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Objective: To assess the headache patterns among medical students of Umm Al-Qura College of Medicine, Makkah, Kingdom of Saudi Arabia. Medical students represent a vulnerable group for primary headache disorders, as they are exposed to various physical and psychological stressors., Methods: We carried an observational, cross-sectional study, and collected data during February, 2017 using electronic questionnaires. The international classification of headache disorders, third edition (ICHD-3) beta edition was used to classify headache into 10 types., Results: A total of 623 responses (82.2%) were received out of 758 participants. The one-year headache prevalence was 558 (89.6%). The most common diagnosis among both genders was frequent tension-type headache (TTH) (n=173, 31.0%), followed by probable infrequent TTH (n=114, 20.4%) and probable frequent TTH (n=63, 11.3%). The greatest proportions of students who reported an impact of their academic level were found among the chronic TTH, migraine without and with aura (n=2, 40.0%; n=14, 34.4%; n=11, 33.3%). Migraine without aura was more prevalent among females (n=29, 10.5%) than males (n=10, 3.5%). Self-medication was common (62.5%-100.0%). Simple analgesics (67.4%-80.0%), sleeping (54.3%-80.0%) and caffeine intake (28.3%-60.0%) were the top 3 therapies that were practiced., Conclusion: The prevalence of headache among Umm Al-Qura university (UQU), Makkah, Kingdom of Saudi Arabia`s medical students appears higher than the prevalence among the general population. This may have a significant impact on academic performance and necessitates special attention. We recommend further studies on interventions to reduce the prevalence and impact of this prevalent problem.

Cerebral venous sinus thrombosis (CVST) is a severe clinical condition that manifests with diverse symptoms that can be mild, taking the form of a headache, or can be life-threatening, with raised intracranial pressure and herniation. Despite systemic anticoagulation treatment, CVST still carries a mortality risk of approximately 10% because of the failure of venous recanalization by anticoagulants alone. This paper describes two cases with extensive CVST who presented with progressive neurological deterioration despite adequate systemic anticoagulation treatment. Both patients were successfully treated with endovascular clot removal using suction thrombectomy techniques with immediate recanalization of the sinuses and rapid radiographic improvement. The described therapy appears effective and safe; however, further studies are needed to validate the effectiveness of this treatment.

Objective: To describe our experience implementing decompressive hemicraniectomy (DH) for eligible patients with malignant middle cerebral artery (MCA) infarcts., Methods: We retrospectively collected data of malignant MCA infarction patients requiring DH at King Abdulaziz University Hospital & King Faisal Specialist Hospital & Research Center, Jeddah, Kingdom of Saudi Arabia between October 2010 and July 2015. Clinical outcome was assessed immediately postoperatively using Glasgow Coma Score (GCS), and at 12 months using the modified Rankin scale (mRS) and Barthel index. Survival was evaluated at thirty-days and one year after surgery., Results: Six out of 10 patients diagnosed with malignant MCA infarction underwent DH. Among the surgically treated patients (n=6), 4 were males (66%), and the median age was 22.5 years. The median time from admission to surgery was 35.5 hours. The median post-operative GCS was 6.5. Three patients (50%) died within 30 days of DH. In those who survived, the median mRS was 4.5 and BI was 7.5., Conclusion: Decompressive hemicraniectomy saves life and has the potential of improving survival functional outcome when done fast and in carefully selected patients. We call for national awareness of the management of such cases and early intervention.

Objective: To investigate the incidence of stroke among pilgrims and describe factors associated with presentation and management during Hajj. Physical stress, age and vascular risk factors render pilgrims at a high risk of stroke., Methods: This is a prospective registry of all acute stroke patients admitted to 6 hospitals during the 2015 Hajj season from 9 September to 4 November. Participating hospitals were King Abdullah Medical City (KAMC), Al-Noor, King Abdulaziz hospital, King Faisal hospital, Hira, and Mena general hospitals; all in Makkah city. Stroke diagnosis was confirmed by imaging. Clinical, demographic and outcome variables were collected., Results: The incidence of stroke during 2015 Hajj season is 8.9/100,000; 186 cases. The peak incidence was noted on the day after Arafat. Saudis represented 17.2% while 36% were females. Hemorrhagic stroke occurred in 35 patients (18.8%). The mean age was 60.8+/-12.9 years while the most common risk factors were hypertension (57.0%) and diabetes (40.9%). Only 5 patients received intravenous tissue plasminogen activator. The median length of hospital stay was 4 days. Twenty-one patients (11.3%) died during hospitalization. The only factor that approached significance in predicting mortality was hemorrhagic stroke (odds ratio of 1.62; 95% CI: 0.97 to 2.70; p=0.063)., Conclusion: Stroke is a major health burden during Hajj. Educational programs for pilgrims and healthcare workers together with protocol-driven care are expected to positively impact stroke care.

Background and Purpose: Within different brain regions, we determine the comparative value of multiphase computed tomographic angiography (mCTA) and computed tomographic perfusion (CTP) in predicting follow-up infarction., Methods: Patients with M1-middle cerebral artery occlusions were prospectively included in this multicenter study. Regional analysis was performed for each patient within Alberta Stroke Program Early CT Score regions M2 to M6. Regional pial vessel filling was assessed on mCTA in 3 ways: (1) Washout of contrast within pial vessels; (2) Extent of maximal pial vessel enhancement compared with contralateral hemisphere; (3) Delay in maximal pial vessel enhancement compared with contralateral hemisphere. Cerebral blood flow, cerebral blood volume, and Tmax data were extracted within these Alberta Stroke Program Early CT Score regions. Twenty-four- to 36-hour magnetic resonance imaging/CT was assessed for infarct in each Alberta Stroke Program Early CT Score region (defined as >20% infarction within that region). Mixed effects logistic regression models were used to compare mCTA and CTP parameters when predicting brain infarction. Area under the receiver operating characteristics was used to assess discriminative value of statistical models., Results: Seventy-seven patients were included. mCTA parameter washout and CTP parameter Tmax were significantly associated with follow-up infarction in all models ( P <0.05). The area under the receiver operating characteristic for mCTA models ranged from 92% to 94% and was not different compared with all CTP models ( P >0.05). Mean Tmax and cerebral blood volume values were significantly different between each washout score ( P <0.01) and each delay score category ( P <0.01). Mean Tmax, cerebral blood flow, and cerebral blood volume values were significantly different between each extent score category ( P <0.05)., Conclusions: Similar to CTP, multiphase CTA can be used to predict tissue fate regionally in acute ischemic stroke patients., (© 2017 American Heart Association, Inc.)

Background and Purpose: Infarct in a new previously unaffected territory (INT) is a potential complication of endovascular treatment. We applied a recently proposed methodology to identify and classify INTs in the ESCAPE randomized controlled trial (Endovascular Treatment for Small Core and Anterior Circulation Proximal Occlusion With Emphasis on Minimizing CT to Recanalization Times)., Methods: The core laboratory identified INTs on 24-hour follow-up imaging, blinded to treatment allocation, after assessing all baseline imaging. INTs were classified into 3 types (I-III) and 2 subtypes (A/B) based on size and if catheter manipulation was likely performed across the vessel territory ostium. Logistic regression was used to understand the effect of multiple a priori identified variables on INT occurrence. Ordinal logistic regression was used to analyze the effect of INTs on modified Rankin Scale shift at 90 days., Results: From 308 patients included, 14 INTs (4.5% overall; 2.8% on follow-up noncontrast computed tomography, 11.7% on follow-up magnetic resonance imaging) were identified (5.0% in endovascular treatment arm versus 4.0% in control arm [P=0.7]). The use of intravenous alteplase was associated with a 68% reduction in the odds of INT occurrence (3.0% with versus 9.1% without; odds ratio, 0.32; 95% confidence interval, 0.11-0.96; adjusted for age, sex, and treatment type). No other variables were associated with INTs. INT occurrence was associated with reduced probability of good clinical outcome (common odds ratio, 0.25; 95% confidence interval, 0.09-0.74; adjusted for age, type of treatment, and follow-up scan)., Conclusions: INTs are uncommon, detected more frequently on follow-up magnetic resonance imaging, and affect clinical outcome. In experienced centers, endovascular treatment is likely not causal, whereas intravenous alteplase may be therapeutic., Clinical Trial Registration: URL: http://www.clinicaltrials.gov. Unique identifier: NCT01778335., (© 2016 American Heart Association, Inc.)

Purpose: We aim to characterize infarct volume evolution within the first month post-ischemic stroke and to determine the effect of recanalization status on early infarct volume estimation., Methods: Ischemic stroke patients recruited for the MONITOR and VISION studies were retrospectively screened and patients who had infarcts on diffusion-weighted imaging (DWI) at baseline and had at least two follow-up MR scans (n = 56) were included. Pre-defined target imaging time points, obtained on a 3-T MR scanner, were 12 hours (h), 24 h, 7 days, and ≥30 days post-stroke. Infarct tissue was manually traced blinded to the images at the other time points. Infarct expansion index was calculated by dividing infarct volume at each follow-up time point by the baseline DWI infarct volume. Recanalization was assessed within 24 h post-stroke. Correlation and statistical comparison analysis were done using the Spearman, Mann-Whitney, and Kruskal-Wallis tests., Results: Follow-up infarct volumes were positively correlated with the baseline infarct volume (ρ > 0.81; p < 0.001) where the strongest correlation existed between baseline and 7-day post-stroke infarct volumes (ρ = 0.92; p < 0.001). The strongest correlation among the follow-up imaging was found between infarct volumes 7-day post-stroke and ≥30-day time points (ρ = 0.93; p < 0.001). Linear regression showed a close-to unity slope between 7-day and final infarct volumes (slope = 1.043; p < 0.001). Infarct expansion was higher in the non-recanalized group than the recanalized group at the 7-day (p = 0.001) and ≥30-day (p = 0.038) time points., Conclusions: Final infarct volume can be approximated as early as 7 days post-stroke. Final infarct volume approximation is significantly associated with recanalization status.

Background and Purpose: We report on workflow and process-based performance measures and their effect on clinical outcome in Solitaire FR Thrombectomy for Acute Revascularization (STAR), a multicenter, prospective, single-arm study of Solitaire FR thrombectomy in large vessel anterior circulation stroke patients., Methods: Two hundred two patients were enrolled across 14 centers in Europe, Canada, and Australia. The following time intervals were measured: stroke onset to hospital arrival, hospital arrival to baseline imaging, baseline imaging to groin puncture, groin puncture to first stent deployment, and first stent deployment to reperfusion. Effects of time of day, general anesthesia use, and multimodal imaging on workflow were evaluated. Patient characteristics and workflow processes associated with prolonged interval times and good clinical outcome (90-day modified Rankin score, 0-2) were analyzed., Results: Median times were onset of stroke to hospital arrival, 123 minutes (interquartile range, 163 minutes); hospital arrival to thrombolysis in cerebral infarction (TICI) 2b/3 or final digital subtraction angiography, 133 minutes (interquartile range, 99 minutes); and baseline imaging to groin puncture, 86 minutes (interquartile range, 24 minutes). Time from baseline imaging to puncture was prolonged in patients receiving intravenous tissue-type plasminogen activator (32-minute mean delay) and when magnetic resonance-based imaging at baseline was used (18-minute mean delay). Extracranial carotid disease delayed puncture to first stent deployment time on average by 25 minutes. For each 1-hour increase in stroke onset to final digital subtraction angiography (or TICI 2b/3) time, odds of good clinical outcome decreased by 38%., Conclusions: Interval times in the STAR study reflect current intra-arterial therapy for patients with acute ischemic stroke. Improving workflow metrics can further improve clinical outcome., Clinical Trial Registration Url: http://www.clinicaltrials.gov. Unique identifier: NCT01327989., (© 2014 American Heart Association, Inc.)

A middle aged patient presented with acute ischemic stroke due to basilar artery occlusion. The patient clinically deteriorated despite intravenous thrombolysis and was referred for mechanical thrombectomy. The right vertebral artery was occluded and could not be accessed despite attempting various shaped catheters, even when a radial artery access was used. The left vertebral artery ended in the posterior inferior cerebellar artery. Eventually, ultrasound guided V3 segment vertebral artery direct puncture was successfully done and the procedure was completed. No access related complications were encountered. Direct cervical arterial puncture can be safely used by experienced operators as a last resort in acute stroke cases with difficult access.

The advent of stentrievers provided momentum for endovascular stroke therapy. Hopes were dampened after three randomized trials showed no clear benefit of endovascular therapy. This review discusses the results of these trials results and shortcomings. A detailed discussion will follow on the design, conduct and analysis of current and future endovascular stroke trials. Steps to improve the workflow of acute stroke cases from the time they enter the emergency department until endovascular reperfusion is achieved can significantly shorten the time from onset to successful reperfusion. These factors in addition to using novel approaches to analyze data and minimize delays caused by the consent process are perceived to be sufficient to demonstrate the efficacy of endovascular stroke therapy.

Background: Stent-assisted coiling is a commonly adopted technique employed in the coiling of broader-based aneurysms. It avoids flow arrest and the risk of vessel rupture associated with balloon-assisted coiling. However, there is a risk of stent thrombosis with the corollary risk of stroke during and after the procedure. Antiplatelet agents are used to mitigate this risk but raise a secondary concern of hemorrhagic complications, particularly with ruptured aneurysm where further interventions such as ventriculostomy occur not infrequently. Stent removal after coil embolization would eliminate the risk of post-procedure stent thromboembolic complications and alleviate the need for continuing antiplatelet therapy., Methods: A prospectively maintained endovascular database was searched to identify patients who underwent stent-assisted coil embolization followed by stent retrieval and removal. The clinical and technical aspects of the cases were obtained in addition to the procedural outcomes., Results: Three cases were identified where the use of the fully resheathable Solitaire AB Neurovascular Remodeling Device permitted the coiling of broad-based aneurysms with subsequent retrieval and removal of the stent. All patients presented with subarachnoid hemorrhage and received aspirin prior to the procedure. Two patients did not require antiplatelet therapy after the procedure. No coil herniation or thromboembolic events were encountered., Conclusions: Stent retrieval and removal can be done safely in selected cases at the end of stent-assisted coil embolization using the Solitaire AB device. This technique avoids the need for continuing antiplatelet therapy, which can be particularly important in the setting of acute subarachnoid hemorrhage.

Background and Purpose: Carotid angioplasty and stenting (CAS) has a higher incidence of periprocedural stroke compared with endarterectomy. Identifying CAS steps with the highest likelihood of embolization may have important implications. We evaluated CAS safety by correlating the findings of procedural transcranial Doppler with postprocedure diffusion-weighted imaging (DWI) lesions., Methods: In this prospective study, transcranial Doppler monitoring was performed during CAS procedures, which were divided into 11 steps. Embolic signals on transcranial Doppler were counted and classified based on the relative energy index of microembolic signals into microemboli ≤ 1 or malignant macroemboli >1. Poststenting MRI was performed in all cases. A negative binomial regression model was used to evaluate the predictive value of transcranial Doppler emboli for new DWI lesions., Results: Thirty subjects were enrolled. Seven of 30 subjects (23.3%) were asymptomatic. The median embolic signal count was 212.5 (108 microemboli and 80 malignant macroemboli). Stent deployment phase showed the highest median embolic signals count at 58, followed by protection device deployment at 30 (P=0.0006). Twenty-four of 30 (80%) had new DWI lesions on post-CAS MRI. The median DWI count was 4 (interquartile range 7). Two of 30 (6.7%) had new or worsening clinical deficits post-CAS. For every malignant embolus, the expected count of DWI lesions increases by 1% ( 95% confidence interval, 0%-2%; P=0.032)., Conclusions: We observed a high incidence of embolic signals during CAS procedure, especially, when devices were deployed. Most subjects developed new DWI lesions, but only 6.7% had deficits. Malignant macroemboli predicted new DWI lesions.

Background and Purpose: The shorter the time interval between the estimation of the ischemic core by imaging and reperfusion, the more likely that core expansion is minimized. We aimed to assess the feasibility of achieving an ultrashort imaging to reperfusion time in routine clinical practice., Methods: The study subjects were a prospective cohort of patients with acute ischemic stroke treated with endovascular therapy in a tertiary center in whom an imaging to reperfusion time of <60 min was achieved., Results: Imaging to reperfusion time of <60 min was accomplished in 11 patients. The median baseline National Institutes of Health Stroke Scale (NIHSS) score was 11 and the median baseline Alberta Stroke Program Early CT Score (ASPECTS) was 8. The median time interval from imaging to endovascular reperfusion was 47 min. The median ASPECTS score on the 24 h CT scan was also 8 and the median 24 h NIHSS score was 1. Upon discharge, 82% of patients achieved a modified Rankin scale score of ≤ 1., Conclusions: An imaging to endovascular reperfusion time of <60 min is feasible and resulted in minimal core expansion on follow-up imaging in patients with acute ischemic stroke.

Introduction: Timely recanalization during endovascular procedures for acute ischemic stroke can be challenging in cases with large clot burden, such as those encountered in the terminal internal carotid T- or L-type occlusion., Methods: A novel but simple technique to achieve fast reduction in clot burden in stroke patients with occlusion of the internal carotid artery termination is described where manual suction using a 60-ml syringe applied through an 8-F balloon guide catheter positioned in the cervical carotid vasculature with proximal flow arrest allows subsequent revascularization of the residual middle cerebral artery clot., Results: The use of manual suction through a balloon-tipped guide catheter in internal carotid artery L- or T-type occlusion is illustrated. This resulted in a significant reduction of the clot burden and facilitated further interventions leading to full recanalization., Conclusion: Manual suction using a 60-ml syringe through a balloon guide catheter is a useful and feasible technique that facilitates thrombectomy of large burden cerebral clots.

Objective: To describe the clinical, molecular, and neuropathological findings of a patient with aquaporin 4-positive relapsing myelitis who developed extensive brain involvement followed by death., Design: Case report., Setting: Foothills Medical Center, Calgary, Alberta, Canada., Patient: A 51-year-old woman with neuromyelitis optica spectrum disorder., Results: Neuropathological examination disclosed neuromyelitis optica lesions, even in areas that appeared normal radiologically and grossly. Immunostaining confirmed the massive disintegration of astrocytes in the acute and chronic lesions, indicating that astrocytes are targeted early in the disease process. Induction of the immune response was demonstrated by reverse-transcriptase polymerase chain reaction analysis of relevant immune response genes., Conclusions: This article supports and supplements current concepts of astrocyte disintegration in neuromyelitis optica and of immune mechanisms in its pathogenesis.