WFN Digital Neurology Updates, WNU 2024, is set to take place on September 26-27. This online event is designed to transcend geographical and logistical barriers, making it accessible to neurologists, researchers, and healthcare professionals worldwide.

A Comprehensive Program

WNU 2024 will provide a platform for sharing the latest updates in critical areas of neurology. Over two days, expert speakers will cover a broad range of topics, including Epilepsy, Dementia, Multiple Sclerosis, Movement Disorders, Stroke, Headache and more.

Convenience and Global Dialogue

The digital format of WNU 2024 not only offers convenience but also fosters a global dialogue. This event will allow for an exchange of ideas and experiences that will enrich our collective understanding and practice of neurology. Furthermore, the event will be CME accredited, enabling participants to earn continuing education credits.

Exclusive Benefits for Participants

We encourage you to explore the program and register for WNU 2024. This event is an excellent opportunity to stay abreast of the latest updates in neurology and to connect with peers from around the world.

Don’t miss the chance to enhance your knowledge and take advantage of the discount for WCN 2025. We look forward to connecting with you during this engaging and stimulating educational experience!

Current status and future treatments.

Safa Younis

Mohammad Wasay

by Mohammad Wasay, MD, FRCP, FAAN, and Safa Younis, MBBS

Tuberculosis (TB) carries a huge burden around the globe. Approximately 25% of the global population is a carrier of the mycobacterium tuberculosis bacterium. About 5%-10% of the individuals in that group will develop tuberculosis during their lifetime.¹

Although pulmonary TB is the primary form, extrapulmonary TB (EPTB) accounts for 15% of cases.² Central nervous system tuberculosis (CNS-TB) is a severe type of tuberculosis, and it accounts for 1%-2% of TB cases worldwide.³ CNS-TB is more common in children and is associated with a high morbidity and mortality, especially in children under 5 years of age and patients under immunosuppression.^4,5 With about 10 million new TB patients diagnosed each year, it is estimated that around 100,000 new cases of CNS-TB occurred in 2019.⁵

Figure 1. Post-contrast CT scan in axial plane showing multiple enhancing lesions in the brain. The diagnosis of TB was confirmed by CSF.

Tuberculous Meningitis

The most common type of CNS-TB is tuberculous meningitis (TBM) with an estimated prevalence of 2.11 per 100,000 people and mortality rates from 20%-50%. One-third of survivors with CNS-TB suffer long-term neurological disabilities such as cranial nerve palsies, hemiparesis, ophthalmoplegia, psychiatric disorders, and seizures. The morbidity and mortality rates of CNS-TB are associated with a country’s TB burden, Human Development Index (HDI), and the prevalence of HIV. Low- and middle-income countries are disproportionately affected.

Tuberculous meningitis is relatively rare and difficult to diagnose, therefore it often goes under-reported. TBM accounts for 5%-10% of all TB cases. It has a high morbidity and is responsible for 40% of deaths due to TB.^8,9

TBM can cause severe complications like space-occupying tuberculomas and cerebral infarction.⁶ This results in a poor prognosis. The frequency of infarction in TBM has a wide range from 15%-27%. A greater occurrence is observed in young children who may be severely affected. Inflammatory basal exudate surrounding critical cerebral arteries like the circle of Willis and its branches can cause a periarteritis that is responsible for obliterative vasculitis and infarction.⁷ Infarction is a predictor of long-term disability in TBM patients.⁸

Tuberculous Myelitis

Tuberculous myelitis affects up to 3% of patients with TB. This is typically due to hematogenous spread of mycobacterium tuberculosis and can involve the spinal cord, roots, or spinal meninges. In developing countries, spinal TB is one of the most common causes of paraparesis.

In a study that took place in Aga Khan University Hospital in Pakistan, 20 patients with TB myelitis were identified through the ICD-9 coding system but only 10 fulfilled the inclusion criteria. The most prevalent symptoms observed in these patients upon presentation included:

• fever (70%)
• paraplegia (60%)
• paraparesis (30%)
• urinary retention (50%)
• bowel incontinence (30%)
• urinary incontinence (20%)
• monoparesis (10%)

Spinal tuberculoma or TB myelitis can occur after initiating antitubercular therapy for tuberculous meningitis or systemic TB. This phenomenon is called a paradoxical response.⁹ The paradoxical response to antitubercular therapy (ATT) typically occurs around two weeks into treatment. It may involve a worsening of existing tuberculous lesions or the appearance of new lesions in patients who initially showed improvement with ATT. Up to 10% of patients with CNS-TB may experience this with a higher rate of up to 30% with those with HIV.¹⁰

Figure 2. Left: Post-contrast T1-weighted MRI in axial plane showing a multilobular enhancing lesion in left frontal lobe. Right: T2-weighted MRI in axial plane showing multilobular mass with surrounding edema. The diagnosis of TB was confirmed by biopsy and histopathology.

Imaging and Diagnosis

Imaging plays a crucial role in diagnosing CNS-TB and its complications, as well as monitoring treatment response. Contrast-enhanced magnetic resonance imaging (MRI) is the preferred modality of choice due to its diagnostic accuracy. CNS-TB may closely resemble other neurological conditions, such as brain tumors. Thus, it is important for clinicians to have better understanding and familiarity of the imaging features of CNS-TB on computed tomography (CT) and MRI to aid in a quick and accurate diagnosis. CNS-TB can present in various ways on imaging, such as a diffuse form like basal exudative leptomeningitis, or localized forms like abscesses, tuberculomas, ventriculitis, or cerebritis. Meningitis (95%) and tuberculomas (2%) are the most common presentations.¹¹

Radiomics is an evolving field of research focused on enhancing diagnostic precision by extracting quantitative data from clinical images. Magnetic resonance (MR) based radiomic features are gaining recognition in numerous intracranial pathologies, including tumors and neurodegenerative disorders. Studies suggest that certain MR textural parameters — including histogram skewness, gray-level co-occurrence matrix (GLCM) correlation, and neighboring gray-level dependence matrix (NGLDM) coarseness — hold promise as imaging biomarkers. Biomarkers such as these have the potential to predict response to treatment in patients with intracranial tuberculomas.¹²

Treatment and Long-Term Care

If clinical suspicion arises from imaging, treatment typically comprises of antitubercular therapy. There is a four-drug regimen (ethambutol, isoniazid, pyrazinamide, rifampin) supplemented with a corticosteroid that may reduce morbidity and mortality. However, drug resistance, immune reconstitution inflammatory syndrome (IRIS), and HIV coinfection can significantly complicate the diagnosis and management of CNS-TB.¹³

According to the British Infection Society, there can be a multiphase treatment therapy for tuberculosis. The initial phase, lasting 2-3 months, involves a combination of isoniazid, pyrazinamide, and rifampin, along with either ethambutol, fluoroquinolone, or a streptomycin. This is followed by a consolidation phase of up to 12 months, during which isoniazid and rifampin are continued. In some cases, the total treatment duration may be extended to 18 months.

For drug-resistant tuberculosis, treatment should be guided by specific resistance patterns and relevant guidelines. Throughout treatment, close monitoring of blood counts, liver function, and kidney function is essential as first-line antituberculosis drugs can cause hematologic abnormalities and organ damage. Vigilance and close monitoring for adverse drug reactions and prompt management are also crucial aspects of care.¹⁴

The success of CNS-TB treatment is highly contingent on timely intervention. Several factors influence the prognosis, with the clinical stage at initial presentation being the most important determinant. If left untreated or unrecognized, this disease can unfortunately lead to fatality within five to eight weeks of the onset of symptoms.¹⁵ •

Mohammad Wasay is Alicharan Endowed professor of neurology at Aga Khan University, past president of the Pakistan Society of Neurology and Pakistan Stroke Society, president of the Neurology Awareness and Research Foundation, trustee and chair of the Specialty Groups Committee of World Federation of Neurology (WFN), secretary of the Environmental Neurology specialty group of WFN, member of the Global Policy Committee of the World Stroke Organization (WSO), and editor of the Pakistan Journal of Neurological Sciences. Dr. Safa Younis completed her bachelor’s in medicine and surgery (MBBS) from Ziauddin Medical University, and is actively involved in raising awareness and promoting brain wellness within the community.

References

1. Dian S, Ganiem AR, van Laarhoven A. Central nervous system tuberculosis. Current Opinion in Neurology. 2021 Mar 3;34(3):396–402. doi:10.1097/wco.0000000000000920.

2. Navarro-Flores A, Fernandez-Chinguel JE, Pacheco-Barrios N, Soriano-Moreno DR, Pacheco-Barrios K. Global morbidity and mortality of central nervous system tuberculosis: A systematic review and meta-analysis. Journal of Neurology. 2022 Mar 15;269(7):3482–94. doi:10.1007/s00415-022-11052-8.

3. Pant A, Farrokhi F, Gyawali P, Yekuno K, Shah O, Singh S, et al. Global research trends in central nervous system tuberculosis — a bibliometric analysis. Journal of Clinical Tuberculosis and Other Mycobacterial Diseases. 2024 Feb;34:100414. doi:10.1016/j.jctube.2024.100414.

4. Dian S, Ganiem AR, van Laarhoven A. Central nervous system tuberculosis. Current Opinion in Neurology. 2021 Mar 3;34(3):396–402. doi:10.1097/wco.0000000000000920.

5. Pant A, Farrokhi F, Gyawali P, Yekuno K, Shah O, Singh S, et al. Global research trends in central nervous system tuberculosis — a bibliometric analysis. Journal of Clinical Tuberculosis and Other Mycobacterial Diseases. 2024 Feb;34:100414. doi:10.1016/j.jctube.2024.100414.

6. Wasay M, Farooq S, Khowaja ZA, Bawa ZA, Ali SM, Awan S, et al. Cerebral infarction and Tuberculoma in central nervous system tuberculosis: Frequency and prognostic implications. Journal of Neurology, Neurosurgery & Psychiatry. 2014 Mar 12;85(11):1260–4. doi:10.1136/jnnp-2013-307178.

7. Taqui AM, Wasay M. Cerebral Infarction in Tuberculous Meningitis. Pakistan Journal of Neurological Sciences. 2011 Jan;6(1):25–9.

8. Wasay M, Khan M, Farooq S, Khowaja ZA, Bawa ZA, Mansoor Ali S, et al. Frequency and impact of cerebral infarctions in patients with tuberculous meningitis. Stroke. 2018 Oct;49(10):2288–93. doi:10.1161/strokeaha.118.021301.

9. Wasay M, Arif H, Khealani B, Ahsan H. Neuroimaging of tuberculous myelitis: Analysis of ten cases and review of literature. Journal of Neuroimaging. 2006 Jun 28;16(3):197–205. doi:10.1111/j.1552-6569.2006.00032.

10. Wasay M. Central nervous system tuberculosis and paradoxical response. Southern Medical Journal. 2006 Apr;99(4):331–2. doi:10.1097/01.smj.0000209231.88651.07.

11. Azeemuddin M, Alvi A, Sayani R, Khan MK, Farooq S, Beg MA, et al. Neuroimaging findings in tuberculosis: A single‐center experience in 559 cases. Journal of Neuroimaging. 2019 May 21;29(5):657–68. doi:10.1111/jon.12627.

12. Muhammad A, Khan S, Mohammad W, Muhammad A, Shoukat A, Khan H. Mr textural features (RADIOMICS) for predicting response to treatment in patients with intracranial tuberculoma: A retrospective cross-sectional study. Pakistan Journal of Neurological Sciences. 2023 Feb 5;17(03). doi:10.56310/pjns.v17i03.176.

13. Gupta M, Tobin EH, Munakomi S. CNS Tuberculosis. [Updated 2024 May 6]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK585138/.

14. Chen W, Huang L, Tang Q, Wang S, Hu C, Zhang X. Progress on diagnosis and treatment of central nervous system tuberculosis [Internet]. Radiology of Infectious Diseases [Radiol Infect Dis]. 2020 [cited 2020 Aug 10];7(4):160-169. https://doi.org/10.1016/j.jrid.2020.07.005.

15. Gupta M, Tobin EH, Munakomi S. CNS Tuberculosis. [Updated 2024 May 6]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK585138/.

The Padma Shri Award is one of the highest civilian honors in India.

By Dr. Gagandeep Singh

Gagandeep Singh

India’s Padma Awards recognize public service and significant achievements across a variety of disciplines such as art, engineering, medicine, social work, literature, education, and sports. They are announced annually on the eve of India’s Republic Day and conferred by the president at a ceremony in New Delhi.

This year, Dr. Chandrashekhar Meshram was presented with the Padma Shri Award. Dr. Meshram is a trustee of the World Federation of Neurology (WFN). He is a multifaceted personality who has excelled in clinical neurology, academic leadership, research, teaching, public health awareness, and social activities.

Coming from a humble rural background, he grew up with commitment, hard work, and innovative ideas to eventually become a WFN elected trustee. He earned his MD and doctorate of medicine in neurology from the Post Graduate Institute of Medical Education and Research in Chandigarh, India. He is currently director and consultant neurologist at the Brain and Mind Institute in Nagpur, India.

He served as president of the Tropical and Geographical Neurology Specialty Group (TGNSG) within WFN for two terms. Under his tenure, the TGNSG became one of the most vibrant specialty groups of WFN. He represented the Indian Academy of Neurology as a national delegate in seven WFN Council of Delegates meetings. He also served the WFN as a member of its Constitution and Bylaws Committee for three terms and as a member of the Scientific Program Committee for two terms.

Dr. Meshram served the Indian Academy of Neurology (IAN) as a member of its executive committee, secretary, and then as president. He was instrumental in transforming the scientific program for the IAN annual conferences. The academy conferred on him Fellow of Indian Academy of Neurology (FIAN) status in 2012.

Known for his phenomenal organizational capabilities, he successfully assembled the 12^th Annual Conference of the Indian Academy of Neurology in 2004 in Nagpur, and the first International Tropical Neurology Conference in 2017 in Mumbai. He was co-chair of the Second International Tropical Neurology Conference in 2018 in Sao Paolo, Brazil. As a course director, he organized 16 sessions of a unique education activity — the WFN-IAN-FINE Neuro Infection Series, and 13 sessions of the Inspiring People in Neurosciences Series, a first-of-its-kind activity by WFN.

Dr. Meshram (left) receiving the 2024 Padma Shri Award from Droupadi Murmu, the Honorable President of India.

Dr. Meshram is the WFN representative for the Western Pacific region of the World Health Organization. He was co-editor of a special issue of the Journal of Neurological Sciences that focused on tropical neurology. He is a section editor of the Encyclopedia of Neurosciences for the section on bacterial and fungal infections, including tropical diseases, and is assistant editor of the international journal eNeurologicalSci. He also serves on the editorial board of the Journal of Neurosciences. He is a member of the infectious disease panel of the European Academy of Neurology.

Dr. Meshram is passionate about public awareness programs and has promoted them for more than 30 years through meetings, radio talks, television, and newspapers. During his 10 years as a chief coordinator for public health education and awareness activities for IAN, he organized programs throughout the country. He developed and furthered several highly acclaimed programs, including “Music, Masala, and Brain,” a sports meet for people with neurological disorders, and painting competitions for school children to raise awareness about the importance of autism, brain health, CNS tuberculosis, dementia, the environment, epilepsy, headache, multiple sclerosis, Parkinson’s disease, and stroke.

He has published more than 450 newspaper articles for public awareness and contributes regularly to World Neurology. He also published a book containing children’s paintings themed on brain disorders.

Dr. Meshram has received other awards, including the Samman Award, conferred on him by the Indian Income Tax Department. He was presented with the Rashtrasant Tukadoji Maharaj Jeevan Sadhana Award in 2017, the highest honor of Rashtrasant Tukadoji Maharaj Nagpur University. He was nominated as brand ambassador of Nagpur by the Nagpur Municipal Corporation for Swachh Bharat Abhiyan (Clean India Mission). The Indian Medical Association presented him with the Dr. Wankar Gold Medal and Lifetime Achievement Award in 2019.

He is a trustee of Baba Amte’s, Maharogi Sewa Samiti, and Vidarbha Sahitya Sangh, a literary and cultural organization. He is the founder and president of the Samyak Medical Foundation, which provides scholarships to meritorious students from low-income areas encouraging them to pursue a higher education. He is also the founder and president of the Orange City Cultural Foundation and has organized six Orange City international film festivals.

Dr. Meshram has been well supported by his family, colleagues, well-wishers, media, and grateful patients. He has the unconditional support of his loving wife Namrata. The couple is blessed with two sons, Aashay and Aviral. Aashay lives in Vancouver and is excelling in his profession as an animation designer, while Aviral is doing a residency in neurology. Dr. Meshram’s father, Dr. Mahadeorao Meshram, was conferred with the national lifetime achievement award, Vayoshrestha Samman, by the Honorable President of India in 2017, for his outstanding and selfless service for the elderly.

Dr. Meshram richly deserves this Padma Shri award. It will undoubtedly inspire future generations of neurologists and promote the growth of neurology in India and other parts of the world. •

Dr. Gagandeep Singh, DM, FRCP, FAMS, is the past president of the Indian Academy of Neurology

Free virtual symposium to take place in November.

By Dr. Olivia Begasse de Dhaem

The World Federation of Neurology (WFN), African Academy of Neurology (AFAN), Global Patient Advocacy Coalition (GPAC), and International Headache Society (IHS) announce the fourth Education in Headache to Healthcare Professionals in Africa (EHHPA) Symposium. It will take place virtually on Nov. 23, 2024. Registration is free and open to health care workers of all levels.

Participation in EHHPA has grown from 550 participants in 2021 to 1,029 participants in 2023. That includes participants from all parts of the world, with the majority (84%) from 38 different countries in Africa. Attendees included neurologists (37%), general practitioners (17%), and neurologists in training (13%).

As a result of the program, 80% of participants have indicated they can distinguish migraine from other headache disorders, and 55% gained confidence in terms of headache management. The top three most-attended sessions were Infection & Headache, Trigeminal Autonomic Cephalalgias, and Secondary Headaches.

This year’s event brings world-renowned speakers to cover practical topics, such as headache evaluation and management in both the primary care and emergency room settings, headache in systemic diseases, the epidemiology of headache in low- and middle-income countries, and headache considerations in and around pregnancy. The symposium will be offered in English with live parallel sessions in French.

Register for the free symposium and share with colleagues and health care workers of all levels. •

Dr. Olivia Begasse de Dhaem, MD, FAHS, is vice chair of the Global Patient Advocacy Coalition (GPAC), medical director and founder of the Institute for Headache and Brain Health, and an assistant professor of neurology at the University of Connecticut.

Raising the voice of pediatric neurology.

Kevin Rostasy and Anna Jansen

By Kevin Rostasy and Anna Jansen

Pediatric neurology is a discipline focused on diagnosis, comprehensive management, and research into diseases of the central and peripheral nervous system from fetal life to transition into adulthood. It is a field that has grown in the last half century and has recently seen leaps in innovation, including diagnostic methods, novel treatments including gene therapy, interventions, and research. It is vital that the significant burden of neurological diseases in childhood is addressed through research and education as these disorders have a lifelong impact on the individual, their careers, and society as a whole.

In 1996, the European Paediatric Neurology Society (EPNS) was legally registered in France based on open individual membership, with English as the official language. The EPNS is now an established international, independent non-profit society for physicians, health professionals, scientists, and students with research and/or clinical interest in pediatric neurology. It is governed by a board of 30 elected members.

The EPNS mission statement is to promote excellence in patient care, research, and education to improve the neurological outcome of children and young people in Europe and across the world. With about 2,500 members, the EPNS membership base has been steadily increasing and strengthening every year. The European Journal of Paediatric Neurology is the official society journal, and is published six times a year. It publishes high-quality papers primarily of a clinical research nature on the whole spectrum of pediatric neurological disease.  

A major focus of the society is to advocate for pediatric neurology at the highest level by nurturing national, multidisciplinary, and international collaborations with similar societies, policymakers, patient groups, and other major stakeholders. The Committee of National Training Advisers (CNA) serves as a vital advisory group to the EPNS and as a link to the national pediatric neurology societies.

In 2023, the EPNS started to build a framework centering on the 10-year Intersectoral Global Action Plan on Epilepsy & Neurological Disorders (IGAP), with the goal of implementing the plan with specific reference to pediatric neurology. IGAP is an unprecedented opportunity to lobby for the importance of brain health, and easy equitable access to the highest standard of patient care in neurology across the patient’s lifespan, while supporting their caregivers and other family members. The EPNS has appointed IGAP representatives in 41 European countries working with the EPNS to implement IGAP at a national level.

The EPNS promotes excellence in education, providing a comprehensive learning environment in pediatric neurology to students, trainees, and qualified professionals in all stages of their careers to improve the neurological outcome of children and young people. For example, a new EPNS Exam has been introduced to assess the basic knowledge needed to underpin pediatric neurology training. In addition, the EPNS Moodle is available to provide a learning platform for EPNS members. The society offers many other regular educational opportunities, including the well-established weekly EPNS webinars, 3-year EPNS rolling training courses covering the major topics in the pediatric neurology syllabus, EPNS Central Eurasia Workshops, and the EPNS Caucasus teaching courses. The EPNS continues to award EPNS Fellowships and EPNS Visiting Teachers to selected EPNS members who benefit from these unique opportunities.

The EPNS strives to foster, expand, and support science and clinical research in child neurology by bringing together the best clinicians and scientists in the field. This includes the society’s flagship biennial EPNS Congresses where delegates enjoy a scientifically stimulating program and interaction. The next EPNS Congress will take place on July 8-12, 2025, in Munich.

The EPNS Research Meeting takes place every other year. It is a forum for researchers in pediatric neurology to present their work, creating the possibility for future collaborative research. The EPNS looks forward to welcoming pediatric neurologist researchers at all stages of their careers to the next EPNS Research Meeting, which will take place Oct. 17-18, 2024, in Ljubljana, Slovenia.

The Young EPNS (YEPNS) is a motivated group bringing together younger members to learn, collaborate, and network. They have made a significant contribution to EPNS activities, including contributing to the EPNS Guidelines Committee, which was created to promote high-quality, homogenous evidence-based patient care.

If you would like to join the EPNS, contact our administration team at info@epns.info.

Education, Promotion, Networking, Science for pediatric neurology •

Kevin Rostasy is president of the EPNS, and Anna Jansen is chair of the EPNS Advocacy and Collaboration Committee.

Medications and services can be costly and difficult to obtain for many Honduran patients.

By Kaitlyn Alleman, Prof. Lawrence Robbins, Genesis Mejias, MD, Sofia Dubon, MD, and Nelson Betancourt, MD

Our rural Honduras neurology and psychiatry clinic conducted a simple survey. The primary purpose of the survey was to assess patient satisfaction. We also asked the patient to rate the most important aspect of the clinic. We collected diagnoses and demographics.

This free clinic was established by neurologist Lawrence Robbins, MD, in 2017, and was featured in the Aug. 9, 2021, issue of World Neurology. There are three neurologists, an EEG technician, two psychiatrists, and a clinic nurse. The neurologists and psychiatrists are dedicated and idealistic. Several thousand patients regularly attend the clinic. The clinic provides free physicians, tests, and medications.

Sixty-seven patients were surveyed: 41 were female and and 26 were male. The ages ranged from 18 to 86. The specific age breakouts were:

Ages 18 to 20: 11 patients

Ages 21 to 40: 23 patients

Ages 41 to 60: 13 patients

Ages 60 and up: 20 patients

The majority of patients resided in rural areas surrounding the main city of Tegucigalpa (there are neurologists in the main cities of Honduras). Most of the patients could not afford neurology or psychiatry services. The patients were randomly chosen, and the survey results were anonymous. Verbal consent was obtained. An Institutional Review Board was used.

The survey collected basic demographic data and diagnoses. Three questions were asked:

What is the most important reason for coming to our clinic?

a. To see the doctor and find out what is wrong

b. To receive medicines

Are you satisfied with the services at the clinic?

a. Yes

b. No

Has your life changed for the better since coming to the clinic?

a. Yes

b. No

The survey also solicited additional comments regarding the clinic.

Results

Question 1: Sixty-two out of 67 patients indicated that seeing the doctor and finding out what was wrong was most important. Only five patients listed receiving the medications as most important. Of these five patients, three had epilepsy as the primary diagnosis, one had migraine, and one was diagnosed with Parkinson’s disease. This was surprising, as we thought the free neurologic and psychiatric medications would be the primary reason for attending.

Question 2: All 67 of the patients listed themselves as satisfied. This is not surprising, as these patients have had no access to neurologic or psychiatric services.

Question 3: Sixty-six patients indicated that their lives had changed as a result of coming to the clinic. One patient did not provide an answer.

Patient comments: Forty patients made positive comments. There were three negative comments. Thirteen comments expressed thanks, 12 mentioned the good service, 10 praised the physicians or staff, three mentioned that everything was free, while two said they liked the medications. The negative comments mentioned that the pharmacy could improve, other specialties were needed, and the clinic should offer better instructions on how to pay.

Neurology Diagnoses in 67 Patients 

Epilepsy: 16 patients (10 females, six males)

Headache (primarily migraine): 13 patients (nine females, four males)

Parkinson disease: 9 patients (two females, seven males)

Miscellaneous: one patient each: dystonia, cysticercosis, muscle disease, fibromyalgia.

Psychiatric Diagnoses 

Depression (includes unipolar and bipolar): 12 patients (eight females, four males)

Anxiety: 11 patients (seven females, four males)

Insomnia: 1 patient (female)

Discussion

The Honduran patients expressed a high degree of satisfaction with the clinic. Most patients indicated their life had changed for the better. One main reason for attending the clinic was to receive a diagnosis. This was surprising, as we would have thought that obtaining the free medications was most important. If we only surveyed patients who had been attending the clinic for some time, the medications may have become the most important aspect.

Epilepsy was the most common neurologic diagnosis, followed by headache and Parkinson’s disease. Depression and anxiety were the primary psychiatric diagnoses. This was a limited number of patients. If we had surveyed 2,000 of our patients, headache probably would have been the most common diagnosis, followed by epilepsy. Although headache is more prevalent than epilepsy in Honduras, patients with epilepsy may be more motivated to seek medical care.

Most Hondurans cannot afford more than basic medical care. There are numerous free clinics providing this care. Medical missions to Honduras are numerous. The Honduran neurologists and psychiatrists are excellent. However, neurologic and psychiatric care is scarce for most of the population. Access to free neurology services is available in the main city of Tegucigalpa, but wait times are long, and rural patients usually cannot make the arduous trip. Patients must pay for an EEG or MRI, both of which are usually unaffordable. An MRI may cost three or four weeks of wages. In our rural clinic, we do 25 EEGs per month at no cost.

Honduran patients have access to basic neurologic medicines. For epilepsy, these include phenobarbital and phenytoin. But even these basic meds may be difficult to access. There is a reasonable selection in Honduras of the various anti-seizure medications. These include carbamazepine, lacosamide, valproic acid, vigabatrin, and others. These are usually unaffordable for most Honduran patients.

For migraines, basic preventives are available, including amitriptyline, beta blockers, topiramate, valproic acid, and a few others. However, only a fraction of patients with migraine are prescribed the preventives. Most cannot afford these medications. Triptans are available but are unaffordable for 95% or more of patients. NSAIDS (both PO and injections) and ergotamine compounds are often prescribed. Opioids are almost never used.

Epilepsy is frequently encountered in Honduras. There is a relatively high prevalence of epilepsy in Latin America. Infectious disease and trauma may account for some of this. Many patients are never diagnosed or treated. Despite the difficulty in obtaining MRIs and EEGs, Honduran neurologists are adept at treating epilepsy. There is an epilepsy surgery program in Tegucigalpa.

Migraine is a major health issue in Honduras. Migraine greatly affects the Honduran patients’ work and home life. For many of the impoverished patients, missing work due to a migraine presents an enormous financial burden. Migraine is vastly undertreated in Honduras.

We can provide many of the neurologic and psychiatric medications, although the Honduran health system does provide basic drugs for neurologic disorders. In this clinic, we provide about 19 neurologic and psychiatric medications. We try to choose medications that are relatively safe and do not require blood testing. They also must be available in Honduras. Although Dr. Robbins can obtain the medications in the U.S., when we run short, we purchase them in Honduras until we can get resupplied from the U.S. Many of the medications are expensive in Honduras.

In summary, this survey indicates a high degree of satisfaction with a rural clinic that provides basic neurologic and psychiatric care. Even though technology and advanced laboratory tests are scarce, the patients greatly appreciate being able to see a neurologist or psychiatrist. The free medications are also a vital part of their care. By providing basic neurologic and psychiatric care, we can significantly improve quality of life. •

Kaitlyn Alleman is a medical student at Rosalind Franklin University in Chicago. Lawrence Robbins is an associate professor of neurology at the Chicago Medical School. Genesis Mejias, MD, is a physician from Venezuela. Sofia Dubon, MD, is a neurologist in Tegucigalpa, Honduras. Nelson Betancourt, MD, is a neurologist in Tegucigalpa, Honduras.