaviours. In regression, self-efficacy was the only variable significantly associated with hypertension self-care behaviours. Self-efficacy fully mediated the relationship between family social support and hypertension self-care behaviours.

CONCLUSIONS

Interventions to enhance hypertension self-care behaviours among Saudi men could focus on increasing individual's self-confidence to perform specific healthy behaviours. Family support can also contribute to the performance of hypertension self-care behaviours.

Functional recovery differences after stroke rehabilitation in patients with uni- or bilateral hemiparesis

OBJECTIVE

To examine the functional recovery differences after stroke rehabilitation in patients with uni- or bilateral hemiparesis.

METHODS

In this retrospective study, we included data from the medical record of all 383 patients with uni- or bilateral hemiparesis after stroke who were admitted to King Fahad Medical City-Rehabilitation Hospital between 2008 and 2014 in Riyadh, Kingdom of Saudi Arabia. According to the site of hemiparesis, we classified patients into 3 groups: right hemiparesis (n=208), left hemiparesis (n=157), and bilateral hemipareses (n=18). The patients (n=49) who did not have either site of hemiparesis were excluded. The Functional Independence Measures (FIM) instrument was used to assess the score at admission and discharge. A post hoc test was conducted to examine the functional recovery differences between groups. Multiple regression analyses were used to confirm the findings.

RESULTS

Amongst the three groups, there were significant (p<0.05) differences in the total-FIM score as well as motor- and cognitive-FIM sub-scores between admission and discharge of stroke rehabilitation. The differences were significantly greater in the bilateral hemipareses group than in either unilateral hemiparesis group. Multiple regression analyses also confirmed that the site of hemiparesis significantly (p<0.05) differs in the total-FIM score as well as motor-FIM and cognitive-FIM sub-scores.

CONCLUSION

Our results demonstrate that differences in functional recovery after stroke rehabilitation may be influenced by the site of hemiparesis after stroke.

Incidence and impact of stroke during Hajj. Results of 2015 Hajj stroke registry

Objective:

To investigate the incidence of stroke among pilgrims and describe factors associated with presentation and management during Hajj. Physical stress, age and vascular risk factors render pilgrims at a high risk of stroke.

Methods:

This is a prospective registry of all acute stroke patients admitted to 6 hospitals during the 2015 Hajj season from 9 September to 4 November. Participating hospitals were King Abdullah Medical City (KAMC), Al-Noor, King Abdulaziz hospital, King Faisal hospital, Hira, and Mena general hospitals; all in Makkah city. Stroke diagnosis was confirmed by imaging. Clinical, demographic and outcome variables were collected.

Results:

The incidence of stroke during 2015 Hajj season is 8.9/100,000; 186 cases. The peak incidence was noted on the day after Arafat. Saudis represented 17.2% while 36% were females. Hemorrhagic stroke occurred in 35 patients (18.8%). The mean age was 60.8±12.9 years while the most common risk factors were hypertension (57%) and diabetes (40.9%). Only 5 patients received intravenous tissue plasminogen activator. The median length of hospital stay was 4 days. Twenty-one patients (11.3%) died during hospitalization. The only factor that approached significance in predicting mortality was hemorrhagic stroke (odds ratio of 1.62; 95% CI: 0.97 to 2.70; p=0.063).

Conclusion:

Stroke is a major health burden during Hajj. Educational programs for pilgrims and healthcare workers together with protocol-driven care are expected to positively impact stroke care.

Reference Values of Functional and Lateral Reach Test Among the Young Saudi Population: Their Psychometric Properties and Correlation with Anthropometric Parameters

Background

Due to lack of normal reference values of forward and lateral reach tests for Saudi young adults, this study aimed to formulate normative values of the forward reach test and lateral reach test and to assess the correlation between the demographic variables and the reach test results.

Material/Methods

We randomly assigned 240 normal young Saudi adults ages 20–23 years to assess reach test scores in forward and lateral directions. All the subjects had been measured for distance reached in forward and lateral direction on graph paper fixed to a white board.

Results

The mean and standard deviation of forward and lateral reach distances were 25±8.14 cm and 19.78±5.70 cm, respectively. Significant differences were found between males and females for forward reach and lateral reach scores (p<0.001). Forward reach and lateral reach values showed a moderate correlation with height, lower limb length, and upper limb length. The intra-rater reliability assessed by intra-class correlation coefficient was 0.91 and 0.92 for the forward and lateral reach test scores, respectively.

Conclusions

This study established reference values of forward and lateral reach scores for Saudi young adults ages 20–23 years. Height, upper limb length, and lower limb length were moderately correlated with the reach distances in forward and lateral directions. Males performed longer reach distances than females.

Effectiveness of an early mobility protocol for stroke patients in Intensive Care Unit

Objectives:

To evaluate the effectiveness of an early mobility protocol for stroke patients in the intensive care unit.

Methods:

Participants were patients with first or recurrent stroke (n=60, age=49.02±6.36 years, body mass index=32.95±5.67 kg/m²) admitted to the intensive care stroke unit in general hospitals, Riyadh during October and December 2016. Single group pretest-posttest design involving an early mobility protocol was started within first 24 hours admission. Pre and post measurements of muscle strength, pulmonary function and quality of life were carried out.

Results:

There were significant improvements in muscle strength of upper and lower extremities´ muscles after treatment (p<0.05), pulmonary functions including Forced Vital Capacity, Forced Expiratory Volume 1 (p<0.05) and quality of life, namely, Barthel Index and modified Rankin Scale (p<0.01).

Conclusion:

This study demonstrates that initiating an early mobility protocol is safe and effective for intensive care unit stroke patients and supports introducing the current protocol as a standard protocol in neurogenic Intensive Care Units.

A national economic and clinical model for ischemic stroke care development in Saudi Arabia: A call for change

BACKGROUND

Stroke is a significant burden in Saudi Arabia and the Saudi Ministry of Health's stroke committee has identified an urgent need to improve care.

AIM

The purpose of this study was to undertake a health-economic analysis to quantify the impact of developing stroke care in the country.

METHODS

An economic model was developed to assess the costs and clinical outcomes associated with an ischemic stroke care development program compared with current stroke care. Based on Saudi epidemiological data, cohorts of ischemic stroke patients enter the model each year for the first 10 years based on increasing incidence. Four treatment options were modeled including reperfusion and non-reperfusion treatments. The development scenario estimates the impact of gradually increasing uptake of more effective treatments over 10 years. Changes in the stroke care organization are considered along with resources required to increase capacity, allowing more patients to be admitted to stroke hospitals and access effective treatments.

RESULTS

The stroke care development program is associated with an increase in functionally independent patients and a decrease in disabling strokes compared with current stroke care. Additionally, the development program is associated with estimated cost savings of $602 million over 15 years ($255 million direct costs, $348 million indirect costs).

CONCLUSIONS

The model predicts that the stroke care development program is associated with improved patient outcomes and lower overall costs compared with the current stroke care program.

Is Duplex carotid artery screening prior to CABG justified?

OBJECTIVE

To evaluate the use of duplex carotid artery screening in patients undergoing coronary artery bypass graft (CABG).

METHODS

This descriptive, observational study was conducted in Radiology Department at King Fahad Military Medical Complex, Dhahran, Kingdom of Saudi Arabia from April 2015-2018. All Saudi patients (n=178) who underwent duplex carotid sonography prior to CABG were retrospectively reviewed for essential morphologic and hemodynamic information to estimate severity of extra-cranial internal carotid artery (ICA) stenosis. Patients with combined CABG and cardiac surgery, and those with limited carotid studies were excluded. Advancing age (65 years or above), gender, smoking, obesity, diabetes (DM), hypertension (HTN), dyslipidemia, coronary vessel disease, cardiac disease and previous stroke were recorded. Post-coronary artery bypass graft neurologic event (namely, transient ischemic attack [TIA] or stroke) was recorded. Chi-square test was used to determine association of stenosis degree with post-CABG neurologic event.

RESULTS

One hundred twenty eight patients (72%) were having ICA disease, while significant carotid artery stenosis (>70%) was seen in 11 patients (6.2%). Post-coronary artery bypass graft neurologic event was seen in 4.5% of patients. Advancing age, significant ICA stenosis and multi-vessel coronary disease were seen associated with a post-CABG event.

CONCLUSION

Significant ICA stenosis on duplex screening in elderly patients with multi-vessel coronary artery disease or certain risk factors may predict post-CABG stroke.

A Genetic Variant of miR-34a Contributes to Susceptibility of Ischemic Stroke Among Chinese Population

miRNAs are small non-coding RNAs modulating gene expression, and variants in miRNA genes are involved in the pathogenesis of ischemic stroke (IS). However, the effect of miR-34a polymorphisms on IS susceptibility has rarely been reported. In the present study, we investigated the association between rs12128240, rs2666433, and rs6577555 of the miR-34a gene and IS susceptibility. Snapshot assay was used to detect miR-34a polymorphisms in 548 IS patients and 560 controls. Relative expression of miR-34a was measured by quantitative real-time PCR. We found that rs2666433 was associated with a significantly increased risk of IS (AA vs. GG: OR = 1.61, 95% CI = 1.05-2.52, P = 0.031; AA vs. GG+GA: OR = 1.58, 95% CI = 1.05-2.45, P = 0.026). For the IS subtypes, rs2666433 was associated with large artery atherosclerosis (AA vs. GG: OR = 2.09, 95% CI = 1.16-3.51, P = 0.007; AA vs. GG+GA: OR = 2.02, 95% CI = 1.15-3.33, P = 0.007; A vs. G: OR = 1.36, 95% CI = 1.07-1.81, P = 0.021). Additionally, the level of miR-34a was significantly up-regulated in IS patients compared to the controls (P < 0.001), and patients with rs2666433 AA genotype had a higher level of miR-34a than those with GG+GA genotypes (P < 0.001). Furthermore, increased level of homocysteine was observed in IS patients compared to the controls (P < 0.001), especially in patients carrying the rs2666433AA genotype compared to those carrying the rs2666433 GG+GA genotypes (P < 0.001). However, no significant association between rs12128240 or rs6577555 and IS was found. Collectively, our study found the association between miR-34a polymorphisms and the risk of IS among the Chinese population. The results may provide an explanation for etiology of IS and a potential biomarker or therapeutic target for IS. HIGHLIGHTS-MiR-34a rs2666433 polymorphism was associated with an increased risk of ischemic stroke.-The level of miR-34a was significantly up-regulated in ischemic stroke patients compared with controls, and patients with rs2666433 AA genotype had a higher level miR-34a than those with GG+GA genotypes.-Furthermore, increased level of homocysteine was showed in IS patients compared to controls, and in patients carrying the rs2666433AA compared to those carrying the rs2666433 GG+GA.

Obstructive sleep apnea and stroke

Obstructive Sleep Apnea (OSA) is a common co-morbid condition in stroke patients. It represents a very important risk factor for stroke in addition to the other established ones such as hypertension, cardiovascular disease (CVD), hyperlipidemia, atrial fibrillation (AF), type 2 diabetes mellitus (T2DM), stress, smoking, and heavy drinking. Although in the United States the prevalence of OSA has somewhat decreased from the previous years, globally its prevalence remains constant, or in some cases, is on the rise. In this review we present the epidemiology for OSA in stroke populations and discuss the risk factors for stroke as well as the underlying pathogenetic mechanisms linking OSA, stroke and CVD. We also emphasize the more thorough evaluation and control of OSA in order to prevent the disabling side effects of a stroke, which not only compromises the physical and mental health of a person and increases the burden on families, but also adds a severe burden to national health economics. OSA should always be considered when assessing a patient with transient ischemic attacks (TIA). Work up and treatment for OSA will not only help prevent stroke with its devastating consequences, but will also help prevent CVD, and ameliorate co-morbid conditions such as diabetes and hypertension in these vulnerable populations.

Factors associated with late arrival of acute stroke patients to emergency department in Saudi Arabia

Background

Tissue plasminogen activator within 4.5 h of onset is effective for acute ischemic stroke. However, only small proportion of patients is treated due to delayed presentation. We aimed to examine the factors associated with delays of stroke patients in Riyadh, Saudi Arabia.

Methods

A cross-sectional survey was conducted at King Abdulaziz Medical City, Riyadh, Saudi Arabia, during a 6-month period. An interviewer administered structured questionnaire addressed to the acute stroke patients or their relatives was used to explore the factors associated with delayed arrival.

Results

A total of 227 patients attending the emergency department were interviewed. The mean age was 60.4 ± 15.6 years. Approximately 56.4% presented after 4.5 h of stroke onset. Factors associated with late arrival were being alone during the onset of stroke, not being transported in an ambulance, not knowing that they were experiencing a stroke, and residing outside the city of Riyadh.

Conclusion

More than half of patients missed the golden hours for thrombolysis due to delayed presentation. Reasons include lack of knowledge, underuse of ambulance and difficult access to care. Urgent community-based interventions are needed to address these factors.

Study of Stroke Incidence in the Aseer Region, Southwestern Saudi Arabia

Recent data regarding first-stroke incidence in Saudi Arabia in general and in the Aseer region in particular are scarce and even lacking. The aim of this work was to study the first-time stroke incidence in the Aseer region, southwestern Saudi Arabia. All first-stroke patients admitted to all hospitals in the Aseer region over a one-year period (January through December 2016) were included. Stroke patients outside the Aseer region were excluded from the study. The incidence per 100,000 patients and the concomitant 95% CI (Confidence Intervals) were computed. The present study included 1249 first-time stroke patients and calculated an overall minimal incidence rate of hospitalized first-time stroke of 57.64 per 100,000 persons per year (95% CI: 57.57-57.70). A steady increase was noticed depending on the patients' age, reaching a figure of 851.81 (95% CI: 849.2-854.5) for those patients aged 70 years and more. Overall, the incidence rate for females (48.14; 95% CI: 48.04-48.24) was lower compared to males (65.52; 95% CI: 65.1-66.0). Taking into consideration the expected rise of the elderly because of the prominent medical services provided by the Saudi government, leading to a subsequent change in the horizontal and vertical age distribution structure of the population, an increase in the number of stroke patients is expected. It is suggested to establish a nationwide stroke surveillance system in the Kingdom, with the objective to report, analyze, and maintain an updated overview of the stroke status in Saudi Arabia.

Length of Stay and Functional Outcomes Among Patients with Stroke Discharged from an Inpatient Rehabilitation Facility in Saudi Arabia

Background

In many countries, the length of stay (LOS) for inpatient rehabilitation following stroke has gradually decreased. It is unclear whether this trend is associated with differences in functional outcomes, especially in developing countries. This study aimed to examine associations between LOS and functional outcomes among patients with stroke discharged from an inpatient rehabilitation facility in Saudi Arabia.

Material/Methods

This retrospective study included all patients (N=409) aged ≥18 years who were admitted to an inpatient rehabilitation for stroke during 2008–2014. There were no deaths in the cohort during the study period. Patients were divided into 4 groups according to days of rehabilitation: ≤30 days (n=114), 31–60 days (n=199), 61–90 days (n=72), and >90 days (n=24). Multivariate regression analyses were used to evaluate functional outcomes using the functional independence measure (FIM).

Results

The fully adjusted model showed that higher total and subscale FIM scores were significantly associated with a LOS ≤30 days (total β: 18.2, standard error [SE]=4.43, P≤0.0001; motor-FIM: β=13.9, SE=3.70, P=0.0002; cognitive-FIM: β=4.3, SE=1.29, P=0.001), and 31–60 days (total β: 11.3, SE=4.07, P=0.005; motor-FIM: β=8.8, SE=3.40, P=0.009; cognitive-FIM: β=2.4, SE=1.19, P=0.038) compared with >90 days.

Conclusions

A short or intermediate LOS is not necessarily associated with worse outcomes, assuming adequate care is provided.

Molecular genetic studies in Saudi population; identified variants from GWAS and meta-analysis in stroke

INTRODUCTION

Stroke is a multifactorial and heterogeneous disorder, correlates with heritability and considered as one of the major diseases. The prior reports performed the variable models such as genome-wide association studies (GWAS), replication, case-control, cross-sectional and meta-analysis studies and still, we lack diagnostic marker in the global world. There are limited studies were carried out in Saudi population, and we aim to investigate the molecular association of single nucleotide polymorphisms (SNPs) identified through GWAS and meta-analysis studies in stroke patients in the Saudi population.

METHODS

In this case-control study, we have opted gender equality of 207 cases and 207 controls from the capital city of Saudi Arabia in King Saud University Hospital. The peripheral blood (5 ml) sample will be collected in two different vacutainers, and three mL of the coagulated blood will be used for lipid analysis (biochemical tests) and two mL will be used for DNA analysis (molecular tests). Genomic DNA will be extracted with the collected blood samples, and specific primers will be designed for the opted SNPs (SORT1-rs646218 and OLR1-rs11053646 polymorphisms) and PCR-RFLP will be performed and randomly DNA sequencing will be carried out to cross check the results.

RESULTS

The rs646218 and rs11053646 polymorphisms were significantly associated with allele, genotype and dominant models with and without crude odds ratios (OR's) and Multiple logistic regression analysis (p < 0.05). Correlation between lipid profile and genotypes has confirmed the significant relation between triglycerides and rs646218 and rs1105364 6polymorphisms. However, rs11053646 polymorphism was correlated with HDLC (p = 0.04). Genotypes were examined in both males' vs. males and females' vs. females in cases and control and we concluded that in rs11053646 polymorphisms with male subjects compared between cases and controls found to be associated with dominant model heterozygote genotypes (p < 0.05).

CONCLUSION

The results of the current study confirmed the SORT1 and OLR1 SNPs were associated in the Saudi population. The current results were in the association with the prior study results documented through GWAS and meta-analysis association. However, other ethnic population studies should be performed to rule out in the human hereditary diseases.

Functional outcomes by age after inpatient stroke rehabilitation in Saudi Arabia

Background

Among various risk factors, age has been identified as a nonmodifiable risk factor for stroke that influences functional outcomes after inpatient stroke rehabilitation in the developed world as well as in Saudi Arabia (SA). The demand for inpatient stroke rehabilitation services increases with population aging and stroke incidence; however, these services are limited in SA.

Objective

To examine functional outcomes by age after inpatient stroke rehabilitation in SA.

Patients and methods

Data from 418 patients with stroke who underwent inpatient stroke rehabilitation at the King Fahad Medical City-Rehabilitation Hospital, Riyadh, SA, between November 2008 and December 2014 were collected from electronic medical records. According to the patients’ age, we classified participants into two groups: adults, aged <65 years (n=255), and older adults, aged ≥65 years (n=163). All patients’ functional statuses at admission and discharge from inpatient stroke rehabilitation were assessed using the functional independence measure (FIM) scale.

Results

The mean age was 59.9 years (SD =9.4). Older adults had significantly smaller changes in functional outcome from admission to discharge on both the total FIM (23 [SD =15.9]) and the motor FIM (21 [SD =15.4]), and they were significantly less independent (36%) compared to adults. In the adjusted models, older adults had significantly lower scores than adults, by 11 points (p<0.0001) for the total FIM score and by 10 points (p<0.0001) for the motor FIM subscale score. There was no significant change with age in the cognitive FIM subscale score.

Conclusion

After inpatient stroke rehabilitation, older adults had limited functional outcomes or were less independent than adults. However, the clinical relevance of this finding is questionable, so there is currently no justification to deny patients access to intensive stroke rehabilitation solely because of advanced age. Future large-scale research is needed to confirm rehabilitation outcomes by including confounders such as social support, socioeconomics, comorbidities, and the patient’s opinion after rehabilitation.

Stroke rehabilitation. A call to action in Saudi Arabia

Stroke is a major cause of death and other complications worldwide. In Saudi Arabia, stroke has become an emerging health issue leading to disability and death. However, stroke care including rehabilitation services, in Saudi Arabia lags behind developed countries. Stroke rehabilitation is an essential recovery option after stroke and should start as early as possible to avoid potential complications. The growing evidence on stroke rehabilitation effectiveness in different health care settings and outcome measures used widely are reviewed in this call to action paper.

Cerebral Functional Reorganization in Ischemic Stroke after Repetitive Transcranial Magnetic Stimulation: An fMRI Study

AIMS

Our study aimed to figure out brain functional reorganization evidence after repetitive transcranial magnetic stimulation (rTMS) using the resting-state functional magnetic resonance imaging (rsfMRI).

METHODS

Twelve patients with unilateral subcortex lesion in the middle cerebral artery territory were recruited. Seven of them received a 10-day rTMS treatment beginning at about 5 days after stroke onset. The remaining five received sham treatment. RsfMRI and motor functional scores were obtained before and after rTMS or sham rTMS.

RESULTS

The rTMS group showed motor recovery according to the behavioral testing scores, while there was no significant difference of motor functional scores in the sham group before and after the sham rTMS. It proved that rTMS facilitates motor recovery of early ischemic stroke patients. Compared with the sham, the rTMS treatment group achieved increased functional connectivity (FC) between ipsilesional M1 and contralesional M1, supplementary motor area, bilateral thalamus, and contralesional postcentral gyrus. And decreased FC was found between ipsilesional M1 and ipsilesional M1, postcentral gyrus and inferior and middle frontal gyrus.

CONCLUSION

Increased or decreased FC detected by rsfMRI is an important finding to understand the mechanism of brain functional reorganization. The rTMS treatment is a promising therapeutic approach to facilitate motor rehabilitation for early stroke patients.

Effects of Functional Limb Overloading on Symmetrical Weight Bearing, Walking Speed, Perceived Mobility, and Community Participation among Patients with Chronic Stroke

Background. Stroke is a leading cause for long-term disability that often compromises the sensorimotor and gait function accompanied by spasticity. Gait abnormalities persist through the chronic stages of the condition and only a small percentage of these persons are able to walk functionally in the community. Material and Method. Patients with chronic stroke were recruited from outpatient rehabilitation unit at Department of Neurology & Neurosurgery, All India Institute of Medical Sciences, having a history of first stroke at least six months before recruitment, with unilateral motor deficits affecting gait. The patients were randomly assigned to either the functional limb overloading (FLO) or Limb Overloading Resistance Training (LORT) group and provided four weeks of training. Result. We found that there was an improvement in gait performance, weight bearing on affected limb, and perceived mobility and community participation. Conclusion. To the best of our knowledge, this is the first study that has evaluated the effects of functional limb overloading training on symmetric weight bearing, walking ability, and perceived mobility and participation in chronic hemiplegic population. The study demonstrated a beneficial effect of training on all the outcomes, suggesting that the functional limb overloading training can be a useful tool in the management of gait problems in chronic stroke patients.