Stroke is the second most common cause of morbidity and death globally, and even with great advancements in prevention and treatment techniques, the burden is still high worldwide1. Stroke related mortality and morbidity is particularly high in countries with low and moderate incomes(LMIC). In 2016, number of death reported from stroke was very high (56%) in countries with low and moderate incomes compared with high-income countries (HICs) where it was only 29% 2.True prevalence of stroke in Pakistan is not exactly known because of lack of epidemiological studies.3 Integrated population and health survey from Khyber Pakhtunkhwa determined the estimated stroke prevalence of 1.2% in KP province of Pakistan4. In Pakistan, risk factors of stroke in Pakistan are enormous. According to a cross-sectional study conducted at a community health center, 39% of adults over the age of 18 have a history of active smoking, hypertension, or dyslipidemia. The same study found that 42% of the individuals had a positive family history of ischemic heart disease, 24% were obese, 19% had hypertension, and 15% had diabetes mellitus.5. Majority of patients with stroke first consult general practitioner in Pakistan. Existing evidence-based guidelines for managing acute ischemic strokes are applicable in those areas where CT scan facility is available and can be applied in many areas of Pakistan with minimal level of resource availability and where District Hospitals lack the facility of neuroimaging. These guidelines will focus on acute ischemic stroke and its secondary prevention.

BACKGROUND AND AIM:Epilepsy stands out as one of the most prevalent neurological conditions. Brivaracetam (BRV) is a noteworthy antiseizure medication (ASM) distinguished by its pronounced and selective interaction with the synaptic vesicle protein 2A (SV2A) within the brain. Prior investigations, including regulatory trials, post-marketing assessments, and comparative meta-analyses, have consistently underscored BRV's equivalency in efficacy and superior tolerability when pitted against other antiseizure drugs. This study aimed to evaluate the effectiveness, safety, and acceptability of BRV in treating epileptic patients in the Pakistani population.METHODS:This prospective observational study, conducted in Pakistan from February to December 2022, employed a non-probability consecutive sampling technique. This study included 368 adult patients diagnosed with epilepsy, with a focus on those aged 18 and above experiencing focal seizures. Demographic data, clinical history, seizure types, and epilepsy profiles were recorded. Patients were administered BRV (Brivera; manufactured by Helix Pharma Pvt Ltd., Sindh, Pakistan) monotherapy therapy under physician guidance and followed up for three months. The study assessed changes in seizure frequency, side effects, and drug resistance at baseline, 14th day, and 90th day. Safety aspects were monitored, including documenting any adverse effects associated with BRV therapy.RESULTS:A total of 368 epileptic patients were included in this study, of which 287 (61.3%) were males and 181 (38.7%) were females. The mean age was 32.91±17.11 years. The mean number of seizures at the baseline visit was 5.74±6.21, at 14 days was 2.89±3.84 and at 90 days was 1.73±5.01 (p<0.001). Overall, a more than 50% reduction in seizure episodes was achieved in 178 (56.3%) patients at day 90, and less than 50% reduction in seizure episodes was achieved by 95 (26.8%) patients on Day 14, with a highly significant association between them (p<0.001). Among 316 patients, only 41 (4.4%) of all BRV-treated patients experienced adverse events; Of these 41 patients, 17 (41.7%) reported dizziness and 14(34.2%) reported behavioral issues.CONCLUSIONS:Epileptic patients receiving BRV demonstrated a substantial reduction of greater than 50% seizure episodes at the end of follow-up visits. Moreover, BRV exhibited fewer adverse effects in individuals with epilepsy.

Background and Aim: Stroke patients are most commonly susceptible to pulmonary infection that adversely affects the duration of hospitalization and clinical outcomes. Stroke affecting the respiratory system and causing neurological damage contributed to higher morbidity and mortality rate due to complications such as stroke-associated pneumonia (SAP). Early identification of high risk stroke patients and their management are imperative to reduce the prevalence of stroke-associated pneumonia. The present study aim was to determine the prevalence of stroke-associated pneumonia in stroke patients. Methodology: This cross-sectional descriptive case series was carried out on 226 stroke patients in the Department of Neurology, Fauji Foundation Hospital, Rawalpindi from January 2020 to December 2021. Stroke patients aged 30 to 70 years of either gender diagnosed with stroke were enrolled. Cough, fever and non-homogenous opacities observed on chest X-rays were used for the diagnosis of stroke. Patients with a history of pneumonia were excluded. Detailed history and complete examination was obtained for stroke diagnosis followed up for 1 month. SPSS version 25 was used for data analysis. Results: Of the total 226 stroke patients, there were 118 (52.2%) males and 108 (47.8%) females. The overall mean age was 48.62±8.45 years. Age-wise distribution of all patients were as follows; 72 (31.9%) 30-40 years, 106 (46.8%) 41-50 years, 32 (14.2%) 51-60 years, and 16 (7.1%) 61-70 years. The prevalence of stroke-associated pneumonia was 46 (20.4%). The incidence of diabetes mellitus, hypertension, ischemic heart disease, atrial fibrillation, congestive cardiac failure, and thrombophilia state was 48 (21.2%), 36 (15.9%), 28 (12.4%), 19 (8.4%), 14 (6.2%), and 8 (3.5%) respectively. Diabetes mellitus patients were more susceptible to stroke-associated pneumonia followed by hypertension and cardiac diseases. The incidence of stroke-associated pneumonia was 33 (14.6%) among patients having 6 to 12 hours stroke length against 13 (5.8%) with shorter duration. Conclusion: The present study found that the prevalence of stroke-associated pneumonia was 20.4% among stroke patients. Diabetes, hypertension, cardiac diseases, atrial fibrillation among stroke patients are the different risk factors that develop stroke-associated pneumonia. Early identification and better management could prevent the stroke-associated pneumonia in stroke patients. Keywords: Prevalence, Stroke-associated pneumonia, Stroke

Objective: The purpose of this study is to determine the frequency of vitamin cobalamin deficiency in macrocystic anemia cases reporting at tertiary care Hospital. Study Design: Cross-sectional Place and Duration: In Medicine department of DHQ Teaching Hospital, Sargodha and DHQ Hospital, Dera Ismail Khan for the duration of six months from August 2021 to January 2022. Methods: Total 210 cases of macrocytic anemia of both genders with ages 18-62 years were presented. Age, sex, and body mass index were among the specific demographics of the enrolled cases that were documented after receiving informed written consent. Ante-cubital fossa blood was sampled for 5 mL. To estimate the amount of vitamin cobalamin using an ELISA test kit, samples were centrifuged and sera were collected. SPSS 24.0 was used to analyze all data. Results: Among 210 cases, 130 (61.9%) were males and 80 (38.1%) females in this study. 70 (33.3%) cases had ages 18-35 years, 90 (42.9%) had ages 36-50 years and 50 (23.9%) had ages >50 years. Mean BMI of the presented cases was 24.66±14.49 kg/m2. We found that 180 (85.7%) patients had deficiency of cobalamin and 30 (14.3%) cases had normal cobalamin. Among 180 cases of cobalamin deficiency, 70 (38.9%) patients were severe, border line was found in 45 (25%) cases and deficient cases were 65 (36.1%). Conclusion: We concluded in this study that patients with macrocystic anemia had higher number of vitamin cobalamin deficiency found in 85.7% cases. Majority of the patients were deficient and had severe deficiency of cobalmin. Keywords: Vitamin Cobalamin, Macrocystic Anemia, Severe Deficiency

Aneurysmal subarachnoid hemorrhage is one of the most commonly known life-threating disease. Many neurological outcomes are associated with SAH. The poor outcomes are associated with the hyperglycemia in the aneurysmal subarachnoid hemorrhage patients. The major risk factor associated with the aneurysmal subarachnoid hemorrhage is hyperglycemia. Objective: The purpose of this research work was to get in-depth understanding of the effect of glycemic control on changes in the outcomes associated aneurysmal subarachnoid hemorrhage. Study design: It is a prospective study with the statistical approach, conducted at Department of Neurology, Fauji Foundation Hospital, Rawalpindi. Methods: The 365 patients visited the neurology department of our institute were included in the study. The duration of this study was March 2020 March 2022. The 56 ± 14 years was the mean age of the patients included in this study. The 106 (29%) out of 365 were male candidates. The half of the patients were treated with the aggressive hyperglycemic management AHM protocol, while other half were treated with the standard glycemic management SGM protocols. The patients was labelled with good glycemic outcome if the mean glucose burden is less than 1.1, and labelled as poor outcome if mean glucose burden is greater than 1.1. The outcomes of the AHM and SGM group were compared. Different logistic regression models were used to quantify the poor outcome effects. Results: The result depicted that the patients treated with the AHM protocols showed lower poor outcomes (28%) as compared to the other treated with SGM. The values remain insignificant after correction of temporal trends. The incidence of the poor outcome can be reduced by the good glycemic control. The clinical vasospasm rates remain same before or after the implementation of AHM controls. Conclusion: The poor outcomes associated with the SAH can be reduced by good glycemic control of the patients. The study depicted the not only the blood glucose level will remain in the range but also better neurological health of the patients’ will be promoted by an effective use of aggressive glucose management on the patients suffering from SAH. Keywords: Aneurysmal subarachnoid hemorrhage, AHM glycemic control, Hyperglycemic outcomes, Vasospasm, logistic regression models.

Background and Aim: Stroke is defined as the sudden onset of neurological deficits caused by vascular supply disruption to brain-specific region, contributing as a major factor for mortality and morbidity worldwide. Globally, approximately two-thirds cases of stroke are caused by hypertension as a major risk factor. The purpose of the current study was to determine the prevalence of stroke patients with newly diagnosed hypertension admitted to tertiary care hospital. Materials and Methods: This cross-sectional study was carried out on 205 stroke patients admitted to the Department of General Medicine, Benazir Bhutto Hospital and Holy Family Hospital, Rawalpindi from April 2021 to March 2022. Prior to study conduction, ethical approval was taken from the institute research and ethical committee. Written informed consent was obtained from each individual. All the participants underwent physical examination after using antihypertensive medication besides detailed history. Blood pressure was measured using standard mercury Sphygmomanometer. Patient having blood pressure ≥ 140/90 mm Hg was considered as hypertensive after measurement with difference of 10 minutes time span. SPSS version 25 was used for data analysis. Results: The overall mean age was 59.6 ± 8.5 years. Of the total 205 stroke patients, there were 140 (68.3%) males and 65 (31.7%) females. Out of 205 patients, 60.5% were rural and 39.5% were urban. The literacy rate was 63.9%. Family history of smoking, diabetes mellitus (DM), and hypertension (HTN) among study population were found in 83 (40.5%), 76 (37.1%), and 71 (34.4%) respectively. Based on computed tomography presentations, the prevalence of newly diagnosed hypertension (HTN) was 122 (59.5%). Out of 122 newly diagnosed hypertensive stroke patients, the incidence of ischemic stroke and hemorrhagic was 67 (54.9%) and 55 (45.1%) respectively. The mean value of diastolic and systolic blood pressure was 86.32 ± 12.62 and 125.59 ± 19.97 mm of Hg respectively. Conclusion: The present study concluded that the prevalence of newly diagnosed hypertension was found higher among stroke cases. Early diagnosis of hypertension by proper screening and effective treatment can reduce the mortality and morbidity caused by stroke and hypertension. Keywords: Hemorrhage, HTN, Ischemia, Stroke.

Background and Aim: Chronic kidney disease (CKD) patients who have hypomagnesemia are at greater risk of mortality and progression. A limited amount of data is available on the prevalence of hypomagnesemia in kidney-related risk factors and chronic kidney disease patients. The present study aimed to assess the Proteinuria-associated hypomagnesemia in chronic renal disease patients: prevalence, risk factors, and effect. Patients and Method: This cross-sectional study was carried out on 128 chronic kidney disease patients in the Medicine Department of Shifa International Hospital, Rawalpindi from January 2022 to August 2022. Patients were categorized into two groups based on estimated glomerular filtration rate (eGFR) are as follows: group-I composed of Proteinuric and group-II non-proteinuric. Prior to study conduction, the ethical committee approved the protocol. Patients with prior history of ileostomy, malignancy, chronic diarrhea, colostomy, and using magnesium based medications were excluded. Detailed history, physical examination, and investigations such as serum total magnesium level (mg/dl), serum sodium level (mg/dl), serum creatinine (mg/dl), and total cholesterol and triglycerides (mg/dl) were recorded. Hypomagnesemia was defined as a serum magnesium level < 1.8 mg/dL. Results: Of the total 128 CKD patients, there were 66 (51.6%) male and 62 (48.4%) females. Group I and II had 64 patients each. The overall mean age of group-I and group-II was 48.82±12.52 and 48.21±10.64 years respectively. The prevalence of hypomagnesemia (<1.8 mg/dL) in the proteinuric group was 20 (31.3%). Diabetic patients are more susceptible to hypomagnesemia. The incidence of diabetic, hypertensive, and both diabetic and hypertensive was 12 (60%), 3 (15%), and 5 (25%) respectively among 20 hypomagnesemia. Hypomagnesemia patients had higher CRP (46 mg/L), UACR (2064 mg/g), lower serum potassium (56.4%), lower mean hemoglobin levels (10.2 g/dL), and lower serum sodium (34.9%) as compared to normomagnesemic patients 12 mg/L, 810 mg/g, 24.8%, 11.25 g/dL, and 8.6% respectively. Conclusion: The present study found that there is an independent association between hypomagnesemia and proteinuria in non-dialysis CKD patients. Anemia and hyperparathyroidism are risk factors for inflammation and anemia in CKD patients pre-dialysis. Dietary magnesium supplementation and hypomagnesemia correction may retard proteinuria and CKD progression in CKD patients. Keywords: Chronic kidney disease, Proteinuria-associated hypomagnesemia, Risk factors

Background and Aim: Acute ischemic stroke patients mainly rely on cerebral blood flow (CBF) to sustain penumbral tissue perfusion in turn depend on arterial blood pressure in affected cerebral autoregulation. Head positioning either sitting-up or lying flat allows gravitational force to enhance leptomeningeal circulation and collateral blood flow. The present study aimed to determine the role of head position in acute ischemic stroke patients. Methodology: This prospective observational study was conducted on 500 stroke patients in the Department of Neurology and Medical department of Fauji Foundation Hospital, Rawalpindi from January 2020 to December 2021. Patients with acute ischemic stroke receive care in either a lying flat on bed or sitting-up position with elevated head position at 30 to 45 degrees. The designated position was established shortly after hospital admission and was held for 24 hours. Outcomes such as pneumonia, aspiration pneumonia, and increased hospital stay, disability, and mortality were associated with flat head position and elevated head position. Modified Rankine scale (0-6) was used for assessing the degree of disability as a primary outcome in three months. Rankine scale higher score indicates the greater disability and maximum score 6 indicate mortality. Results: The average time from initiation of assigned position and onset of ischemic stroke symptoms was 14 hours (IQR 5-35). Patients in the sitting position group (93%, p<0.001) were more likely than the lying-flat group (82%, p<0.001) in maintaining their position for 24 hours. Based on a modified Rankine scale, both lying flat and sitting-up position groups had no significant differences in a proportional-odds model in terms of 90-days disability outcomes distribution. The mortality rate in lying flat and sitting-up position was 6.8% and 6.9% (p=0.79). Also, both groups had no significant differences in terms of severe outcomes including pneumonia. Conclusion: The present study found that disability outcomes in acute stroke patients were similar irrespective of their position either flat or sitting position with head elevated at 30 to 45 degree for 24 hours. The prevalence of AIS was 95.6%. Keywords: Head position, Acute ischemic stroke, Outcomes

Objective: The purpose of this study was to determine the factors that increase a patient's chances of death from COVID-19. Study Design: Retrospective study Place and Duration: Medicine department of Benazir Bhutto Hospital (BBH) and Holy Family Hospital (HFH), Rawalpindi during the period from November 2021 to April 2022. Methods: Total 142 patients of both genders of confirmed coronavirus disease were included. After receiving informed written consent from each participant, detailed demographic information was obtained. This information included the participant's age, gender, body mass index, and list of co-morbidities. Frequency of mortality and factors that increase a patient's chances of death were recorded. SPSS 24.0 was used to analyze all data. Results: We found that 87 (61.3%) cases were males and 55 (38.7%) patients were females. Majority of the patients 53 (37.3%) had age >45 years. 65 (45.8%) patients were smokers. Severity of disease was found in 76 (53.5%) cases. There were 95 (66.9%) patients had hypertension, diabetes mellitus found in 75 (52.8%) cases, cardiovascular disease in 48 (33.8%) cases, pulmonary disease in 40 (28.2%) cases and chronic kidney disease in 34 (23.9%) cases. Among 142 patients, 27 (19.01%) patients were died. Among non-survivals, kidney dysfunction was the most common reason found in 17 cases, followed by cardiovascular and diabetes mellitus. Conclusion: We came to the conclusion that clinical risk factors for a fatal consequences associated with coronavirus include chronic chronic conditions, complications, and demographic variables. These risk factors include acute renal injury, diabetes, hypertension, heart disease, male sex, older age, current smoker, and obesity. The findings might be used to future study on the disease as well as its control and prevention. Keywords: Coronavirus, Comorbidities, Mortality, Severity

Background: Headache is characterized by the painful and disabling disorder of the central nervous system CNS. The most common symptoms experienced by the person suffering from the headache are pain in head, neck and face. Objective: This study aims to assess the prevalence of primary types of headaches, knowledge of their types, their impact on the productivity and work efficiency of the healthcare professionals in a tertiary care health institution. Study design: This cross sectional study was conducted at Neurology Department, Fauji Foundation Hospital, Rawalpindi for duration of 1 year from December 2020 to December 2021. Material and Methods: An estimated number of 1000 adult healthcare professionals aged above 18 were included in this research. Simple convenience sampling technique was used for sampling. According to the Inclusion criteria the individual should be an adult healthcare professional. According to the exclusion criteria Individuals below the age of 18, not a part of the tertiary care hospital were excluded. Data was collected through using a structured questionnaire comprised of three sections. Results: To proceed with this study, 1000 healthcare professionals were selected for this survey. The participants submitted questionnaires. The respondents include 440 doctors and 560 nurses. Their age was from 20 to 60 years. The ages of the doctors were above thirty and the age of the nurses was above 25 years. Among them, 6 participants were identified with two basic types of primary headache, and 36 were suffering from other kinds of issues like CDH, neuralgia, and unknown types of headache. Only two nurses were suffering from MOH. Sleep patterns also play role in headache disorders. Conclusion: This study predicted that the probability of primary headache issues is greater in medical care professionals as compared to the general public. Both nurses and doctors are more prevalent to headache issues. Multiple factors are linked with the prevalence of headache issues i.e. gender, age, sleep patterns, and night shifts. These factors may lead to migraine and TTH. For the welfare of health of medical professionals, there is a need for awareness related to different health issues and all the factors causing headache disorders. Keywords: Headache disorders, neuralgia, Sleep patterns, and primary headache.

Background and Purpose: Coronavirus disease 2019 (CO­VID-19) has an increased propensity for systemic hypercoagulability and thromboembolism. An association with cerebrovascular diseases, especially cerebral venous thrombosis (CVT), has been reported among these patients. The objective of the present study was to identify risk factors for CVT as well as its presentation and outcome in COVID-19 patients. Methods: This is a multicenter and multinational observational study. Ten centers in 4 countries (Pakistan, Egypt, Singapore, and the United Arab Emirates) participated in this study. The study included patients (aged >18 years) with symptomatic CVT and recent COVID-19 infection. Results: Twenty patients (70% men) were included. Their mean age was 42.4 years, with a male-to-female ratio of 2.3:1. Headache (85%) and seizures (65%) were the common presenting symptoms, with a mean admission Glasgow Coma Scale (GCS) score of 13. CVT was the presenting feature in 13 cases (65%), while 7 patients (35%) developed CVT while being treated for COVID-19 infection. Respiratory symptoms were absent in 45% of the patients. The most common imaging finding was infarction (65%), followed by hemorrhage (20%). The superior sagittal sinus (65%) was the most common site of thrombosis. Acute inflammatory markers were raised, including elevated serum D-dimer (87.5%), erythrocyte sedimentation rate (69%), and C-reactive protein (47%) levels. Homocysteine was elevated in half of the tested cases. The mortality rate was 20% (4 patients). A good functional outcome was seen in the surviving patients, with a mean modified Rankin Scale score at discharge of 1.3. Nine patients (45%) had a modified Rankin Scale score of 0–1 at discharge. Conclusion: COVID-19-related CVT is more common among males at older ages when compared to previously reported non-COVID-19-related CVT cases. CVT should be suspected in COVID-19 patients presenting with headache or seizures. Mortality is high, but functional neurological outcome is good among survivors.

Background and Aim: Depression is associated with hypothyroidism. Somatostatin and serotonin are known to influence the hypothalamus-pituitary-thyroid axis, resulting in depression in hypothyroid patients. Neurological symptoms such as behavioral disturbances, anxiety, and depression can be associated with thyroid hormone deficiency. The present study aimed to evaluate the depression illness in primary hypothyroidism patients presented to endocrine clinics. Patients and Methods: This descriptive cross-sectional study was carried out on 124 primary hypothyroidism patients presented to the endocrine clinic of Hayatabad Medical Complex, Peshawar during the period from February 2022 to January 2023. Patients of either gender aged >17 years and diagnosed with hypothyroidism based on T3 or T4 lower level (<1.71 pg/mL or T4 <0.7 ng/dL), higher TSH level (>4.94 uIU/mL), and TSH lower levels (<0.35 uIU/mL) were enrolled. Besides obtaining sociodemographic information, status of thyroid function status, and depression associated factors were noted. Patient Health Questionnaire (PHQ-9) was used for screening the depression among hypothyroidism patients. Moreover, the laboratory results were obtained from the patient's medical records. SPSS version 27 was used for descriptive statistics. Results: The overall mean age was 40.16 ± 10.52 years with an age range from 18 to 70 years. There were 115 (92.7%) females and 9 (6.3%) male. About 8.2% of patients were illiterate. There were 86.7% (n=85) married. The prevalence of varying degree depression illness was 36.7% (n=36). Fatigue, hair loss, memory problem, and gland enlargement were the most prevalent depression associated symptoms. The incidence of normal, low, and elevated TSH levels were 56.1% (n=55), 7 (7.1%), and 36.8% (n=36) respectively. The most common symptoms of hypothyroidism were fatigue and reproductive issues, followed by hair loss, weight gain, thyroid gland enlargement, and cognitive difficulties. The incidence of mild, moderate, moderately severe, and severe depression was 39.8% (n=39), 12.2% (n=12), 20.4% (n=20), and 5.1% (n=5) respectively. Among hypothyroid patients, the prevalence of most stressful issues such as family, social, emotional issues, and stressful life conditions were 29 (29.6%), 22 (22.4%), 18 (18.4%), and 62 (63.3%) respectively. Conclusion: The present study concluded that hypothyroid patients are more likely to suffer from depression and outlined the symptoms most commonly associated with depression. The incidence of depression in hypothyroid patients was 36.7%. Pregnancy, economic problems, educational problems, emotional problems, and social problems were the most common stressful situations among hypothyroid people. Patients with hypothyroidism are inclined to depression regardless of their TSH level or other risk factors such as socioeconomic problems. Keywords: Depression, Primary hypothyroidism, Treatment-resistance depression, Patient Health Questionnaire-9

Objective: We aimed to assess the response and impact of covid 19 pandemic at tertiary care centers in Pakistan especially pertaining to neurological care, facilities and training. Methods: A pre-tested survey form was sent to 40 neurology tertiary care centers in all the provinces in the country in the first week of July 2020. 33 filled forms were received, out of which 18 were public (government) and 15 were private hospitals. Results: Estimated 1300 HCW (faculty, medical officers, trainees and nurses) work at these 33 participating centers. There were 17 deaths among HCW (1.3%) at ten centers. Sufficient personal protective equipment (PPE) were provided to 158 HCW (12%). 129 (10%)HCW tested positive for COVID 19 at 31 centers including trainees/ medical officers (39), consultants (29) and nursing and other staff (61). Due to low neurology admissions, 23/33 hospitals (70%) posted neurology trainees in COVID 19 units to contribute to covid care. Less than 50% hospitals did covid screening PCR before admission to neurology wards. Only 10% hospitals provide training and regular update to HCW. Neurology tele-health services were started for clinically stable patients at 15 (45%) centers. Only 60% neurology training programs were able to start online training. Ongoing research studies and trials focusing neurological manifestations of COVID-19 were done at 10 (30%) centers. Modification of facilities for COVID patients showed that 24(72%) hospitals strictly reduced the number of attendants accompanying patients. Only 10 (30%) centers had neurophysiological tests being conducted on COVID-19 patients. Mental health support services to HCW were provided at 12 (36%) centers. Conclusions: Among HCW 10% tested positive for covid and 1.3% died. Mental health support services offered for HCW were available in 36% institutions. Neurology training was substantially affected due to low admissions, limited ward rounds and limited availability of online training.

Background and methods Intravenous thrombolysis for acute ischemic stroke in the Middle-East and North African (MENA) countries is still confined to the main urban and university hospitals. This was a prospective observational study to examine outcomes of intravenous thrombolysis-treated stroke patients in the MENA region compared to the non-MENA stroke cohort in the SITS International Registry. Results Of 32,160 patients with ischemic stroke registered using the SITS intravenous thrombolysis protocol between June 2014 and May 2016, 500 (1.6%) were recruited in MENA. Compared to non-MENA (all p<0.001), median age in MENA was 55 versus 73 years, NIH Stroke Scale score 12 versus 9, onset-to-treatment time 138 versus 155min and door-to-needle time 54min versus 64min. Hypertension was the most reported risk factor, but lower in MENA (51.7 vs. 69.7%). Diabetes was more frequent in MENA (28.5 vs. 20.8%) as well as smoking (20.8 vs. 15.9%). Hyperlipidemia was less observed in MENA (17.6 vs. 29.3%). Functional independence (mRS 0-2) at seven days or discharge was similar (53% vs. 52% in non-MENA), with mortality slightly lower in MENA (2.3% vs. 4.8%). SICH rates by SITS-MOST definition were low (<1.4%) in both groups. Conclusions Intravenous thrombolysis patients in MENA were younger, had more severe strokes and more often diabetes. Although stroke severity was higher in MENA, short-term functional independency and mortality were not worse compared to non-MENA, which could partly be explained by younger age and shorter OTT in MENA. Decreasing the burden of stroke in this young population should be prioritized.

Background Locked-in syndrome, although a notoriously famous clinical entity, the rarity of the condition coupled with the variability of clinical features on acute presentation represents a potential diagnostic pitfall for the emergency physician. Case A previously healthy 25-year-old female was brought to our Emergency Department after being found unresponsive. On examination, she was conscious and alert with a Glasgow Coma Score of 9; on neurological examination, the patient was quadriplegic and unable to speak but was able to move her eyes and blink. Non-contrast brain computed tomography (CT) revealed a hyperdense basilar artery, and CT cerebral angiography confirmed basilar artery thrombosis. Conclusion This case highlights the need for a high index of suspicion to make a diagnosis of locked-in syndrome in the Emergency Department, especially in young patients with no apparent risk factors for an ischemic stroke. The hyperdense basilar artery sign is one of the earliest signs on non-contrast CT imaging and may be the only clue to guide further management in a patient with basilar artery occlusion.

Inflammatory bowel disease (IBD) is an idiopathic autoimmune disease.Extra intestinal manifestation of IBD has been reported to be 25 to 35%.There is a well-known risk of thrombosis in patients with IBD.It rarely involves cerebral vasculature in the form of arterial stroke or venous sinus thrombosis.This case is about 35 yrs old male who was a known case of ulcerative colitis for the last 10 years.He presented with history of severe thunderclap headache for the last few hours along with vomiting.He also had three episodes of seizure, generalized tonic clonic in nature.The examination does not show any focal asymmetry except mild drowsiness.His CT brain showed Focal cortical and subcortical area in the left posterior parietal region displaying multiple foci of hyper density with perifocal edema.CT venogram showed an intraluminal filling defect in the superior sagittal sinus suggestive of venous sinus thrombosis.Conclusion: Cerebral venous sinus thrombosis are considered as one of the rare but fatal complication of inflammatory bowel disease.It must be considered in all those with inflammatory bowel disease wherein absence of any other vascular risk factor patient presents with acute severe headache and focal or diffuse neurological symptoms including seizure.