Different strokes

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

Rituximab treatment in myasthaenia gravis

Myasthaenia gravis [MG] is an autoimmune disease involving the postsynaptic receptors in the neuromuscular junction. The condition is characterised by fatigable weakness of the skeletal muscles and is uncommon in children. Acetylcholinesterase inhibitors and immune-modifying medications are usually considered the mainstay of treatment. However, these medications have to be given on a lifelong basis so that patients remain in remission; furthermore, drug-related side-effects can have a major impact on quality of life. We report two paediatric cases who were treated for MG at the Sultan Qaboos University Hospital, Muscat, Oman, in 2007 and 2008, respectively. Rituximab was eventually administered to each patient after their condition failed to improve despite several years of standard treatment with acetylcholinesterase inhibitors and immune-modifying medications. Overall, rituximab resulted in complete remission in one case and significant clinical improvement in the other case

Spectrum of cerebral venous thrombosis in oman

Objectives: Cerebral venous thrombosis [CVT] can have varied and life-threatening manifestations. This study aimed to examine the spectrum of its clinical presentations and outcomes in a tertiary hospital in Oman

Methods: This retrospective study was conducted at the Sultan Qaboos University Hospital, Muscat, Oman, between January 2009 and December 2017. The medical records of all patients with CVT were reviewed to determine demographic characteristics, clinical features and patient outcomes

Results: A total of 30 patients had CVT. The mean age was 36.8 +/- 11 years and the male-to-female ratio was 2:3. Common manifestations included headache [83%], altered sensorium [50%], seizures [43%] and hemiparesis [33%]. Underlying risk factors were present in 16 patients [53%]. Computed tomography or magnetic resonance imaging of the brain was abnormal in all patients, with indications of infarcts [40%] and major sinus thrombosis [100%]. There were five cases [20%] of deep CVT. The patients were treated with low-molecular-weight heparin, mannitol and anticonvulsants. The majority [77%] had no residual neurological deficits at follow-up

Conclusion: These findings indicate that CVT is a relatively uncommon yet treatable disorder in Oman. A high index of suspicion, early diagnosis, prompt anticoagulation treatment and critical care may enhance favourable patient outcomes

Frequency of obstructive sleep apnea syndrome among patients with epilepsy attending a tertiary neurology clinic

Epilepsy is a common neurological disorder with a median lifetime prevalence of 14 per 1000 subjects. Sleep disorders could influence epileptic seizure. The most common sleep disorder is obstructive sleep apnea syndrome [OSAS] which occurs in 2% of adult women and 4% of adult men in the general population. The aim of this study is to estimate the frequency of OSAS among patients with epilepsy and to study the seizure characteristics among those patients with co-morbid OSAS. Patients with a confirmed diagnosis of epilepsy who attended the Sultan Qaboos University Hospital neurology clinic were recruited for the study between June 2011 and April 2012. Patients were screened for OSAS by direct interview using the validated Arabic version of the Berlin questionnaire. Patients identified as high-risk underwent polysomnography. A total of 100 patients with epilepsy [55 men and 45 women] were screened for OSAS. Generalized and focal seizure was found in 67% of male and 27% of female patients. Six percent of the participants had epilepsy of undetermined type. Only 9% of the sample was found to have high risk of OSAS based on the Berlin questionnaire. No significant correlation was found between risk of OSAS, type of epilepsy, and anti-epileptic drugs. The risk of OSAS was marginally greater in patients with epilepsy compared to the general population with the overall prevalence of 9%

Eating epilepsy in Oman. A case series and report on the efficacy of temporal lobectomy

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

Misdiagnosis of myasthenia gravis and subsequent clinical implication: a case report and review of literature

The autoimmune disease, myasthenia gravis [MG], can mimic a variety of neurological disorders leading to a delay in diagnosis and treatment. On occasions, misdiagnosis of MG could lead to unnecessary and potentially harmful therapeutic interventions. We report on a 12 year-old boy, in whom MG was mistaken for meningitic sequelae and subsequently for critical neuropathy/myopathy resulting in considerable morbidity for nearly a decade. Subsequent correct diagnosis and optimal management resulted in significant improvement in his functional status. We discuss the importance of considering MG as one of the potential differential diagnoses among cases of recurrent respiratory pump failure, or unexplained bulbar symptoms where documentary proof of the previous diagnoses including work-up for MG is lacking. We also review the literature on MG misdiagnosis and highlight the potential pitfalls in MG diagnosis

Acute drug overdose: clinical profile, etiologic spectrum and determinants of duration of intensive medical treatment

Acute drug overdosing is an important cause of organ dysfunction and metabolic derangements and the patients often require intensive care. This study aims to determine the clinical pattern of severe drug overdose as well as the factors influencing the duration of intensive care. The clinical characteristics and course of consecutive adult patients admitted with a diagnosis of acute drug poisoning in the ICU of a tertiary hospital in Oman from January 2007 to December 2008 were reviewed retrospectively from the electronic case records. Acute drug poisoning [n=29] constituted 3.9% of admissions to the ICU. Mean age was 29.38 +/- 7.9 years. They were brought in by their relatives [72%] or the state services [24%]. Accidental poisoning was noted in 21 patients [72%] and suicidal overdosing in 6 [21%]. The commonest drug was an opioid [65.5%]. Glasgow Coma Scale score of

Spinal cord infarction following abdominal surgery and postoperative epidural analgaesia

Ischemic infarction is a rare cause of acute myelopathy. We report the case of a young woman admitted to Sultan Qaboos University Hospital, Oman, who developed extensive spinal cord infarction in the setting of surgical evacuation and packing of liver haematoma and post-operative epidural analgesia. She had no vascular risk factors for stroke. The vascular mechanism underlying ischemic myelopathy and the relationship to abdominal surgery and epidural analgesia are discussed