Outcomes and predictors of seizure recurrence in post-stroke epilepsy, a retrospective hospital-based study

BACKGROUND

The occurrence of seizures following a stroke is a well-recognized complication associated with a significant increase in morbidity and mortality. Despite the numerous studies examining outcomes and risk factors related to post-stroke seizures (PSS), there remains a lack of clarity regarding the clinical characteristics, treatment, and PSS recurrence (PSSR) rates in patients experiencing their initial episode of PSS.

PURPOSE

This study aimed to determine the risk factors for developing recurrent seizures after first PSS and their effects on functional outcomes and mortality.

METHODS

All patients underwent an electroencephalography (EEG) and were monitored for a minimum of 24 months following the first PSS. The primary endpoint was the recurrence of seizures. Predictive factors for PSSR were determined by using the Cox-proportional hazards model, and the cumulative latency of recurrence at 90, 180, 360, and 720 days was estimated using Kaplan-Meier analysis.

RESULTS

Seizure recurred in 36.8% (39/106). Significant association of PSSR was noted with female gender, use of older anti-seizure medications (ASMs) (p<0.001), EEG findings as focal slow wave activity (p<0.001), Ictal epileptiform abnormalities (p=0.015), status epilepticus (p=0.015), and with severe disability (p=0.008). However, multivariate cox-proportional hazards model showed significant association of female gender (HR=3.28; 95% CI: 1.42-7.58; p=0.006). Hazard ratio (HR) was increased with older ASMs use, focal aware seizure types, Ictal EAs, and periodic discharges on EEG; though, statistically significant.

CONCLUSION

Factors such as the type of ASMs, EEG findings, and seizure type were significantly linked to PSSR. Female gender was the only independent predictor established. Additionally, significant functional decline was reported with recurrence.

Clinical Implications of Various Electroencephalographic Patterns in Post-Stroke Seizures. The Utility of Routine Electroencephalogram

Objective: Post-stroke seizures (PSS) are one of the major stroke-related complications. Early therapeutic interventions are critical therefore using electroencephalography (EEG) as a predictive tool for future recurrence may be helpful. We aimed to assess frequencies of different EEG patterns in patients with PSS and their association with seizure recurrence and functional outcomes. Methods: All patients admitted with PSS were included and underwent interictal EEG recording during their admission and monitored for seizure recurrence for 24 months. Results: PSS was reported in 106 patients. Generalized slow wave activity (GSWA) was the most frequent EEG pattern observed (n  =  62, 58.5%), followed by Focal sharp wave discharges (FSWDs) (n  =  57, 55.8%), focal slow wave activity (FSWA) (n  =  56, 52.8%), periodic discharges (PDs) (n  =  13, 12.3%), and ictal epileptiform abnormalities (n  =  6, 5.7%). FSWA and ictal EAs were positively associated with seizure recurrence (p < .001 and p  =  .015 respectively) and it remained significant even after adjusting for age, sex, stroke severity, stroke subtype, or use of anti-seizure medications (ASMs). Other positive associations were status epilepticus (SE) (p  =  .015), and use of older ASM (p < .001). FSWA and GSWA in EEG were positively associated with severe functional disability (p  =  .055, p  =  .015 respectively). Other associations were; Diabetes Mellitus (p  =  .034), Chronic Kidney Disease (p  =  .002), use of older ASMs (p  =  .037), presence of late PSS (p  =  .021), and those with Ischemic stroke (p  =  .010). Conclusions: Recognition and documentation of PSS-related EEG characteristics are important, as certain EEG patterns may help to identify the patients who are at risk of developing recurrence or worse functional outcomes.

Estimated prevalence study of attention-deficit/hyperactivity disorder among eastern province children in the Kingdom of Saudi Arabia

Background

Studying mental disorders in children is significantly important due to the huge suffering of educational and psychosocial impairments in adult life. Attention-deficit/hyperactivity disorder (ADHD) is considered the most common mental disorder in children, especially in early school-aged children. It manifests in about 8%-12% of children in the world. In Saudi Arabia, it affects 4%-12% of children.

Objective

The study aimed to count the number of undiagnosed ADHD cases and the associated risk factors in Eastern Province in Kingdom of Saudi Arabia (KSA).

Methods

A cross-sectional study was performed among girls' and boys' children aged 6-10 years old in Eastern Province in KSA with a random selection of parents. Sample size is equal to 1658. The assessment was done by an online questionnaire filled it by parents using Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition diagnostic criteria and Connor's scale of ADHD excluding any developmental or mental disorder at the beginning of the questionnaire.

Results

After excluding the participants who were diagnosed with behavioral and growth developmental disorder, the remaining 1430 have been screened for ADHD based on Connor's scale. 185 of a child out of 1430 were suggested to have ADHD, of which 10 out of them show the signs of ADHD, 76 of them have moderately severe ADHD, and 99 out of them have atypical or severe ADHD based on Connor's scale of ADHD. The study shows that there is a significant relationship between the positive screening of ADHD and gender males (71.35%), females (28.64%), family history (20.5%), nervous system diseases (4.32%), brain damage from trauma (9.72%), smoking habit of the mother (8.64%), smoking during pregnancy (3.78%), mother exposure to second-hand smoking (42.16%), child exposure to a toxic substance like lead during the early life (1.62%), and the preterm labor (15.13%). However, the study shows there is no significant relationship between the positive screening of ADHD with age, drinking alcohol, and central nervous system infection.

Conclusion

The prevalence of undiagnosed ADHD is slightly high. Also, it has many causes of ADHD including gender, smoking, parental psychiatric disorders, and obstetric and pregnancy problems.

Association between glycated hemoglobin and functional outcomes in patients with intracranial large artery atherosclerotic disease-related acute ischemic stroke: identifying the magic number

Objective

This study aimed to investigate the effect of the glycated hemoglobin A1c (HbA1c) level on the functional outcome (FOC) in patients with intracranial large artery atherosclerotic disease (ICLAD)-related acute ischemic stroke (AIS).

Methods

This retrospective study enrolled patients with ICLAD-related AIS who were admitted to King Fahd University Hospital between January 2017 and September 2021. Patients were divided into two groups based on the optimal cutoff HbA1c level determined using receiver operating characteristic curve analysis-those with HbA1c ≤6.9% and those with HbA1c >6.9%. Demographic and other clinical characteristics were compared between the two groups using chi-square tests. The association between HbA1c and 90-day FOC was assessed using the chi-square test and odds ratios (ORs). Multivariate analysis was performed to adjust for confounding factors.

Results

A total of 140 patients were included in the analysis. A significant association was observed between the HbA1c level and FOC. Compared to patients with HbA1c ≤6.9%, patients with HbA1c >6.9% were more likely to have an unfavorable FOC [p = <0.001, OR = 2.05, 95% confidence interval (CI) = 1.33-3.14]. The association between HbA1c >6.9% and unfavorable FOC was sustained even after adjusting for confounding factors (p = 0.008) and atherosclerosis risk factors (p = 0.01). HbA1c >6.9% was also associated with higher ORs for in-hospital complications (p = 0.06, OR = 1.34, 95% CI = 1.02-1.77) and mortality (p = 0.07, OR = 1.42, 95% CI = 1.06-1.92) although these associations did not attain significant p-values.

Conclusion

HbA1c >6.9% was significantly associated with unfavorable FOC in ICLAD-related AIS. However, further studies with larger sample sizes are required to verify whether HbA1c is an independent predictor of poor FOC. Nevertheless, targeting HbA1c <7% should be the goal of physicians when managing patients at high risk of ICLAD.

An Observational Study Comparing the Safety and Efficacy of Conventional Anticoagulation Versus New Oral Anticoagulants in the Management of Cerebral Venous Sinus Thrombosis

Objective: To compare the safety and efficacy of conventional anticoagulants with new oral anticoagulants (NOACs) for management of cerebral venous sinus thrombosis (CVST).

Methods: This was a retrospective, prospective cohort study of patients who presented with CVST to a tertiary stroke center in the Middle East from January 2012 to October 2019. Patients with a diagnosis of CVST were identified, and data were analyzed for demographic characteristics. Specific consideration was given to compare the efficacy and safety of different anticoagulation treatments.

Results: A total of 36 patients were included in the final analysis, with 15 (41%) men and 21 (59%) women and a male to female ratio of 1:1.4. Most of the patients (n = 22, 61%) were Saudi. Their ages ranged between 15 and 82 years (mean ± SD age of 34.22 ± 13.16 years). Headache was the most common feature, present in 22 (61%) of the patients, followed by unilateral weakness in 15 (41%) and cranial nerve palsies in 11 (30%). The most common etiology was prothrombotic state (both hereditary and acquired thrombophilia: n = 16, 45%). Other etiologies were postpartum state/oral contraceptive pill usage in 7 (19%), infections in 7 (19%), and trauma in 3 (8%). Most of the patients (n = 24, 67%) still received conventional anticoagulation (warfarin/low molecular weight heparin), but 9 (25%) of the patients consented to start NOACs. Efficacy (as measured by clinical improvement plus rate of recanalization of previously thrombosed venous sinuses) showed no statistically significant difference, although it proved to be better tolerated, as none of the patients stopped the treatment due to adverse events and risk of major bleeding was significantly low in the NOAC group. Nine patients in the warfarin group stopped medication, while none in the NOAC group did so (P = .034).

Conclusion: NOACs were found to be at least as good as conventional anticoagulation for the management of CVST. However, efficacy was almost similar, a finding that is consistent with most of the published case series and the few recently published prospective studies. Larger prospective and population-based studies are needed to clarify our preliminary results.

Clinical Correlates of Electroencephalographic Patterns in Critically Ill Patients

OBJECTIVE

The objective of this study was to determine the frequency and clinical correlates of different electroencephalographic patterns and their association with clinical outcomes in critically ill patients.

SUBJECTS AND METHODS

This retrospective cross-sectional study was performed in the Neurology Department of King Fahd Hospital of the University, Kingdom of Saudi Arabia and involved a review and analysis of medical records pertaining to 179 intensive care unit patients who underwent electroencephalography (EEG) in the June to November 2018 period.

RESULTS

Among the different etiologies, presence of spike and wave or sharp wave (SWs) was associated with encephalitis (P = .01) and large artery stroke (P = .01), whereas markedly attenuated EEG activity (p = .04) and burst suppression (P = .01) were associated with large artery stroke and hypoxic ischemic encephalopathy (HIE), respectively. Generalized theta activity (P = .01) was significantly found in patients of septic encephalopathy, while generalized delta activity (P = .02) and asymmetrical background (P = .04) were significantly associated with traumatic brain injury. Presence of periodic discharges in EEG was significantly associated with more adverse clinical outcomes (P = .001), whereas rhythmic delta activity (RDA) (P = .03), persistent focal slow wave activity (P = .01), and asymmetric background (P = .002) were found in patients who were discharged from hospital with sequelae of current illness.

CONCLUSION

Certain EEG patterns are associated with particular underlying etiologies like SWs for encephalitis, markedly attenuated EEG activity and burst suppression with large artery stroke and HIE, respectively. Whereas few EEG patterns, including periodic discharges, RDA, persistent focal slow wave activity have some prognostic value in critically ill patients. However, they cannot be used as markers for prognostic assessment of patients without considering other clinical and diagnostic variables. Further larger prospective studies with continuous EEG monitoring with control of confounding factors are needed.

Prevalence of Medically Resistant Epilepsy in Saudi Arabia

OBJECTIVES

The objective of this study was to evaluate the prevalence of medically resistant epilepsy (MRE) in our hospital and to compare the prevalence with that in other populations.

METHODS

We retrospectively analyzed the data of patients who visited the epilepsy clinics at King Fahd University Hospital, Al-Khobar, Saudi Arabia between January 2017 and December 2018. This study included patients aged ≥14 years who had at least 2 unprovoked seizures 24 h apart. Patients who had provoked seizure(s), paroxysmal events, or syncope or had incomplete medical records were excluded. The definition and classification of the International League Against Epilepsy were used. Moreover, we searched the En-glish literature using PubMed and Google Scholar to compare the prevalence of MRE between our population and other populations.

RESULTS

In total, 1,151 patients were screened, and 751 patients were included in the final analysis. Of the 751 patients, 229 (male: 56.3%, female: 43.7%; mean age: 32.07 years, and standard deviation, 12.2 years) had MRE, with a cumulative prevalence of 30%. The etiology was as follows: unknown, 63.3% (n = 145); structural, 31.9% (n = 73); genetic, 3.1% (n = 7); and infectious, 1.7% (n = 4). None of the patients had metabolic or immune-related etiologies.

CONCLUSION

The prevalence of MRE in our population (30%) is close to that in other populations (30-36.5%). Early identification of such patients is crucial to improve their management.