BACKGROUND:Comorbid conditions in epileptic patients depend on many factors like etiology, type of epileptic syndromes, social and environmental factors, which may differ from one region to another, which encourages us to do this study in Sudan, which is one of the low-income countries. Limited information is available regarding this in our region. METHODS:This is a hospital-based, prospective, descriptive, and cross-sectional study aimed at determining the common medical, neurological, psychological, and cognitive comorbidities. Data were obtained by interviewing 115 epileptic patients attending the outpatient clinic of the Academic Charity Teaching Hospital and the National Center for Neurological Science using a questionnaire from November 2019 to March 2020. RESULTS:Out of 115 patients, 52.2% (60/115) were females. The duration of epilepsy ranged from 1 year to 37 years. A high rate of unemployment (72.2%) and a low level of education (36.5%) were observed among epileptic patients in Sudan. The number of comorbidities ranged from one (58.3%) to four (0.9%). Neurological comorbidities (67%) were the commonest, followed by medical (32.2%), psychological (26.1%), and lastly cognitive comorbidities (13%). The most prevalent comorbidities were migraine (33.7%), hypertension (27%), depression (50%), and impaired memory (13%). CONCLUSION:This study sheds light on important prognostic factors in epileptic patients, which have not been previously analyzed in other research, particularly in Sudan. It introduces a new perspective on the condition, paving the way for further contributions in future studies.

A growing trend of using vitamins has been documented, yet prescription pattern and reasons for use were not studied. The vitaminsindustry claims benefit in treating several neurological disorders in the absence of supportive evidence. The aim of this study was to explore the prescription pattern among patients attending neurology clinic.

Thursday, April 30April 14, 2020Free AccessCircadian Rhythm Pattern Of Stroke: Study From Sudan. (4237)Tahir Obeid, Maisa Elfadul, and Noon HakimAuthors Info & AffiliationsApril 14, 2020 issue94 (15_supplement)https://doi.org/10.1212/WNL.94.15_supplement.4237 Letters to the Editor

The American Academy & Neurology (A. A. N.) and American Epilepsy Society (A. E. S.) posted an evidence-based guideline for management of first unprovoked seizures which addresses the risk or recurrence, the effect of AED on short and long-term prognoses and the risk of adverse events of AED prescribed.

Juvenile myoclonic epilepsy is the commonest form of idiopathic epilepsy which is usually misdiagnosed. Myoclonic morning jerking is the hallmark of the syndrome with generalized tonic clonic convulsion occurring in most, but absences are less frequent. The author describes his published experience on this syndrome which includes: clinical, EEG findings, some of genetic aspects and factors that lead to diagnostic errors. The current literature on the syndrome and some highlights on progressive myoclonic epilepsy, which is one of the commonest differential diagnoses, are also presented.

Submitted by: Mohamed A. Gornas, MD, Ayman A. El-Mesallamy, MD, Tahir H. Obeid, FRCP, FAAN, Anas E. Babiker, CSCST Cardiology, MSc Interv. Cardiology. From the Department of Neurology (Gornas, Obeid), the Department of Radiology (El-Mesallamy), and the Department of Cardiology (Babiker), Alzaytouna Specialist Hospital, Khartoum, Sudan. Address correspondence to: Prof. Tahir H. Obeid, University of Medical Sciences and Technology, PO Box 12810, Khartoum, Sudan. Fax. +249 183224799. E-mail: obeidth7@gmail.com

Transforaminal cervical epidural steroid injection (TFCESI) is a common non-surgical adjunct in the management of patients with cervical radiculopathy. It has gained popularity over the interlaminar approach because of its direct delivery of the steroid into the site of pathology. These procedures require fluoroscopic guidance in addition to digital subtraction angiography (DSA) as they provide direct visualization of the site of treatment. Several complications have been attributed to these injections including increased pain at injection site, increased radicular pain, lightheadedness, increased spine pain, non-specific headache, and nausea. However, numerous reports have described devastating complications related to these injections.1,2 We report a transient neurologic sequelae in a patient that underwent a cervical epidural injection without fluoroscopic guidance. A 38-year-old Sudanese female underwent a TFCESI for cervical C5 radiculopathy of the right upper limb in a private hospital in Khartoum, Sudan. She was seen in our hospital 2 weeks prior to the procedure for radicular pain without any associated neurological deficit. The procedure was not carried out under fluoroscopic guidance or DSA. No details of the procedure were obtained. On the day of the procedure, she developed right shoulder weakness with mild heaviness of the right lower limb. She presented to our facility 2 days later and had no improvement of her symptoms. Neurological examination revealed evidence of cervical myelopathy evident by paraparesis of the lower limbs with power grade 4 (MRC), the right being more affected than the left. Lab investigations including complete blood count, screening for connective tissue diseases, and CSF for oligoclonal bands were all normal. The brain MRI revealed no abnormality. However, the MRI of the cervical spine demonstrated an intramedullary plaque like-lesion of abnormal signal intensity corresponding to the C5-6 region (Figure 1). She was initially treated with steroids as the initial impression was of an underlying demyelinating disease. She showed complete recovery of her symptoms after 6 weeks follow-up, except for impaired sensations of the C5 dermatome of the right side and power of grade 4+. Figure 1 Sagittal T2 MRI of the cervical spine of a 38-year-old female who underwent an epidural steroid injection of the neck showing a right-sided intramedullary area of abnormal signal at the C5-6 level. Epidural steroid injections (ESI) are a widely used procedure for the management of low back and neck pain with and without radiculopathy.3 Patients are usually injected with corticosteroids into the epidural space, where they are believed to have an anti-inflammatory effect on the spinal nerve.3 Several trials show moderate benefit from these injections; however, there is still controversy concerning their long-term effect.4 In our case, the patient developed acute transient paraparesis of the limbs, more on the right side. She showed marked improvement in the following weeks. The cervical MRI revealed an abnormal signal intensity corresponding to the C5-6 region. This could be explained by the fact that the cord infarction was only partial with ischemia occurring to the small branches of the radicular arteries. The cause of ischemia could be due to direct injection of the drug into the radicular arteries as the procedure was carried out blindly or as a result of embolization caused by particulates from the steroid used. It is unlikely to be clinically isolated syndrome or multiple sclerosis in the absence of supportive evidence, and ischemia of the cord is the most likely explanation. Although TFCESI is considered safe, there are no trials supporting safety or efficacy.3 They are associated with rare, but devastating complications including paralysis, brainstem infarction, epidural lipomatosis, and epidural abscess.1,2 There is a significant risk of serious neurologic injury following TFCESI. The causes being either an embolic effect or intra-arterial injection of a steroid causing a distal infarct. A recent outbreak of fungal meningitis was reported due to the use of infected corticosteroids leading to 750 cases of fungal infection and 64 reported deaths.5 The incidence of these rare complications remains unknown, though these procedures under fluoroscopic guidance and DSA may reduce these complications. Both patients and practitioners alike should be aware of the serious risks associated with these injections. We emphasize that TFCESI should be carried out under fluoroscopic guidance with control enhancement with DSA.

Foster Kennedy syndrome (FKS) is a very rare neurological syndrome with a unique ophthalmological manifestation described in 1911 by Robert Foster Kennedy attributed to anterior fossa mass lesion and raised intracranial pressure (ICP) caused by the tumor's mass effect. Meningioma is the most common cause of the syndrome. Rarely vascular lesions and tuberculous meningitis had been reported as a cause of FKS. Here we present a case of Foster Kennedy-like syndrome, in which meningioma compressed one optic nerve and cerebral venous sinus thrombosis impair cerebral venous drainage inducing intracranial hypertension, and papilledema in the other eye. This case emphasis the importance of considering of CVST as underlying pathogenesis of raised ICP in absence of cerebral edema or obstructed hydrocephalus.

Purpose: Epilepsy has been linked to divine, demonic and supernatural powers throughout its long history.This study was conducted to explore if misconceptions such as possession by demons (Jinns) are still believed to be a cause of epilepsy among educated Saudis today.Method: This study was conducted among university-educated school teachers and undergraduate students. The findings are based on a structured questionnaire enquiring about familiarity with epilepsy, sources of knowledge, and depth of knowledge about specific aspects of epilepsy.Results: Responses from 398 participants were included in the analysis of the results. Most participants had witnessed epileptic seizures. 2/3 of the participants reported that they had learned about epilepsy from friends and relatives. 72(43.1%) members believed that epilepsy is a psychiatric disease. 62(40.3%) of the school teachers and 123 (50.4%) of the students in the study considered possession as a cause of epilepsy. The majority of the cohort believed medical treatment for the condition exists despite the fact that a significant number believed that faith healers and traditional medicine can be of help in the treatment of epilepsy.Conclusion: Jinn possession is still believed to be a cause of epilepsy in Saudi society, even among fairly well-educated people. This finding emphasizes the urgent need for public education campaigns at all levels of education. (C) 2012 British Epilepsy Association. Published by Elsevier Ltd. All rights reserved.

In January 2007, a 21-year-old woman presented to the emergency department with abdominal pain, fever, nausea, vomiting and diarrhoea for 6 hours. She had no other associated symptoms with unrevealing previous history. On examination she was ill-looking, conscious and oriented, with a temperature of 39.2°C, blood pressure 96/52 mmHg and pulse rate 140 beats per minute, and had clinical evidence of dehydration. Her abdomen was rigid, mainly in the right lower quadrant, with sluggish bowel sounds. The rest of the clinical examination was normal including the neurological examination. The results of blood tests were white blood cell count= 19 × 109/litre (normal range (NR) 4–11× 109/litre) with 91% neutrophils, sodium 138 mmol/litre (NR 135–145 mmol/litre), potassium 3.4 mmol/litre (NR 3.5–5 mmol/litre), serum glucose 7.1 mmol/litre (NR 4–6 mmol/litre). A chest radiograph was normal; the abdominal X-ray showed dilated bowel loops and no free gas under the diaphragm. The initial differential diagnosis was gastroenteritis vs acute appendicitis. The normal abdominal ultrasound and normal computed tomography (CT) scan made the diagnosis of appendicitis very unlikely. The patient was admitted as a case of gastroenteritis and improved on intravenous hydration, pain control, and intravenous ciprofloxacin 400 mg 12-hourly and metronidazole 500 mg 8-hourly. Twenty-nine hours after admission she complained of headache, became increasingly lethargic and febrile (39°C), and the abdomen was still rigid. Her level of consciousness deteriorated with Glasgow Coma Scale of 8/15 (eye opening 2/4, verbal response 2/5 and motor response 4/6) and nuchal rigidity was obvious at this stage. Formal neurological exam was not feasible because of the patient's condition, but she was moving all her limbs and had no obvious clinical evidence of lateralizing signs. Bacterial meningitis was suspected and treated with intravenous dexamethasone 6-hourly, ceftriaxone 2 g 12-hourly and vancomycin 1 g 12-hourly. An hour later, while awaiting a CT scan she developed tonic clonic seizures with fixed dilated pupils and was transferred to the intensive care unit where she was immediately intubated and ventilated. CT of the brain was normal (Figure 1). Lumbar puncture revealed a total cell count of 80 × 109/litre with 52% polymorphs and 48% mononuclear cells, protein concentration 8.3 g/litre (NR 0.1–0.4 g/litre), glucose concentration was <0.03 mmol/litre (NR <20 mg/dl), and Gram staining of CSF showed Gram-positive diplococci. Subsequently, CSF and blood cultures yielded Streptococcus pneumoniae sensitive to penicillin so she was given intravenous penicillin G 4 million units 4-hourly. Over 2 days she developed septic shock requiring inotropes, and remained in a deep coma. Magnetic resonance imaging of the brain showed diffuse leptomeningeal enhancement and multiple infarctions in both cerebral hemispheres, the brainstem and cerebellum (Figure 2). Unfortunately the patient never regained consciousness and 5 days after presentation she died despite all supportive measures.

Orbital myositis is a rare non-granulomatous inflammatory process within the orbit. Grave's disease and lymphoproliferative disorders are considered the most common cause of orbital myositis. The idiopathic form should be considered after exclusion of known causes or associations. Isolated orbital myositis is a very rare form of this disease. We report a case of an isolated lateral rectus myositis to draw the attention of physicians to this condition, as prompt treatment in our patient resulted in complete recovery.

OBJECTIVETo evaluate the clinical characteristics and etiology of epilepsy at age 60 years and above in the Western Region of Saudi Arabia (KSA), as epilepsy is now considered to be the third most frequent neurological problem in the elderly population.METHODSWe retrospectively reviewed the medical records of patients 60 years and above at King Khalid National Guard Hospital, Jeddah, KSA between 1999 and 2007 with new onset of seizures and diagnosed as suffering from epilepsy. We excluded patients 60 and above with provoked seizures.RESULTSSeventy-five patients of late onset epilepsy were studied. Partial seizure (focal) was found in 40 patients (53.3%); generalized tonic clonic seizures in 18 patients (24%); unclassified seizure in 13 patients (17.5%); and status epilepticus in 4 patients (5.3%). Stroke was the underlying etiology in 52 patients (69.3%); brain tumor was found in 8 patients (10.7%), trauma in 3 patients (4%), and infection in 3 patients (4%). None of the patients had a family history of epilepsy. No cause (idiopathic) was found in 9 (12%) patients.CONCLUSIONThe most common type of epilepsy at age 60 and above in our study is symptomatic epilepsy with stroke as the leading cause. Modifying risk factors for stroke such as: hypertension, diabetes mellitus, and high cholesterol may reduce the incidence of epilepsy in this age group.

Stigma is considered to be one of the most important factors that have a negative influence on people with epilepsy (PWE) and their families. It is a global issue commonly encountered in PWE in all cultures. Stigma may have deleterious effects on the patient's life, more than epilepsy itself. It is the duty of all health professionals to try and improve the quality of life of PWE beyond seizures control, and one of the important ways to do so is by fighting stigma. Many different health professionals including physicians, surgeons, social workers, psychologists, psychiatrists, and nurses deal with PWE, and hence stigma in PWE can be encountered and dealt with by many diverse specialties. Unfortunately, this issue is addressed primarily in specialized journals like Epilepsia, Epilepsy and Behavior, Seizure, and Social Science Medicine. Professionals interested mainly in epileptology or social sciences read such journals, and we feel that this issue should be addressed in a journal targeting readers of different specialties and interests.

OBJECTIVE:To describe the clinical features of 5 patients with rare atypical presentation of idiopathic intracranial hypertension (IIH), and propose the possible mechanism of this atypical presentation. METHODS:We carried out a retrospective study of 5 patients admitted at King Khalid National Guard Hospital, Jeddah, Kingdom of Saudi Arabia with IIH during the period from January 2001 to December 2005. All were females with their age ranges from 24 to 40 years. The clinical presentations, and the laboratory and imaging studies were analyzed. The opening pressures of the lumbar puncture tests were documented. RESULTS:All patients were presented with headache. One had typical pain of trigeminal neuralgia, and one with neck pain and radiculopathy. Facial diplegia was present in one patient, and 2 patients had bilateral 6th cranial neuropathy. Papilledema was present in all patients except in one patient. Imaging study was normal in all patients, and they had a very high opening pressure during lumbar puncture, except in one patient. All patients achieved full recovery with medical therapy in 6 to 12 weeks with no relapse during the mean follow up of 2 years. CONCLUSION:Atypical findings in IIH are rare and require a high index of suspicion for early diagnosis.