New Courses in Neuroepidemiology

First Caucasus Region Course of Neuroepidemiology

The high-level, full-immersion course takes place in December.

By Carlos N. Ketzoian

The First Caucasus Region Course of Neuroepidemiology will take place Dec. 8-14, 2024, in Yerevan, Armenia. It will be the first time the course has taken place in the Asian-Oceania region of the WFN Member Societies.

For years, the Specialty Group on Neuroepidemiology of the World Federation of Neurology (WFN) has promoted specialty courses aimed at young neurologists and health professionals in their first years of training.

These high-level, full-immersion courses allow participants to share five days of training, exchange experiences, and establish professional collaborations that go beyond the course.

Two of these courses took place in Latin America (one in 2018 in Panama, and one in 2023 in Uruguay). Next year, courses are planned to take place in Peru and in Benin, Africa.

The course in Armenia is organized by Yerevan State Medical University, under the auspices of WFN.

The topics will include:

  • surveys in neuroepidemiology
  • analytic studies, case-control studies
  • cohort studies
  • clinical trials
  • genetic epidemiology
  • application of statistics to epidemiology
  • inferences from epidemiologic research
  • neuroepidemiologic studies in low- and middle-income countries
  • geo-epidemiological methods for neuroepidemiologic studies
  • diagnostic tests
  • how to carry out an epidemiological study in low frequency neurological diseases
  • epidemiology of some neurological disorders in the region (dementia, Parkinson’s disease, and stroke)

The methodology includes lectures, discussion of examples from different types of studies, and analysis of papers published with different study designs.

Visit the Yerevan State Medical University website for more information. You can also email Prof. Artashes Tadevosyan at Yerevan State Medical University, Department of Public Health and Health Care Organization.

The Neuroepidemiology Specialty Group is chaired by Pierre Marie Preux. His email address is preux@unilim.fr.  •

Carlos N. Katsoian is a neurologist, epidemiologist, and neurophysiologist from the Neuroepidemiology Section, Institute of Neurology, University Hospital, School of Medicine in Montevideo, Uruguay.

 

The 10th International Course of Neuroepidemiology

The course includes four days of training and education.

By Carlos N. Ketzoian

The 10th International Course of Neuroepidemiology: Methods and Clinical Applications will take place Nov. 20-24, 2024, at the Ettore Majorana Center for Scientific Culture in Erice, Italy. The World Federation of Neurology (WFN) has endorsed this event.

This historical course of neuroepidemiology originated in 1981 with Prof. Bruce Schoenberg.1

Erice’s neuroepidemiology courses are an essential point of reference for those who are interested in the subject. Over the years, the structure, thematic content, and methodology have evolved in order to adapt to the changing needs of an international audience and to include methodological developments.

A scientific committee and teaching team, including more than 15 worldwide leaders in neuroepidemiology and other related sciences, will lead the course. It is a high-level, full-immersion course where participants share four days of training, exchange experiences, and establish professional collaborations that go beyond the course.

The topics include:

  • surveys in neuroepidemiology
  • analytic studies
  • clinical trials
  • genetic epidemiology
  • application of statistics to epidemiology
  • metanalysis
  • inferences from epidemiologic research
  • neuroepidemiology in developing countriespidemiology of some neurological disorders (ALS, dementia, migraine, multiple sclerosis, Parkinson’s disease, and stroke)

The methodology includes lectures, discussion of examples from different types of studies, and practical interactive tutorials.

For more information, contact Prof. Paolo Ragonese or Sole Blu Congress Secretariat.

The Neuroepidemiology Specialty Group is chaired by Pierre Marie Preux. He can be reached at preux@unilim.fr. •

Carlos N. Katsoian is a neurologist, epidemiologist, and neurophysiologist from the Neuroepidemiology Section, Institute of Neurology, University Hospital, School of Medicine in Montevideo, Uruguay.

Reference

1. Walter A. Rocca, Paolo Ragonese, Marco D’Amelio, Giovanni Savettieri (2022) Teaching Research Methods to Young Neurologists: The Erice International Courses. J Mov Disord 2022;15(3):227-231.

Organ Extracts for Diseases of the Nervous System

A forgotten paradigm involving the pineal gland.

By Peter J. Koehler

Figure 1. Drawing of René Descartes by Jan Lievens, 1644-1649. Collection Groninger Museum, on loan from Municipality of Groningen, donated by Hofstede de Groot, Photo © Marten de Leeuw.

Some time ago, I wrote about brain stones, intracranial calcifications that have been found at autopsies for many centuries. (See World Neurology, January 2017) In this context, the pineal gland was in the spotlight after the French philosopher René Descartes (1596-1650, see Figure 1) wrote down his ideas about the physical part of the soul supposedly localized in this structure.1

In the subsequent 150 years, there were lively discussions between physicians, who were proponents and opponents of this idea. The finding of stones in this organ played an important role. It was only around 1800 — when critical observers began to apply the numerical method, as Pierre-Charles-Alexandre Louis (1787-1872) did for bleeding2— that physicians began to realize that discovering a stone in the pineal gland was a normal finding above a certain age. More than 100 years later, there was renewed interest in the pineal gland at a time when extracts from all kinds of organs were used to treat diseases, in particular mental deficiency. The term organotherapy was introduced for this purpose.

Figure 2. Portrait of Charles-Édouard Brown-Séquard (© Bibliothèque Interuniversitaire Santé).

Organotherapy

French physician and physiologist Charles-Edouard Brown-Séquard (1817-1894; see Figure 2) came up with the idea of extracting therapeutic fluid from glands.

He and his predecessor at the Collège de France in Paris, physiologist Claude Bernard (1813-1878), who described glucose as an internal secretion of the liver, are considered founders of endocrinology. Brown-Séquard formulated early ideas of glands with internal secretion and experimented with extracts of all kinds of organs.3,4 He had first suggested administering seminal fluid intravenously to old men in order to rejuvenate them in 1869.5 Following years of experimentation with gland extracts, including the application of testicular gland extracts on himself — claiming that it had led to improvements in his bodily functions and intellectual faculties — he published a kind of review paper in the British Medical Journal (1893). (See Figure 3.)

Figure 3. Brown-Séquard’s publication in the British Medical Journal of 1893

Brain Extracts

Brown-Séquard provided the methods to produce the extracts and presented the work that he had conducted on several organ extracts, including the pancreas, liver, thyroid, and sexual organs. Interestingly, he also wrote that “the cerebral or medullary liquid, extracted either from the grey or white matter of the cerebrospinal centers, has been most extensively used.” It had been used for the treatment of neurasthenia, locomotor ataxia [tabes dorsalis], and epilepsy.6 The treatment of neurasthenia — a popular diagnosis at the end of the 19th century7— was reported successful in 50% to 60% of patients. Brown-Séquard attributed this effect to the invigoration of the nervous system and the enhancement of cell regeneration.

In the same year, the New York Therapeutic Review published “Injections of Organic Fluids According to Professor Brown-Séquard’s Method.” It praised the use of organ extracts for the treatment of a range of illnesses — in particular of the nervous system — including chorea, epilepsy, locomotor ataxia, and neurasthenia. It claimed that extract of pancreas could be used to treat diabetes, extract of grey matter could treat neurasthenia, and testicular extracts could be used to treat a range of diseases.4 However, as definitions of diseases were not always clear, scientific criticism was not long in coming. Solomon Solis-Cohen (1857-1948), professor of clinical medicine and applied therapeutics at the Philadelphia Polyclinic, criticized the use of brain extracts. Unlike the thyroid gland, he wrote that “the brain, so far as we know, secretes nothing physical. So far as we know, there is no symptom or symptom-complexus which can be attributed to defect in any supposed secretory function of the brain.”8

Chastity Gland

In his informative article on the history of ideas on the pineal gland, neurologist and medical historian Francis Schiller (1909-2003) pointed to another connection with endocrinology.9 In 1898, Otto Heubner (1843-1926, eponymist of Heubner’s recurrent artery) described a 4-year-old child suffering from pubertas praecox — the premature development of primary and secondary sexual characteristics — caused by a pineal gland tumor. Ideas arose as to whether the pineal gland might have an inhibiting effect on sexual development.

In the early 20th century, the Viennese neurologist Otto Marburg (1874-1948) suggested the pineal gland functions in normal conditions as a Keuschheitsdrüse [chastity gland], suppressing the premature development of sexual characteristics.8 The American neurosurgeon Harvey Cushing (1869-1939) pointed out an antagonism with respect to human sexual development between the pineal gland (epiphysis) and the pituitary gland (hypophysis), not only with respect to their position above and below the brain, but also in function when it comes to tumors. (See Figure 4.)

Tumors of the pineal gland would cause premature development of primary and secondary sexual characteristics, whereas those in the pituitary gland would destroy hormonal regulation and lead to the contrary. In 1912, Cushing wrote: “[The pineal gland] is undoubtedly of physiological importance … it would appear that there is a measure of antagonism, insofar as sexual development is concerned, between hypophysis and epiphysis. However, it must be confessed that the syndrome of supposed pinealism has been observed only in connection with tumors of the gland which have led to an obstructive hydrocephalus and thus of necessity to secondary hypophysial disturbances.”8

Figure 4. Pineal gland (at L on the left and at D on the middle figure) from Vesalius’ De humani corporis fabrica of 1543.10 The figure on the right is a modified sagittal view from the early 20th century, showing both glands.11

Pineal Gland Extract for Mental Disability

In his book The Origins of Organ Transplantation, medical historian Thomas Schlich wrote that “organotherapy was generally rejected around 1900, since neither the clinical data nor the experimental results were considered adequate evidence for its effectiveness.”5 However, in neurology as well as psychiatry, organ extracts continued to be applied. The term endocrine psychiatry has been applied to the latter.

In the 1910s, researchers H.H. Goddard and Walter S. Cornell in Vineland, New Jersey, working under Charles Loomis Dana (1852-1935), professor of nervous diseases at Cornell Medical College, New York, and physician William Nathaniel Berkeley (1868-1928), author of The Principles and Practice of Endocrine Medicine (1926), studied the function of the pineal gland. They were interested in feeding experiments.12 Pineal gland abstract was given orally to 25 children. Each child was paired with a control who was not given treatment. After two months, the effect was not clear, and the experiment was extended for another two months. They concluded that “one cannot but feel that there is a distinct influence in the extract toward mental power.” They compared it with the influence of thyroid extracts on children suffering from congenital iodine deficiency syndrome.13

Meanwhile, Berkeley published on improvements he had achieved with “the use of pineal gland in the treatment of certain classes of defective children” and in 12 patients with pre-senile dementia.14,15 The Austrian philosopher and esotericist, founder of anthroposophy, Rudolf Steiner (1861-1925) prescribed pineal gland extracts for children with mental disabilities.9

Pineal Gland Extract for Psychosis

It was also administered to psychotic patients as was recently reviewed in “Organ Extracts and the Development of Psychiatry: Hormonal Treatments at the Maudsley Hospital 1923-1938.”16 No less than 17 studies on pineal gland extracts for schizophrenia were found before 1950.8

In 1921, the Nederlands Tijdschrift voor Geneeskunde reviewed a study on the pineal gland, reporting its influence on psychic functions. In some types of insanity — in particular schizophrenia — extracts of the gland were believed to inhibit signs of sexual overstimulation. Apparently, the drug was available under the name Epiglandol.17 The interest in a possible relationship between schizophrenia and the pineal gland did not terminate after the discovery of the secretion of melatonin in 1958.18,19 •

References

1. Descartes R. (1649) Passions de l’âme. Le Gras, Paris.

2. Morabia A. Pierre-Charles-Alexandre Louis and the evaluation of bloodletting. J R Soc Med. 2006 Mar;99(3):158-60.

3. Aminoff MJ (2011). Brown-Séquard: An Improbable Genius Who Transformed Medicine. Oxford, University Press: 235-260.

4. Borell, M. (1976) Brown-Séquard’s organotherapy and its appearance in America at the end of the nineteenth century. Bull Hist Med 50: 309–320.

5. Schlich, T. (2010). The Origins of Organ Transplantation. Rochester: University of Rochester.

6. Brown-Séquard CE (1893) New therapeutic method consisting in the use of organic liquids extracted from glands and other organs. Brit Med J 1:1145-1147;1212-1214.

7. Gijswijt-Hofstra M. Introduction: Cultures of Neurasthenia from Beard to the First World War. Clio Med. 2001; 63:1-30.

8. Solis-Cohen S (1893). The therapeutic properties of animal extracts. Philadelphia Polyclinic and College for Graduates in Medicine, vol. II, no. 11, pp.309-18. Available via The therapeutic properties of animal extracts – Digital Collections – National Library of Medicine (nih.gov) ; accessed August 11th, 2024.

9. Schiller F (1995) Pineal gland, perennial puzzle. J Hist Neurosci 4:155-165.

10. Vesalius (1543). De humani corporis fabrica, Libri septem, Basel, Ioannis Oporini, pp. 611 and 615. Available via https://www.e-rara.ch/bau_1/content/titleinfo/6299027 ; accessed August 11th, 2024.

11. Sobotta J (1920) Atlas der deskriptiven Anatomie des Menschen. 3rd part. Lehmanns, München, p. 606.

12. Dana CL, Berkeley WN. The functions of the pineal gland. With report of feeding experiments by Goddard, H.H., Walter S Cornell. Medical Record 1913; 83:835.

13. Goddard HH. The Vineland experience with pineal gland extract. JAMA 1917; 18:1340-1.

14. Berkeley W (1914) The use of pineal gland in the treatment of certain classes of defective children. Medical Record 85:513–515.

15. López-Muñoz F, Molina JD, Rubio G et al (2011) An historical view of the pineal gland and mental disorders. J Clin Neurosci 18:1028-1037.

16. Evans B, Jones E (2012) Organ extracts and the development of psychiatry: hormonal treatments at the Maudsley Hospital 1923-1938. J Hist Behav Sci 48:251-276.

17. Koopman. Nieuwe onderzoekingen over de pijnappelklier. Ned Tijdschr Geneeskd 1921; 65:1449-50.

18. Kappers JA. The mammalian pineal gland, a survey. Acta Neurochir (Wien). 1976;34
(1-4):109-49.

19. Wurtman RJ. Melatonin as a hormone in humans: a history. Yale J Biol Med. 1985 Nov-Dec;58(6):547-52.

Prof. Marco Tulio Medina Recognized

Marco Tulio Medina

Award given for contributions to epilepsy in Latin America.

Prof. Marco Tulio Medina, previous president of the Pan American Federation of Neurological Societies and previous co-opted trustee of the WFN, was recognized by the International League Against Epilepsy (ILAE) Latin American Commission, on June 15, 2024, in Santa Domingo in the Dominican Republic. He was acknowledged for his leadership, work, and contribution to the ILAE vision and mission in the Latin American region. •

World Brain Day From 2014-2024

Reviewing the themes and progress of World Brain Day through the years.

Tissa Wijeratne

By Prof. Tissa Wijeratne

The annual World Brain Day (WBD) campaigns from 2014 to 2024 have significantly advanced global awareness and advocacy for neurological health. Each year, the campaign has focused on a specific theme, addressing critical neurological issues and fostering global collaboration among health care professionals, policymakers, and the public.

The journey began in 2014 with “Our Brain, Our Future,” establishing the importance of prioritizing brain health worldwide. Subsequent campaigns have spotlighted epilepsy (2015), brain health in aging (2016), stroke prevention (2017), the impact of air pollution on brain health (2018), migraine management (2019), Parkinson’s disease (2020), and multiple sclerosis (2021). These initiatives have not only raised awareness but also promoted preventive strategies and innovative treatments tailored to each condition.

In 2022, the campaign expanded its focus to “Brain Health for All,” emphasizing the global necessity of promoting brain health for overall well-being. The 2023 campaign addressed “Brain Health and Disability,” highlighting the need for early intervention, access to rehabilitation services, and social inclusion for those with neurological conditions.

The 2024 campaign has taken a decisive step by advocating for brain health and prevention in direct alignment with the WHO’s Intersectoral Global Action Plan (IGAP) on Epilepsy and Other Neurological Disorders. This year’s focus underscores the importance of implementing the WHO IGAP toolkit, which provides a comprehensive framework for prevention, early diagnosis, and equitable access to care. By promoting these strategies, the campaign aims to reduce the global burden of neurological disorders and enhance the quality of life for individuals affected by these conditions.

These campaigns have played a crucial role in advancing the global conversation on brain health, influencing policies, and improving lives. The success of these initiatives is a testament to the tireless efforts of member neurology societies worldwide.

On behalf of the global neurology community, we extend our deepest gratitude to all the member neurology societies for their unwavering support and commitment. Your collaboration and dedication have been instrumental in making these campaigns impactful and meaningful, contributing to a future where brain health is prioritized for all. Together, we continue to work toward a world where everyone can achieve and maintain optimal brain health. •

Prof. Tissa Wijeratne is co-chair of World Brain Day.

Making a Difference Down Under

An Australian high school student celebrates World Brain Day 2024.

Sarah McPartland

By Sarah McPartland

I was inspired by Prof. Tissa Wijeratne, co-chair of World Brain Day, to develop a template for how our school community could raise awareness about the 10 vital steps (“Life’s Ten”) to good brain health through the “Brain Health and Prevention” campaign. This initiative served a dual purpose: educating our student body and uniting us in a fun and meaningful way to not only learn but also raise funds for this important cause.

As school captain, I brought this idea to our student senate meeting, and I was thrilled by the overwhelming support from my fellow students and the senior staff within our leadership team. We’ve since created a poster that will be displayed throughout the school leading up to the events we’ve planned.

Brain health is crucial for laying the foundation for future well-being. Simple preventative steps, like eating healthy or getting enough sleep, can protect young brains from cognitive decline and neurological conditions later in life. By establishing these good habits now, our generation can enhance our learning abilities and improve our quality of life as we age.

Every weekend, I visit my grandfather, who suffers from vascular dementia and Alzheimer’s disease. Seeing others in his senior care facility who are unable to speak or move without a nurse’s assistance has deeply affected me. Knowing that we can equip the next generation with proactive and practical ways to prevent such a decline in quality of life motivates me. This knowledge has the potential to significantly reduce the number of individuals facing cognitive decline in the future.

Our goal is to pioneer brain health education within our school by implementing a Brain Health Week. Each day of this week will focus on two of the 10 essential steps for maintaining healthy cognition. We want to ensure that students understand these steps and can apply them practically in their daily lives. These steps will support their learning, decision making and long-term cognitive health.

The week will culminate in a pajama day fundraiser on Friday, highlighting the importance of adequate sleep as a preventative measure. The funds raised will be donated to a brain health charity, allowing students to not only learn how to maintain good brain health themselves but also contribute to research aimed at preventing cognitive decline.

Through these efforts, our leadership team hopes to empower students to maintain optimal cognitive function throughout their lives. •

Sarah McPartland is year 12 school captain of Melton Christian College in Melton, Victoria, Australia.

World Brain Day 2024 in Tunisia

Event themed around stroke – a leading cause of disability in Tunisia.

Riadh Gouider

By Prof. Riadh Gouider

The Tunisia World Brain Day event, held on July 10, 2024, in Tozeur under the patronage of the Minister of Health, focused on the prevention of disability which, along with stroke, was theme of the event.

Stroke is a leading cause of disability and mortality in Tunisia. Telethrombolysis, a method that enables the indication and administration of thrombolytic treatments via telemedicine, offers a promising solution for improving stroke management in underresourced areas without access to neurologists. The purpose of this event was to advance understanding and practices related to telethrombolysis and its critical role in stroke care and preventing disability. Speakers included many heavyweights in neurology.

  • Prof. Wolfgang Grisold, president of the World Federation of Neurology (WFN), provided an online opening and presented a global perspective on neurology. He also expressed the WFN’s support for initiatives aimed at enhancing neurological care all over the world.
  • Prof. Valeria Caso, past president of the European Stroke Organization (ESO) and board member of the World Stroke Organization (WSO), shared international case studies and experiences in telethrombolysis, illustrating the global relevance of this approach.
  • Prof. Riadh Gouider, president of the Tunisian College of Neurology and Neurosurgery, detailed recent innovations in telemedicine within Tunisia and their impact on stroke care.
  • Prof. Chokri Mhiri, head of the department of neurology at the University of Sfax, presented an update on the current practices and advancements in thrombolysis.
  • Prof. Mariem Damak of the University of Sfax, Dr. Habib Haguiga, emergency physician in Tozeur, and Prof. Habiba Mizouni of La Rabta Hospital in Tunis, discussed guidelines and challenges in stroke care in Tunisia and elaborated on the objectives and progress of the telethrombolysis project.
  • Prof. Didier Smadja, from Paris, highlighted the urgent need to expand telestroke services through national and international collaborations and the establishment of a telethrombolysis network that would connect health centers across Tunisia with Tunisian and international experts. This network would aim to improve clinical outcomes, reduce disparities in access to care, and promote expertise in neurovascular pathologies among Tunisian neurologists. If this pilot project proves successful, it could be extended throughout Tunisia and potentially to other African countries.

The event also marked the inauguration of a local telethrombolysis pilot project, which is a collaborative effort involving three teams: the Emergency Department of Tozeur, the radiology team from Rabta in Tunis, and the Neurology Department of Habib Bourguiba Hospital in Sfax. •

Prof. Riadh Gouider is co-chair of the WFN Education Committee and past WFN trustee.

A Neurology Teaching Course in Uganda

International collaboration provides a potential future platform for bilateral knowledge exchange.

Dilraj Singh Sokhi

By Dilraj Singh Sokhi

The dire lack of neurologists in Africa has been well documented over the decades. However, the situation has, unfortunately, scarcely changed. Uganda has six neurologists for a population of 47 million. Although there are growing multifaceted movements on the continent to address this workforce gap, it would take generations to reach levels stipulated by the World Health Organization (WHO).

There are a handful of postgraduate neurology training centers in the region, but only one in East Africa (Nairobi, Kenya) and none in Uganda. Education about the nervous system needs to continue and expand in the region, especially given its disproportionately large burden of neurological disease. Innovation is thus required in delivering this education, and we outline here one such successful endeavor in Uganda.

The Organization of Islamic Cooperation (OIC) is an intergovernmental organization with a membership of 57 states spread over four continents. It aims to promote international peace and harmony globally, including through supporting scientific knowledge exchange via its Standing Committee on Scientific and Technological Cooperation (COMSTECH). The Science, Technology and Innovation (STI) arm of COMSTECH recognizes the need for improving medical sciences knowledge dissemination. In this regard, it brought three neurologists together to deliver a one-day certificate course in neurology at two centers in Uganda that would normally not have regular access to neurology expertise.

Our first stop was the Equator University of Science and Technology (EQUSaT), which was founded in 2021 through mutual agreement between the Republic of Uganda and the University of Lahore in Pakistan. The pioneering medical and dental students had recently commenced their clinical rotations, and it was an opportune time to discuss and demonstrate the clinical skills required for assessing patients with neurological conditions.

We presented a blended variety of talks, from didactic lectures to case-based hands-on teaching. The timetable covered the spectrum of neurology, including neurocritical care elements, from clinically relevant neuroanatomy and neuroimaging to topic-based lectures and discussions on the most common conditions (as identified by the Global Burden of Disease findings): epilepsy, headache, infections of the nervous system, and stroke. Students and doctors from neighboring colleges and hospitals were invited, and we undertook pre- and post-course evaluations to help learners assess the impact the course made on their neurology knowledge.

We replicated the workshop in the more established OIC-cofounded Islamic University in Uganda (IUIU), at the Habib Medical School in Kampala. The chief guest was the Deputy High Commissioner of Pakistan in Uganda, His Excellence Bilal Abdul Mohsin. The efforts of delivering the course were recognized as a potential future platform for ongoing bilateral knowledge exchange, collaboration, and innovation, as well as strengthening the bonds between Pakistan and Uganda.

Aga Khan University in Karachi already delivers an annual online certificate course in neurology, which is open for anyone to enroll at a modest price. However, neurology remains a clinical specialty. Therefore bedside teaching and examination remain a vital part of training, as we did in the courses in Uganda. Simple but impactful multi-country ventures such as these are important examples of how to extend the reach of neurology education in resource-limited settings such as East Africa. They are well aligned with the educational mission of the World Federation of Neurology. •

Dr. Dilraj Singh Sokhi is associate professor and associate fellowship director of neurology at Aga Khan University in Kenya.

Join Us for the WFN Digital Neurology Updates: WNU 2024

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!

Council of Delegates Meeting and More

Prof. Wolfgang Grisold highlights upcoming elections, global activities, World Brain Day, and educational efforts.

I hope you have had a nice summer, and all your work has been rewarding. For the World Ferderation of Neurology (WFN), the past months have been successful, and I want to update you on the upcoming Council of Delegates (COD) meeting, global activities, World Brain Day (WBD) 2024, education, and future meetings.

COD Meeting

This year’s COD meeting will convene on Sept. 25, 2024. A new trustee will be elected, replacing Prof. Alla Guekht, who successfully completed two terms as a trustee. Prof. Guekht has been very active, and during her term she has contributed enormously toward advancing the WFN in the global arena, working with the World Health Organization (WHO) and the U.N. Economic and Social Council. Prof. Guekht’s mission for global neurology was successfully supported by WFN intern Dr. Ksenia Pochigaeva, who monitored and updated us on important events.

The WFN board consists of four officers, three elected trustees, and up to two co-opted trustees. The trustees are regulated by the U.K. charity law, and they bear full personal responsibility for their tasks. The elected trustees may opt to elect two co-opted trustees for one year. These elections depend on requirements such as balance of the regions, gender, or other specific issues. This year’s co-opted trustees are Prof. Maria Benabdeljlil (Morocco) and Prof. Minerva Ruiz (Mexico).

The vote for the elected trustee position will be electronic, with six candidates applying for the position. (Read their statements.) These candidates have been scrutinized and recommended by the WFN Nomination Committee.

WFN leadership will undergo major changes in 2025, with terms ending for the president, past president, and one trustee. With a change of this magnitude, we need to ensure continuation on both the ends of the president’s term will be implemented. To facilitate this continuation, we suggest having the president-elect voted on one year earlier, and having the past president continue for another year, with both serving as advisors on the board. This suggestion will be made as a motion at the COD meeting by the trustees this year.

The WFN as a global organization has many long-term projects and responsibilities for global activities as well as education and meetings. For a simple overview, we have created a page to help guide visitors through the WFN activities.

In addition to the trustees’ reports, several committees will present their reports at the COD meeting. The financial audit (a yearly report for the U.K. Charity Commission) will be sent in advance, and delegates will be able to ask questions and give their final approval.

At this time, there will also be a call for the World Congress of Neurology (WCN) 2029, which will take place in Europe.

Global Activities

(Left to right) Prof. M. Benabdeljlil, Prof. Riadh Gouider, Natacha Kiswendsida (epilepsy trainee), Prof. Wolfgang Grisold, and Dr. Steven Lewis.

Global activities continue jointly with the WHO and the U.N. ECOSOC. On July 8, 2024, the WHO IGAP Toolkit was released. The WFN was honored to be a speaker at the release, which was a successful presentation of longstanding developments and will help all stakeholders implement the IGAP project. There are many entry points to the project, and all WHO member states will have the opportunity to adapt the IGAP to their needs by using this toolkit.

The main pillars of the IGAP are advocacy, prevention, therapy, research and development, and public health. These pillars provide opportunities for all to participate and reach the goals. As with our participation in the development and support of the toolkit, the WFN has taken the IGAP as a personalized agenda to move and develop further, and we welcome the WHO’s strong engagement in neurology. This is a unique opportunity, and the IGAP will continue to be a permanent platform for global neurology that will aid in implementing neurology and neurology services in all countries in need.

(Left to right) Prof. M. Benabdeljlil, Prof. Riadh Gouider, Dr. Mundih Njohjam (epilepsy trainee), Prof. Wolfgang Grisold, and Dr. Steven Lewis.

At the U.N. ECOSOC meeting in New York, the WFN was represented by Prof. Guekht. This United Nations High-Level Political Forum (HLFP) on sustainable development took place July 8-17, 2024, under the auspices of the ECOSOC. The main theme of the ECOSOC was “Reinforcing the 2030 agenda and eradicating poverty in times of multiple crises: the effective delivery of sustainable, resilient, and innovative solutions.” The WFN submitted a written statement on “Advancing Brain Health for Sustainable Development: A Call to Action.”

WBD Activities

WBD 2024 featured the topic “Brain Health and Prevention,” and followed our series of WBDs promoting brain health. It added to previous important features such as disability, which was the theme in 2023. Both dedicated WBDs have left us with many suggestions and tasks. We have learned that disability is more common than we assume. The recent update of the Global Burden of Disease has confirmed this and increased the spectrum from 17 to 34 neurological conditions.1 Disability in neurological disease not only includes long-term care and rehabilitation, but also the prevention of neurological diseases and avoidance of stigma.

Prevention, which was chosen for this year’s WBD, is a powerful tool that may be underused. We have seen many examples, including stroke, cerebrovascular disease, and several others. Recently, we have been exposed to many prophylactic recommendations to prevent dementia.2 In addition, we also face the introduction of new therapies, and we hope to gain strength and competence in these important areas to prevent and even cure dementia.

As with any biological condition, there are factors that can be modified, and others that can not. The impact of aging on cell biology and on the body are well known to neurologists. Many age-related factors, such as brain volume, cognitive capacities, performance of the neuromuscular system, and posture and gait, are implicitly incorporated into our daily work. We are aware that brain function in aged individuals varies, depending on many factors. The topic of aging and senescence is important for all parts of the body.3 Insight into these mechanisms will be important for future research.

As the age pyramid affects all global regions, this is a common issue for neurology worldwide. In addition to research, prevention, and care, we must also be aware to prevent ageism as brain health concerns the entire life span.4

Please see our report on WBD 2024. The webinar was attended by 1,000 participants. See a list of selected articles about WBD. (See Table 1 at the bottom of the page.)

Several awards for brain health projects were presented during a meeting of the Chinese Society of Neurology.

Chinese Society of Neurology

The Chinese Society of Neurology set aside July 21, 2024, to celebrate brain health and prevention. The event featured a large meeting with keynote lectures and several dedicated sessions about brain health at the China National Convention Center in Beijing. The theme was “World Brain Day 2024: Brain Health and Prevention.” The goals were to enhance public awareness of brain health, foster scientific advancement in brain health, and prevent and treat significant neurological and psychiatric disorders, including cerebrovascular diseases, cognitive disorders, and depression. There was also a focus on children’s brain development.

The conference invited prominent experts and scholars from both domestic and international arenas. Their presentations brought focus to the latest research advancements. There were also themed forums that presented and explored 12 specialized reports from various angles.

On WBD, Beijing Tiantan Hospital offered a free neurologic consultation day.

During the meeting, several awards for brain health projects were presented. On WBD, Beijing Tiantan Hospital offered a free neurologic consultation day that was well attended. Please also see the JNS WFN service page for more details.

WFN Educational Activities

We invite you to participate in the WFN’s educational activities. The e-Learning Hub has now received an improved, user-friendly interface, which will help guide all users of our website to engage in our archive and see past educational activities. Users can also connect to ongoing international activities.

The WFN Digital Neurology Update (WNU) takes place virtually Sept. 26-27, and serves as an update platform for neurology. There will be six plenaries from world-renowned experts on stroke, epilepsy, movement disorders, multiple sclerosis, headache, and dementia. During a break, attendees will have the opportunity to see industry and society events. Each day will conclude with six teaching courses in the afternoon. These will focus on important topics such as stroke, epilepsy, neuromuscular disorders, headache, the autonomic system, and the emerging topic of neuroepidemiology. All registered participants will be able to see all six teaching courses.

AFAN group photo after the closing ceremony.

For October, we plan a joint session with the World Stroke Organization (WSO) at the World Stroke Congress in Abu Dhabi. The session will focus on palliative care in stroke, which confirms the WFN’s major interest in disability, long-term care, and palliative care.

The International Congress on Neuromuscular Diseases (ICNMD), the WFN’s neuromuscular congress, will be held Oct. 25 in Perth, Australia. After circulating the globe, the ICNMD has found excellent hosts in Perth and will present a congress incorporating all parts of the neuromuscular system, such as motor neuron disease, peripheral nerves, neuromuscular transmission, and muscle. We expect an exciting program. For those unable to travel to this destination, we will provide a virtual program that will cover the highlights.

Jointly with the International Headache Society, Global Patient Advocacy Coalition, the American Migraine Foundation, and the African Academy of Neurology (AFAN), we will continue our e-learning days on headache. The next session, Education in Headache to Health Care Professionals in Africa, is planned for Nov. 23, 2024. Register for the free session.

Early in 2025, we will have a joint educational day with the Asian and Oceanian Association of Neurology (AOAN) on movement disorders, autoimmune diseases, and the brain.

Prof. Gallo Diop receives the acknowledgement from WFN President Prof. Wolfgang Grisold.

We supported and attended the July meeting of AFAN in Dakar. There was a joint education session with AFAN on Africa, and Prof. Gallo Diop was honored by the WFN.

We also conducted a site visit at our successful WFN Training Center in Dakar. Interviews with the staff and the trainees confirmed the high level of the training center. Please read more on the educational situation in the WFN service pages in the Journal of the Neurological Sciences.

The WFN continuously offers positions for training in our WFN Training Centers. For Cape Town, a new four-year training position was announced in July 2024. The position generated 165 applications, which is a new record of interest.

Jointly with the AAN, the WFN is developing a global program for Advocacy and Leadership for low middle and low income countries. You can find more information on the WFN website.

Please follow our website, social media, and the JNS WFN service page for more news from WFN. •

Table 1. Organizations and publications featuring WBD articles.

Organization or Publication

Article Title

Link

The Lancet

World Brain Day 2024: A Focus on Brain Health and Prevention

https://www.thelancet.com/journals/laneur/article/PIIS1474-4422(24)00270-9/fulltext

WFN

World Brain Day 2024

https://wfneurology.org/world-brain-day-2024

PR Newswire

2024 World Brain Day Dedicated to Brain Health and Prevention

https://www.prnewswire.com/in/news-releases/2024-world-brain-day-dedicated-to-brain-health-and-prevention-302137564.html

Journal of Neurological Sciences

World Brain Day 2024: Promoting Brain Health and Prevention

https://www.jns-journal.com/article/S0022-510X(24)00230-2/abstract

EPNS

World Brain Day 2024

https://www.epns.info/world-brain-day-2024/

National Library of Medicine

Wolrd Brain Day 2024: A Focus on Brain Health and Prevention

https://pubmed.ncbi.nlm.nih.gov/39033775/

WFN

World Brain Day: Background

https://wfneurology.org/world-brain-day-background

National Today

World Brain Day 2024

https://nationaltoday.com/world-brain-day/

World Neurology

World Brain Day 2024: Promoting Brain Health and Prevention Globally

https://worldneurologyonline.com/article/world-brain-day-2024-promoting-brain-health-and-prevention-globally/

Revival Research Institute

World Brain Day 2024: Tips to Improve Your Brain Health

https://revivalresearch.org/blogs/world-brain-day-2024

UBC News

World Brain Day 2024: Protecting Our Future

https://events.ubc.ca/event/world-brain-day-2024-protecting-our-future/

Science Open

World Brain Day 2024

https://blog.scienceopen.com/2024/07/world-brain-day-2024/

Aspire

World Brain Day 2024

https://aspire.care/featured/world-brain-day-2024/

Medindia

World Brain Day 2024: Advocating for Brain Health and Prevention

https://www.medindia.net/news/healthwatch/world-brain-day-2024-advo cating-for-brain-health-and-prevention-216489-1.htm

American Brain Foundation

World Brain Day: 4 Simple Ways to Support Brain Health

https://www.americanbrainfoundation.org/world-brain-day-4-ways-to-support-brain-health/

References

1. Collaborators, GBD. Nervous System Disorders. 2024. Global, regional, and national burden of disorders affecting the nervous system, 1990-2021: a systematic analysis for the Global Burden of Disease Study 2021. Lancet Neurol.

2. Livingston G, Huntley J, Liu KY, Costafreda SG, Selbaek G, Alladi S, Ames D, Banerjee S, Burns A, Brayne C, Fox NC, Ferri CP, Gitlin LN, Howard R, Kales HC, Kivimaki M, Larson EB, Nakasujja N, Rockwood K, Samus Q, Shirai K, Singh- Manoux A, Schneider LS, Walsh S, Yao S, Sommerlad S, and Mukadam N. 2024. Dementia prevention, intervention, and care: 2024 report of the Lancet standing Commission. Lancet.

3. Ogrodnik M, Carlos Acosta J, Adams PD, d’Adda di Fagagna F, Baker DJ, Bishop CL, Chandra T, Collado M, Gil J, Gorgoulis V, Gruber F, Hara E, Jansen-Durr P, Jurk D, Khosla S, Kirkland JL, Krizhanovsky V, Minamino T, Niedernhofer LJ, Passos JF, Ring NAR, Redl H, Robbins PD, Rodier F, Scharffetter-Kochanek K, Sedivy JM, Sikora E, Witwer K, von Zglinicki T, Yun MH, Grillari J, and Demaria M. 2024. Guidelines for minimal information on cellular senescence experimentation in vivo. Cell 187 (16):4150- 4175.

4. Marques, S, Mariano J, Mendonca J, De Tavernier W, Hess M, Naegele L, Peixeiro F, and Martins D. 2020. Determinants of Ageism against Older Adults: A Systematic Review. Int J Environ Res Public Health 17 (7).

Central Nervous System Tuberculosis

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 •

End TB Strategy

To raise the profile of neurological disorders globally, the World Federation of Neurology (WFN) leverages its position as a WHO non-state actor and a non-governmental organization in consultative status with the UN Economic and Social Counsel (ECOSOC). The WFN commends the progress of the End TB Strategy, adopted by the World Health Assembly in 2014 as part of the Sustainable Development Goals (SDGs), and has taken the opportunity to intervene on several occasions to bring attention to the neurological complications of tuberculosis.

A written statement was submitted during the September 2023 SDG Summit in New York, highlighting the need for collaboration among multiple stakeholders and equitable access to health care to ensure the success of the End TB Strategy. The role of neurologists is crucial for the diagnosis, treatment, and prevention of the dangerous neurological complications of TB, including tuberculous meningitis. In May 2024, the WFN delegation had the privilege to address the World Health Assembly in Geneva and reaffirm the interconnection between decreasing the burden of tuberculosis and neurological health.

—Ksenia Pochigewa, Alla Guekht, Wolfgang Grisold.

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/.

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