Background: Hemorrhage volume is an important predictor of outcome in patients with intracerebral hemorrhage (ICH). It is not clear why in some patients ICH volume is larger than in others. Identification of modifiable factors responsible for large-volume hemorrhage in hypertensive patients may help to reduce ICH-related morbidity and mortality. Objective: The objective of this study was to identify predictors of large-volume ICH in hypertensive patients. Methods: At a tertiary care center in Karachi (Pakistan), 157 hypertensive patients with ICH were prospectively analyzed in 2008–2009, and hemorrhage volumes were determined using CT or MRI and various factors, including duration of hypertension, medical treatment, compliance, co-morbidity, and hematologic and coagulation profiles. Logistic regression analysis was used to identify predictors of high-volume hemorrhage. A volume >30 mm³ was defined as high-volume hemorrhage. Results: Of 157 patients with hypertensive ICH evaluated, 133 patients were included in the study, and 24 patients with brain stem, cerebellum and pure intraventricular hemorrhage were excluded. The mean age of the study patients was 55 years; 56 patients (70%) were male. High-volume hemorrhage (>30 mm³) was noted in 47 (35%) patients. Mortality was significantly increased in patients with high-volume ICH (32 vs. 6% in patients with low-volume ICH). In univariate analysis, factors significantly associated with large-volume ICH were male gender (p = 0.002), hypertension lasting >10 years (p = 0.03), warfarin treatment (p = 0.05), use of >1 anti-hypertensive agent (p = 0.001) and poor compliance with medication (p = 0.001). In multivariate analysis, use of >1 anti-hypertensive agent and poor compliance were also predictors of large-volume ICH. Conclusion: High-volume hemorrhage was less common (28%) in our patients with hypertension and ICH. Use of >1 anti-hypertensive agent and poor compliance were predictors of large-volume ICH.

Brivaracetam is a new antiepileptic drug with limited data in children. The objective of this study was to assess the efficacy/tolerability of brivaracetam. This is a retrospective chart review of children/adolescents with refractory epilepsy treated with brivaracetam from 2016 to 2018. The primary outcome was seizure reduction (decrease in seizure frequency >50%). Twenty-three patients were identified. Mean age at initiation was 12.5 years. Fourteen were females. Epilepsy was focal in 11, generalized in 6, and mixed in 3. Average dose was 3.9 mg/kg/d. The mean duration of treatment was 8.2 months. Eight had greater than 50% decrease in seizure frequency, of which 7 had focal epilepsy, and 1 had Lennox-Gastaut/mixed epilepsy. Two had drowsiness and 3 behavioral complaints. One experienced tingling and dizziness. Our retrospective review suggests that brivaracetam is an effective therapy for refractory focal epilepsy in children older than 4 years of age.

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.Keywords: Venous Thrombosis; Cerebral Thrombosis; Cranial Venous Sinuses; Neurological Manifestations; Patient Outcome Assessment; Oman.

Patient: Male, 76Final Diagnosis: Strongyloides hyperinfection syndromeSymptoms: Abdominal pain • diarrheaMedication: Cyclophosphamide • PrednisoneClinical Procedure: —Specialty: Infectious DiseasesObjective:Rare diseaseBackground:Currently, it is normal to screen for Strongyloides as part of the workup in pre-transplant patients who have eosinophilia. Given the high mortality rates in Strongyloides hyperinfection, this article illustrates the need to screen all patients with eosinophilia who will be started on immunosuppression.Case Report:We present here an interesting case of a 76-year-old man with membranous glomerulopathy who developed a severe Strongyloides hyperinfection that required an ICU stay and ultimately led to his death a few weeks after initiation of cyclophosphamide and steroids.Conclusions:We recommend that a detailed workup to detect or rule out this parasitic infection be conducted prior to the initiation of immunosuppression in any patient with eosinophilia.