Risk Factors of the First-Time Stroke in the Southwest of Saudi Arabia: A Case-Control Study.

Worldwide, stroke is the second leading cause of death and a frequent cause of permanent disability. The objective was to identify the first-time stroke modifiable risk factors in the Aseer region, southwest Saudi Arabia. In a multicenter hospital-based case-control study design, all first stroke patients admitted to hospitals in the Aseer region were included consecutively over one year. Age, sex, and geographical residence-matched controls were selected and included in a ratio of 1:1. Data collected included altitude (low or high), nationality, marital status, educational level, family history of stroke, history of diabetes mellitus, history of systemic hypertension, high cholesterol level, current smoking, obesity, and regular exercise practice. The study included 1249 first-time stroke patients and 1249 age, sex, and residence-matched controls. Hypertension, diabetes mellitus, obesity, and high cholesterol were significantly highly prevalent among cases (57.7%, 49.4%, 42.0%, 29.4%, respectively) compared to controls (31.8%, 25.9%, 30.8%, 12.1%, respectively). Practicing regular exercise was significantly highly prevalent among controls (29.9%) compared to cases (13.1%). Multivariable logistic regression analysis revealed that systemic hypertension (adjusted odds ratio (aOR) = 2.12, 95%CI: 1.74-2.57), diabetes mellitus (aOR = 1.73, 95%CI: 1.41-2.21), obesity (aOR = 1.95, 95%CI: 1.61-2.28) and high cholesterol (aOR = 1.64, 95%CI: 1.28-2.10) were significant risk factors, while regular exercise practice was a significant protective factor (aOR = 0.12, 95%CI: 0.05-0.26) for stroke. Hypertension, diabetes mellitus, obesity, and high cholesterol are major risk factors for stroke in the Aseer region of southwest Saudi Arabia. The protective role of regular physical activity in reducing the risk of stroke is evident. The observed higher prevalence of potentially modifiable risk factors among stroke cases encourages an urgent need to develop and implement a national program to control these factors.

Clinical and epidemiological profile of cerebral venous thrombosis. A Multicenter retrospective study in Aseer Region Saudi Arabi.

OBJECTIVE: To assess the epidemiological pattern and correlates with the clinical outcome of Cerebral venous thrombosis (CVT) in Abha, Kingdom of Saudi Arabia. METHODS: A retrospective record_based cohort design was conducted including all patients admitted with diagnosis of CVT in 2 main tertiary hospitals in Aseer Region between 2015 to the end of 2018. The study hospitals were Aseer Central Hospital and Armed Forces Hospitals Southern Region. The data were collected by structured data sheets, including sociodemographic data. Assessment of known risk factors for CVT, clinical presentation, treatment received, and clinical outcome after treatment were extracted. RESULTS: The study included 119 patients with CVT, whose ages ranged from 15 to 97 years, with a mean age of 35.5-/+14.1 years. Majority of the patients were females (81.5%). Headache was the most presenting (82.4%) symptom, followed by vomiting (30.3%) and a decreased level of consciousness. Thirty_three cases (27.7%) had complications, and recanalization was recorded among 92 cases (94.8%) based on follow up vascular imaging. CONCLUSION: The study revealed that most of the cases of CVT had favorable clinical outcome and recanalization, especially those who had a shorter duration untildiagnosis. Young females were the most affected group.

Awareness of stroke among patients attending primary healthcare services in Abha, Southwestern Saudi Arabia.

OBJECTIVE: To examine the awareness about major symptoms, risk factors, and response to stroke among the population in Abha, Southwestern Kingdom of Saudi Arabia. Improving stroke-related knowledge may advance stroke prevention and reduce pretreatment delay and disabilities. METHODS: We conducted a cross-sectional study among a representative sample of primary healthcare adult patients between January-May 2016 and used a validated Arabic questionnaire to evaluate the participants` awareness about stroke. RESULTS: The study involved 1472 adults. Only 63.6% and 43.7% of participants correctly recognized thrombosis and hemorrhage as types of stroke. Commonly identified risk factors were hypertension (55.8%), dyslipidemia (45.8%), and smoking (41.9%). Sudden severe headache (54.1%), dizziness (51.0%), and difficulty in speaking (44.3%) were the most frequently recognized symptoms. The most frequently reported correct responses to stroke were contacting a doctor (73.0%), going to the hospital (67.2%), and calling an ambulance (52.4%). Improper responses to stroke (ignoring the condition or self-prescription) were noted in 18.8% of participants. Logistic regression revealed that physicians, nurses, friends and relatives as a source of knowledge were significantly associated with a lower insufficient knowledge of stroke symptoms and risk factors. On the other hand, women, persons above 40 years old, and married persons were significantly more prone to have insufficient knowledge about a proper response to stroke. CONCLUSION: Our study revealed a notable deficit of knowledge about warning symptoms, risk factors, and proper response to stroke. Health education strategies to improve stroke awareness are required and could potentially prevent and improve the outcome of stroke.

In Hospital Stroke Mortality: Rates and Determinants in Southwestern Saudi Arabia.

Objectives: The present study analyzed in-hospital first-time stroke mortality in southwestern Saudi Arabia over one-year to assess the in-hospital stroke case fatality rate, mortality rate and explore the factors associated with in-hospital stroke mortality. Study Design: Hospital based follow-up study. Methods: First-time stroke patients admitted to all hospitals in Asser region over one-year period (January through December 2016) were included in the study. Data about personal characteristics, pre-stroke history and clinical criteria, on admission clinical criteria, in-hospital complications and survival status were collected. The last reported Aseer region population was used to calculate age and sex stroke mortality rate per 100,000 population/year. Hazard ratios (HR) and concomitant 95% confidence intervals (95% CI) were computed using multivariate Cox regression survival analysis. Kaplan-Meier curve survival analysis for stroke patients were plotted. Results: A total of 121 in-hospital deaths out of 1249 first-time stroke patients giving an overall case fatality rate (CFR) of 9.7%. Non-significant difference with gender and age were observed in CFR. Overall, in-hospital stroke mortality rate was 5.58 per 100,000/year. Males and elders showed a significantly higher mortality rates. Multivariable Cox regression analyses revealed pre-stroke smoking (HR = 2.36), pre-stroke hypertension (HR = 1.77), post-stroke disturbed consciousness (HR = 6.86), poor mobility (HR = 2.60) and developing pulmonary embolism (HR = 2.63) as significant predictors of in-hospital stroke mortality. Conclusions: In Southwestern Saudi Arabia, the in-hospital stroke mortality rate is higher in men and increases with aging. The prognosis of acute stroke could be improved by smoking cessation, better control of hypertension and prevention of in hospital complication particularly pulmonary embolism.

Quality of life assessment among multiple sclerosis patients in Saudi Arabia.

OBJECTIVE: To determine the quality of life (QoL) among multiple sclerosis (MS) patients in Kingdom of Saudi Arabia. METHODS: A cross-sectional study was carried out to assess the QoL of MS patients during the period from November 2016 to May 2017. Patients were recruited from tertiary hospitals in 5 regions in the kingdom. Clinical and demographic data were collected and information on patients` health status using the self-report SF-36 questionnaire to assess QoL. The Patient Determined Disease Steps (PDDS) was used to measure disability. Data were analyzed using descriptive statistics, the Mann-Whitney test, the Kruskal Wallis test and Spearman`s coefficient correlation. RESULTS: From the 598 MS patients studied, 384 (64.2%) were female. The mean score for males was higher than females in all SF-36 QoL subscales. The mean age was 32.4 years (SD=8.4). The mean duration of illness was 6.5 years. Patients had the lowest scores in role motioning/emotional scale (mean=42.6, SD=43.3). The PDDS was negatively correlated with all SF-36 QoL subscales. Self Report-36 QoL for MS patients differed significantly through demographic characteristics at a level of significance of 0.05. CONCLUSION: Multiple Sclerosis patients have a low QoL score and need more comprehensive management by their treating physicians. Further development of the registration will provide access to the entire population of MS patients and help comprehensively analyze the factors that affect the quality of their lives.

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.

Pharmacogenetics of CYP2C19 genetic polymorphism on clopidogrel response in patients with ischemic stroke from Saudi Arabia.

OBJECTIVE: To elucidate the degree of genetic polymorphisms CYP2C19 (CYP2C19*2, CYP2C19*3) of key drug metabolizing enzymes on the antiplatelet effect of clopidogrel response in patients with acute ischemic stroke from Saudi Arabia. METHODS: A case-control study carried out at Neurology Clinics at Asser Central Hospital, Abha, Kingdom of Saudi Arabia from October 2015 to January 2016 and included 25 stroke patients responding to clopidogrel therapy and 25 stroke patients non responding to clopidogrel monotherapy. After obtaining their informed consent, the blood samples were collected and genotyped for CYP2C19 polymorphisms by the polymerase chain reaction-restriction fragment length polymorphisms (PCR-RFLP Method). Allele frequencies were derived from genotypic data and platelet aggregation was measured using multiple electrode aggregometry on the multiplate analyser. Chi Square tests, p-values, odds ratio (OR) and corresponding confidence intervals were calculated for each polymorphism. RESULTS: The CYP2C19*2 (681G>A) and CYP2C19*3 (636 G>A) polymorphism were seen to be in Hardy-Weinberg equilibrium and showed significant allelic and genotypic association between responders and non-responders to clopidogrel (p<0.01). The CYP2C19*2: allelic chi-square=21.49, p=0.000036, OR=5.52 (2.42-12.83); Genotypic Chi-square=10.27, p=0.001, OR=7.88 (1.78-9.73). The CYP2C19*3: Allelic chi-square=11.66, p=0.0006, OR=3.45 (1.57-7.70); genotypic chi-square=4.37, p=0.036, OR=3.69 (0.90-5.81). The variant allele (homozygous and homozygous Mutant) showed significant influence on platelet inhibition and the antiplatelet effect of clopidogrel in ischemic stroke. CONCLUSION: Our findings provide certain evidence on the genetic effect of CYP2C19 on clopidogrel responsiveness in stroke patients from Saudi Arabia.

Intraparenchymal hemorrhage in a patient with osteogenesis imperfecta and plasminogen activator inhibitor-1 deficiency.

BACKGROUND: Osteogenesis imperfecta is associated with susceptibility to connective tissue damage, including intracranial but usually extra-axial hemorrhage. Plasminogen activator inhibitor-1 deficiency is a rare fibrinolytic cause of systemic bleeding diathesis. OBJECTIVE: To describe a case of a brainstem intraparenchymal hemorrhage associated with connective tissue and coagulation disorders. DESIGN: Case report. SETTING: Academic medical center. PATIENT: A 36-year-old woman with a history of osteogenesis imperfecta presented to the emergency department after an argument, during which she developed left ear pain and right eye esotropia followed by quadriparesis and somnolence. Neuroimaging showed a tegmental mesencephalic hemorrhage. MAIN OUTCOME MEASURES: Results of computerized tomography, magnetic resonance angiography, and parenchymal imaging; and serum hematologic markers. RESULTS: No underlying vascular abnormality or mass lesion was found. Among coagulopathic serum markers, only plasminogen activator inhibitor-1 activity level was abnormally low. CONCLUSION: Intraparenchymal hemorrhage may occur in the setting of a fibrinolytic inhibitory deficiency and osteogenesis imperfecta.