By Chandrashekhar Meshram

Chandrashekhar Meshram

The second wave of the COVID-19 pandemic was devastating in India with a sudden spurt in cases during the second quarter of the year, and with the count of daily cases crossing 400,000. During this pandemic, there was another epidemic of the fungal infection mucormycosis.

This pandemic and epidemic completely exposed the lacunae in the health care system in the country. There was a shortage of medicines, a shortage of hospital beds, a shortage of oxygen supply, and a shortage of health care personnel, resulting in high morbidity and mortality. According to the statement on June 28 by the Union Health Minister, 40,845 cases of mucormycosis were reported in the country. Out of these, 85% patients had COVID-19, 62% had diabetes as a comorbidity, and 63% of patients had received steroids. The alarming fact is that 32% of the patients were in the age group of 18 to 45 years.

Mucormycosis is caused by saprophytic fungi of the order Mucorales, which are found in decaying organic matter and soil samples. Rhizopus Arrhizus is the most common etiological agent in India. Mucormycosis is an angioinvasive disease causing tissue infarction and necrosis. Rhino-orbito-cerebral mucor is the most common presentation, followed by pulmonary, cutaneous, gastrointestinal, renal, and disseminated disease.

Rhino-orbito-cerebral mucormycosis (ROCM) is often encountered by neurologists. Clinical manifestations of ROCM syndrome include new onset unilateral headache, facial pain, facial numbness, orbital pain, diplopia, ophthalmoplegia, impairment of vision, orbital swelling, ptosis, proptosis, papilledema, nasal discharge, and epistaxis. Black discoloration of skin and mucosa are characteristic of mucor infection. Sometimes there is cavernous sinus thrombosis and internal carotid artery block. The majority of patients with ROCM in association with COVID-19 develop symptoms between day 10 and day 15 post COVID-19. However, delayed presentation can occur up to three months.

MRI images of mucormycosis with cavernous sinus involvement in a patient with COVID-19.

Imaging findings on CT or MRI that suggest the diagnosis are non-enhancing hypointense mucosa over nasal turbinate and nasal septum (black turbinate sign), concomitant involvement of paranasal sinuses and orbit, bone erosion or destruction, cavernous sinus involvement (figure), and ischemic stroke.

The diagnosis is confirmed by demonstrating fungus with special stains in tissues obtained from nasal scraping or surgery.

Mucormycosis is a medical emergency, and treatment should start with antifungal drugs, surgical intervention, and correction of metabolic abnormalities or risk factors. Amphotericin B is the first-line drug of choice. Liposomal form of Amphotericin B (LAmpB) is preferred in view of a better side effect profile. The efficacy of conventional deoxycholate amphotericin B (dAmpB) is not inferior to the liposomal form but has more side effects. However, the cost of LAmpB is 10 times more. Nephrotoxicity is the most common side effect of dAmpB.

Other drugs used in the treatment are posaconazole and isavuconazole. Oral medication can be used for longer duration. The duration of treatment is not known and has to be decided on a case-to-case basis. Ampho B is recommended for initial 4-6 weeks, which can be followed by posaconazole or isavuconazole for a few more weeks.

Surgical treatment includes debridement or excision of necrotic tissue. Depending on the site of involvement, an ENT surgeon, ophthalmologist, dental surgeon, and neurosurgeon should be part of the team. Surgical intervention at early stage improves the outcome. Functional endoscopic sinus surgery, paranasal sinus debridement, and orbital exenteration are commonly required surgical procedures in ROCM.

The major drawbacks in managing mucormycosis in India are a gap in treatment protocol and non-affordability of LAmpB due to financial constraints.

The mortality rate of mucormycosis in India is in the range of 28–52%, and it increases to 80% in intracranial extension of disease. High mortality is due to delays in seeking medical attention and diagnosing the disease and challenges in managing the advanced stage of infection. There is an urgent need to increase awareness among the general public and doctors for early diagnosis and treatment.

The intriguing question is why there has been such a recent spurt of cases of mucor in India? Though mucormycosis is globally distributed, its estimated prevalence even before the COVID-19 pandemic was 70 times higher in India as compared to global data. The possible reason for the high prevalence is the abundant presence of Mucorales in the community and the hospital environment and the high prevalence of diabetes in the Indian population. The sudden spurt during the second wave might be due to a lowering of immunity by the new strain of COVID-19 making these patients susceptible for fungal infection. •

Chandrashekhar Meshram is chair of the The Tropical and Geographical Neurology Specialty Group of the WFN.

By Satish Khadilkar and Sarosh Katrak

The COVID pandemic had universal effects on medicine, and Mumbai was no exception. In fact, being a densely populated city with lots of international travelers, the cases appeared early and the magnitude was high, throwing the health system off gear.

While most of the younger neurologists continued to work, they had to be involved with COVID duties as well. The focus shifted to service medicine and service neurology in a major way, and academic activities had to take a back seat.

The AAN-WFN Continuum Program has been operational in Mumbai since 2005, initiated by S. M. Katrak as per the advice given by Ted Munsat. The first event was held at Mumbai on

July 17, 2005, on multiple sclerosis and was attended by postgraduate students from five institutions. Following the success of the program at Mumbai, teachers in other cities of India also conducted Continuums in their cities, and the programs were well regarded by students and practitioners.

Satish Khadilkar had attended the programs since the beginning and participated more actively in the later years, taking up the responsibility as co-convenor of the program with Katrak’s guidance and advice, and as convenor since 2021.

Virtual platforms gradually developed, and the government opened up online consultations in 2020. We decided to shift to an online platform for this CME program. Having worked with physical copies of Continuum and in-person meetings, it was a challenge to acclimatize to this form of learning.

Interestingly, it did not prove too difficult, particularly for younger colleagues. We conducted the first online Continuum program Dec. 27, 2020, on the topic of neurocritical care. It was attended by 48 participants.

In 2021, we have conducted programs on dementia, epilepsy, and demyelinating disorders, which were attended by approximately 50-85 students from various institutions in Mumbai, other places in the state of Maharashtra, and a few from the state of Gujrat. We incorporated the Google forms for virtual feedback. All participants do not complete the forms, and we are exploring ways to facilitate the process.

We have recently adopted a system wherein a mentor helps the presenter to prepare his slides. This approach has much increased the clarity and utility of the presentations, time management, homogeneity of the group, and the individuals find themselves more involved. We intend to persist with this pattern and are in discussion with other centers in India to adopt this method in their centers for these Continuum programs. •

By Peter J. Koehler

Christiaan Huygens; painting by Caspar Netscher (public domain).

Many famous persons, today as well as in the past, suffer(ed) from migraine. With a prevalence of around 16% for women and 8% for men, it ranks high in the Global Burden of Disability.1 Going back in history, it may be difficult to make a retrospective diagnosis, in particular, if not all symptoms, as described in current diagnostic classifications, are mentioned. However, the disability can often be recognized quite easily, as in the following case. In this essay, I will discuss a 17th century scientist, who was suffering from frequent headaches, possibly migraine.

Conversation in Latin at Age 9

Christiaan Huygens (1629-1695) was born in The Hague (Netherlands) as the second son of Suzanna van Baerle (1599-1637) and Constantijn Huygens (1596-1687), who had been a diplomat and secretary of two Princes of Orange. Constantijn was also a poet and composer. He was interested in the arts and is considered by some the discoverer of the talent of Rembrandt (and Lievens), who at the time were working in nearby Leyden. He was acquainted with Descartes and played an important role in the publication of his Discours de la méthode (Dioptics). Most probably, they first met at Hofwijck castle, Huygens’ summer residency just outside of The Hague, in May 1642. Descartes wrote about Constantijn Huygens. “The honour to know him I cherish as one of the most happy things that happened to me.” Huygens wrote about Descartes: “Truly, he is a man superior to all esteem that one would wish to render him.”

Design for a microscope in letter to his brother Constantijn 1678.9

Christiaan was educated at home and excelled in nearly all subjects. He was able, for instance, to converse in Latin at age 9. Following a two-year study period of law and mathematics at Leyden University, he continued his studies at the Orange College in Breda. Despite his father’s wish to become a diplomat, Christiaan was interested in mathematics rather than law. He, as well as his father, corresponded with the French philosopher and mathematician Marin Mersenne (1588-1648). Constantijn called his son “mon Archimède,” in imitation of the Mersenne, who had noticed the remarkable gift of young Christiaan and encouraged him to continue his mathematical studies.

Designs for an Improved Microscope

Brass microscope with five diaphragms and object revolver for six specimens after design by Christiaan Huygens (c 1680). Courtesy Boerhaave Museum, Leiden (V 26952).

Thus, Christiaan became famous as mathematician, physicist (considered a founder of mathematic physics), and astronomer, who corresponded with and became Fellow (1663) of the Royal Society (London), as well as member (and research director) de l’Académie des Sciences (Paris). At the latter academy, he was served and paid by King Louis XIV. Christiaan invented the pendulum clock2 and described light as a wave phenomenon;3 moreover, he discovered the moon Titan of Saturnus (1655; publication of De Saturni Luna observatio nova in 1656). He constructed a variety of optical instruments, often in close association with his older brother Constantijn.4 He not only used telescopes, but was also interested in microscopes. Already in the 1650s, the brothers had compound microscopes. Christiaan’s enthusiasm for this instrument increased after he had translated and presented the work of Antoni van Leeuwenhoek at the Paris Académie. He also wrote to Nehemia Grew (1641-1712), the Secretary of the Royal Society in London, that he “directed [his] mind to constructing a new microscope, excited by that new observation, which shows that the semen is full of living vivacious animalcula.”5 As Van Leeuwenhoek’s letter was published in the Philosophical Transactions only a year after receipt, Huygens’ short description became the first.4 Not satisfied with Leeuwenhoek’s original instrument, Huygens made six designs of an improved simple microscope with a diaphragm revolver as well as a specimen revolver. The improvement concerned the quality of the image and the manipulation of the specimens.4 In August 1678, he wrote to his brother about a more practical type of microscope. The design was used by several instrument makers.

Incapacitating Headache

In the 22-volume Oeuvres Complètes (OC 1888-1950), that includes his correspondence (in Latin, German, English, and Italian) and writings, mainly written in (old) French, interesting information can be found about his chronic headache.

In 1652, in a letter to Frans van Schooten junior, who was professor of mathematics at the University of Leyden, Christiaan wrote about his headaches for the first time. He must have been 23 years old. Due to headache that was not always present, but occurred at the most inconvenient moments, he was often unable to work, unless he was able to overcome the pain by willpower. About 10 years later, we learn about the treatment that was applied as advised by his physician. In a letter to his younger brother Lodewijk, he complained about his headaches and mentioned that he had had himself bled and purged. These kinds of treatments were indeed quite common and should be explained in the context of contemporary humoral medicine.7

Since my latest [letter] I have taken advise of our medic Libergen [sic], who had me purged and bled, having done that, I had a nasty cold as I have never known to have had, in such a way that I not only have to stay at home, but also have to abstain from reading, writing, or meditating, because as soon as I do I have a headache.

The Liebergen family counted numerous physicians. Huygens probably referred to Willem van Liebergen (1601-1674), who had studied philosophy and medicine at Leyden University.

Christiaan had to apologize himself regularly for his behavior due to headache. After he moved to Paris and became a member of the new Académie Royale des Sciences, he wrote to the husband of his sister Susanna that due to headache, he had been unable to write him, although he usually was punctual with this respect. He still felt some remnants of the latest period.

A few months later, in November 1666, he wrote to the same person that writing caused headache. In 1677, Constantijn sr. wrote about his son’s health. “My Archimedes has recovered well enough from his ailment, although always frail and subject to headaches.” A year later, Constantijn jr. wrote, “My brother has a severe headache.” At age 56, Christiaan was still suffering from headaches, writing “I have written a part of the memoirs, as you know and would have completed it without headaches that, since Easter day, have annoyed me and by which, still today, I did not go outside.”

Half a year later, he wrote again to his brother Constantijn that “since three days there is a constant fog here that gives me very annoying migraines.” In the spring of 1686, he wrote to the same brother that next to an inguinal hernia, he was still suffering from headaches. “Meanwhile I am suffering as you may believe, in addition I have been tormented anyhow all these days by my migraines, that now begin to leave me.”

Correspondence With European Scientists

In his correspondence with many famous persons of the period, Christiaan sometimes referred to his headache. In January 1664, the French poet and critic Jean Chapelain (1595-1674), who also corresponded with Constantijn sr., wrote to Christiaan: “I am glad at least about the relief that you experienced with respect to you headache.” Toward the end of that year, Christiaan wrote to natural philosopher Sir Robert Moray (1608-1673), one of the founding members of the Royal Society, “Not having been able to respond in the usual way, I should not let leave the mail another time without acquitting myself of this duty despite an annoying headache that lasted this whole day and brings me in a mood of rather doing nothing.” Moray responded:

All your letters oblige me very much. However, your latest of the 21st does so even more than all previous ones. Writing me a long letter, full of nice things, while a headache tempts you not to do anything, well deserves to be estimated as a very special sign of extraordinary affection, it is therefore quite reasonable that I write a prompt and, as much as I can, satisfactory response.

And in 1692, in a letter to the German philosopher and mathematician Gottfried W. Leibniz (1646-1716), with whom he wrote on the mathematization of physics and on whom he had an important influence, he wrote: “I am very obliged for showing interest in my health, that since my last [letter] has suffered much from migraine during that long freeze.”

Mother and Sister Suffering Too

A hereditary factor may have played a role in Christiaan’s headache as his sister Susanna (1637-1725) wrote about her own migraine in 1680. “It is to my great regret, my dear brother, that I learn … that you have been uncomfortable by pain and heat in the head … I hope to learn soon that you will not complain anymore. I certainly have my part of migraine sometimes, and I complain more than anybody of those, who suffer of similar discomforts.” Christiaan and his sister may have inherited the affliction from their mother. She suffered from migraine and menstruation troubles, for which she had to be put a diet and was prescribed bleeding as well as purging.

Treatment With Water and Tea

In August 1654, Christiaan stayed in a spa in the mountains of the eastern part of the present Belgium. This was a well-known town with healing cold mineral springs since the 14th century that had resulted in the eponym spa. His father was staying there too and took water a couple of times. In one of the poems written for Mdm Emilia de Mérode-van Wassenaar during a stay, Constantijn Sr. wrote about migraine (1654):

Trouvez vous pas quelque migraine
Qui vous eschauffe le cerveau?
Si ma conjecture n’est vaine
Il vous reste tant soit peu d’eau

[Don’t you feel any migraine
That sets on fire your head?
If my diagnosis is right
Water is the only cure to save you]

Constantijn Sr. probably used the water more often than his son Christiaan, who was rather critical about its healing effects.

In the first half of the 17th century, tea was used as a remedy and reserved to high society. In the course of the century, however, it became more widespread and not just as a drug. Next to purging and bleeding, Christiaan indeed drank tea and apparently was satisfied about it. In 1663, still staying in Paris, he wrote to his brother Constantijn “If there is a way to send me … a pound or a half of the good tea, you would do me a great pleasure, as, since some weeks, I have felt myself admirably well by only taking the leafs in the mouth, as soon as I feel myself indisposed by headache, because that cures me without fail.” Furthermore, water cures, as usual at the time,7 were attempted.

Migraine and the Use of Optical Instruments

Letter by Huygens to Leibniz (1692) (from Oeuvres Complètes vol. 10, p. 268).

During the 19th century, migraine, in particular migraine with aura, was associated with scientists, who were using optical instruments. French physicist and astronomer Dominique François Jean Arago (1786-1853), Scottish physicist David Brewster (1781-1868), and British Astronomer Royal George Biddell Airy (1801-1892) are persons often referred to. Airy’s son, the physician Hubert Airy (1838-1903), who was also a victim to visual auras, believed it had its origin from their habits of accurate observation leading to intensive eye-work and brain-work, exposing them to the risk of impairment of the eyesight. He gave some striking descriptions of his own auras and added several figures of his experiences. The aura was emphasized rather than the headache. There is no indication that Huygens was suffering from auras.

Comorbid Depression

The recurrent episodes, some of which being clearly incapacitating, and familial occurrence suggest that Huygens was suffering from migraine, although some symptoms that would be expected were not described. Another aspect of his health was that he went through at least two periods of melancholia hypochondrica, notably in 1670 and 1676. Assuming we would diagnose this disease as a depressive disorder today, we know this is associated with migraine. And of course, melancholy was considered the disease of scholars at least in the century that started a few years after Christiaan Huygens’ decease in 1695. •

1. Steiner TJ, Stovner LJ, Jensen R, Uluduz D, Katsarava Z; Lifting The Burden: the Global Campaign against Headache. Migraine remains second among the world’s causes of disability, and first among young women: findings from GBD2019. J Headache Pain. 2020;21:137
2. Huygens C. Horologium Oscillatorium sive de motu pendulorum. Paris, Muguet, 1673.
3. Huygens C. Traité de la lumière, Leiden, Pieter v.d. Aa, 1690.
4. Fournier M. Huygens’ designs for a simple microscope. Annals of Science 1989;46: 575-596.
5. Huygens C. Oeuvres Complètes X. Correspondence of June 6, 1678. No. 2125 ; p. 77 (translation in ref. 3).
6. Koehler PJ. Huygens’ headache. Cephalalgia. 2015;35:1215-9.
7. Koehler PJ, Boes CJ. A history of non-drug treatment in headache, particularly migraine. Brain. 2010;133:2489-500.
8. Koehler PJ, Boes CJ. History of Migraine. In: Swanson et al. eds. Migraine. Handbook of Clinical Neurology. In press.
9. Huygens C. Oeuvres Complètes VIII. Correspondence of August 11, 1678. No. 2133 ; pp. 90-3.

Alla Guekht

It has been a tremendous privilege to serve as Elected Trustee of the World Federation of Neurology with the rich tapestry of more than 120 national societies and hard work of the most talented professionals in neurology in the world. It was a great honor to be able, especially at the challenging times of COVID-19 pandemic, to contribute to achieving the WFN mission to foster quality neurology and brain health.

As the trustee of the WFN, I have become integrated into its outstanding multifaceted work. I have learned so much from our president, esteemed colleagues in the Board of Trustees, WFN committees, regional and national organizations, neurologists from many countries of the world, and the WFN staff members.

In my role as the WFN trustee, I contributed to the successful development of the collaboration with the WHO. Adoption of the Resolution WHA 73_R10: Global Actions on Epilepsy and Other Neurological Disorders was the landmark event and unprecedented recognition of the global importance of these conditions; the WHO made a commitment to develop a 10-year Intersectoral Global Action Plan on Epilepsy and Other Neurological Disorders and to include in this plan “ambitious, but achievable, global targets on reducing preventable cases of, and avoidable deaths …, strengthening service coverage and access to essential medicines, improving surveillance and critical research and addressing discrimination and stigma.” The WFN, in collaboration with the International League Against Epilepsy, the International Bureau for Epilepsy, the International Child Neurology Association and European Federation of Neurological Associations, powerfully advocated for this resolution, actively participating in the 71st and 72nd WHA and the 146th WHO executive board meeting, where the historical decision to discuss a possible draft resolution on further action on epilepsy and other neurological disorders had been made.

Notably, WFN actively supported the WHO actions aimed on prevention and treatment of non-communicable disorders, and, indeed, productive collaboration with the WHO strengthened the Global Neurological Alliance.

As the WFN trustee, I have been deeply involved in the WHO COVID-19 NeuroForum and NeuroResearch Coalition, co-chairing the WHO NeuroForum follow-up and long-term impact working group, which meaningfully contributed to the creation of the WHO Case Report Form for Post-COVID conditions and is working on several important projects on prevention and care of patients with its neurological manifestations.

I worked in the WFN Membership Committee, communicating with several neurological societies, and bringing them closer to the WFN as the potential new members. I was privileged to contribute actively to the WCN.

I feel very much honored to be nominated for the re-election. During my term as WFN trustee, I have become aware of both the exciting opportunities as well as the significant challenges facing the global neurological community. If re-elected, I will continue to serve faithfully to the WFN, working diligently, fostering partnership with national, regional, and international neurologic societies and disease-based organizations, further developing collaboration with the WHO in order to assist the WFN to achieve its mission to improve neurological care, education, and research worldwide. •

Riadh Gouider

I trained at the Charles Nicolle Hospital in Tunis, and in La Pitié Salpêtrière Hospital in Paris. This mixture of learning and training encouraged me to explore global neurology.

My journey with the World Federation of Neurology (WFN) began in 1993 during the 15th World Congress of Neurology (WCN) in Vancouver. Since then, my enthusiasm and commitment to WFN has never wavered.

Being the national delegate of the Tunisian Society of Neurology for almost a decade (2005-2015) showed me how important a delegate can be as a crucial link between his national society and the international neurology community.

Appointed as a regional director for Pan-Arab region from 2008-2010 and regional director Africa from 2012-2015 taught me the crucial role of the six regions in WFN strategy and actions, especially when the neurology resources are scarce.

To support the WFN in its mission to promote global neurological education and training, I participated in the accreditation of three teaching centers : Rabat, Dakar, and Cairo.

Lately, I had the honor to be designated as the convenor of the first WFN/AFAN e-Learning Day, which took place in October 2020, the second will be held in November 2021.

My involvement on several committees of WFN: as a co-chair of the e-Learning Task Force, the Education Committee, the specialty groups, and the e-Communication Committee, provided me with invaluable insight into those committees’ functions, the development of their activities, and their positions within WFN.

The most important influence was my election for two terms as an elected trustee from 2014 to 2020. This position filled me with a strong sense of pride and gave me the chance to significantly contribute to the challenges the WFN has faced and the opportunities to participate in the activities of the WCN meetings.

I have had the honor of serving the WFN through a variety of roles.

I feel that I am experienced and honored to stand for the role of first vice president.

If elected, I pledge to support the mission of the WFN to contribute to the advancement of teaching and practice of neurology throughout the world.

I will focus on:

– Provision of access to quality training programs and teaching materials to neurologists, trainees, and health care professionals from all over the world through the e-learning capabilities.

-Creation of more teaching centers all over the world, especially Africa, Central and Southeast Asia, Latin America, parts of Eastern Europe, providing equal educational opportunities in regions with fewer neurologists.

-Strengthening relations among south and north countries and be an active contributor to the dissemination of information and scientific progress.

To further empower and strengthen the links of communications between WFN and regional organizations.

Enhance the cooperation of WFN with international organizations such as the WHO and neurological NGOs.

My fellow delegates, I am asking for your vote to be elected as first vice president. Regardless the results of the election, I promise to continue working for the WFN with the same enthusiasm and commitment. •

Gustavo Román

I was honored by my nomination as candidate for vice president of the World Federation of Neurology (WFN) from the American Academy of Neurology and neurologists from Colombia, my homeland, Brazil, Chile, Honduras, Panama, Uruguay, Spain, and France.

My mentor, Prof. Charles Poser, who served as editor of World Neurology in 1960 instilled in me the importance of the WFN in a globalized world. Over four decades, I served two terms as elected trustee of the WFN and participated in numerous activities.

I was born in Colombia and as an intern encountered the challenges of neurologists working in tropical countries: confronting formidable diseases with minimal diagnostic tools and a limited therapeutic arsenal. With a scholarship, I studied at the Salpêtrière in France and learned the enduring value of clinical neurology and neuropathology. Back in Colombia, I was appointed neurology faculty and wrote two textbooks: Practical Neurology and Tropical Neurology.

I joined Texas Tech University as professor of neurology and interim chair of neurology. In 1990, I was appointed chief of neuroepidemiology at the National Institutes of Health (NIH). I published HTLV-1 and the Nervous System; contributed to the diagnostic criteria for vascular dementia and guidelines for epidemiological studies on epilepsy; I co-authored Neurocysticercosis: A Clinical Handbook and participated in a multinational study of epidemic neuropathy in Cuba. I chronicled this experience in the book Cuban Blindness: Diary of a Mysterious Epidemic Neuropathy.

I returned to teaching at the University of Texas San Antonio as professor of neurology, medicine (geriatrics), and geriatric psychiatry and established the Alzheimer Disease Clinic. In 2010, I was selected the “Jack Blanton Endowed Chair” to organize a new memory center at Methodist Neurological Institute where I currently serve as professor of neurology, Weill Cornell Medical College, New York, and Texas A&M College of Medicine.

At the beginning of the pandemic, in early 2020, as chair of the environmental neurology specialty group of the WFN, I proposed creating international neurological registries of COVID-19 among neurological societies worldwide (Lancet Neurology 2020;19:484). With the group, I wrote the first comprehensive review on the neurology of COVID-19 (J Neurol Sci 414 (2020) 116884). These efforts resulted in the formation of scientific groups, such as the global COVID-19 Neuro Research Coalition (Ann Neurol 2021;89:1059).

As vice president of the WFN, I pledge to continue addressing the needs of neurologists worldwide during this pandemic, with emphasis on education and accessibility to scientific information to better serve neurological patients. Nontraditional methods and creative solutions such as telemedicine that have proven effective during the pandemic may have myriad applications in regions of the world with few neurologists.

We must be ready for future challenges, and the WFN is the only institution capable of serving as link of union and coordinating core for neurologists around the world. As vice president, I pledge to advance the goals and mission of the WFN in forging the future of neurology around the world. •

Guy Rouleau

I am honored that the Canadian Neurological Society (CNS) has nominated me for the position of WFN first vice president.

Following medical school at the University of Ottawa, I did neurology training at McGill University and research training at Harvard (PhD 1989). I then began my career as a clinician-scientist at McGill. In 2004, I moved to the University of Montreal as director of research at Ste‐Justine Hospital. I returned to McGill in 2013 as chair of the department of neurology and neurosurgery, and director of the Montreal Neurological Institute-Hospital (MNI). My work focuses on genetic diseases of the brain, and I have published over 800 articles in peer‐reviewed journals and have been cited over 85,000 times.

I collaborate with neurologists from every continent. Among many other international activities, I co-organized two Congrès de Neuroscience du Mali à Bamako, and I lead a project in Shenzhen, China, assisting the development of advanced therapies for epilepsy and movement disorders. I initiated the WFN-Neurological Institute-Canadian Neurological Society Departmental Visit program for young South American neurologists. The MNI funds these visits and provides the training. We are organizing a similar program for young African neurologists. As Canadian delegate to the WFN for six years, I know the organization well. In that role, I helped the CNS make a successful bid to host the 2023 WCN in Montreal. As WFN first vice president, I would be ideally positioned to contribute to the success of this upcoming congress.

I hope to increase the WFN’s impact on the practice of international neurology. The advent of the internet, social networks as well as accelerated medical discoveries, bring rapid, constant change requiring that organizations regularly reassess their structures and modes of operation.

As first vice president, I would recommend establishing a task force to make recommendations about how to:

Modernize: Currently, the president is elected quadrennially. The past president has no official role, leading to a loss of experience and talent. To ensure continuity, most professional organizations have a president-elect, president, and past-president. This structure could be explored.

Democratize: We need to find ways to ensure that younger people are more engaged and better represented within the WFN. The WFN must be relevant to neurologists of all ages and professional stages. The gender balance and diversity in the WFN’s leadership must also be improved.

Open: The impact of the open sharing of information is growing and has been accelerated by the COVID-19 pandemic. Sharing of information in medicine must become the norm. The WFN should adopt the open science ethos to allow equal access to information, ensure transparency, reproducibility, and equity. Under my leadership, the MNI has become a world leader in open science. Experience and methods developed there can help the WFN facilitate the spread of open science in the world of neurology.

On a personal level, I have spent nearly 40 years practicing neurology. I remain fascinated by the work we do, and I feel I still have much to contribute to our field. •

Ryuji Kaji

For the cause of World Federation of Neurology (WFN) in this challenging time, it has been my privilege and pleasure to serve as the first vice president of the WFN during an unprecedented time of worldwide crisis caused by the pandemic, which has altered the way we conduct the business as the new normal. We are at a turning point in modernizing the structure and function of the federation to meet the new demands. I am proud to be nominated as a candidate for the office of president at this important juncture.

As a graduate from Kyoto University in 1979, I started my professional career as a neurologist studying in the U.S. as a clinical fellow at the University of Pennsylvania. After returning to Japan with my mentor, Prof. Jun Kimura, to teach at our alma mater, I first described the use of IVIG to reverse muscle atrophy in multifocal motor neuropathy, an ALS-like disease.

Encountering a patient with task-specific dystonia, while doing EMG, I became interested in movement disorders, and our group has found new genes causing dystonia. In 2000, I was elected as a member-at-large for the International Federation of Clinical Neurophysiology (IFCN), which I served until 2006. I organized, with IFCN support, a symposium to develop a guideline for early diagnosis of ALS, now adopted as Awaji criteria (an island of Japan).

From 2006 until 2013, I was elected twice as a trustee of WFN under Prof. Aarli and Prof. Hachinski. First, I chaired the membership committee, successfully soliciting six new member societies. Second, I led Asia Initiative to vitalize Asian Oceanian Association of Neurology (AOAN), which now serves as a model of regional organizations in all continents with the help of Prof. Shakir. In 2017, I was elected as first vice president, and have since assisted Prof. Carroll in organizing the congresses and promoting the education of neurologists globally, a major thrust of WFN objectives.

If elected president, I would like to move forward on several initiatives. We must seek to achieve greater worldwide recognition of our discipline and make the prevention and treatment of neurologic conditions the No. 1 priority of governmental medical policies. Specifically, we should encourage and assist the education of young neurologists in developing countries. In undertaking these goals: I will abide by the basic mission of WFN to “foster quality neurology.”I will review the regional representations of trustees to make all the continents fairly represented with the best use of co-opted positions. I will make the regional liaisons stronger by closer contacts with the presidents and delegates of our member societies.

I have learned from the fellow trustees how to accomplish the best consensus with proper balance of assertion and compromise. I believe that it will take a team effort to successfully run an international organization. It is my sincere hope that together we can achieve our objectives and further improve the value and prestige of WFN. •

Wolfgang Grisold

I would like to apply for the position of the president of the WFN.

Having served as the secretary general of the WFN for the past eight years, I have gathered knowledge on all areas of current and previous activity. I designed and organized several initiatives, and made substantial contributions to WFN’s growth as a globally operating organization. Based on countless conversations with representatives and insights I have gained, I am convinced that my agenda for the presidency meets the needs of the WFN and its membership. My proposed agenda revolves around three key goals.

The first is to intensify the collaboration of all WFN members across countries and regions. Neurological diseases are becoming increasingly prevalent throughout the globe and neurologists are at the forefront to solve the great challenges of our time. As our members bring in distinct strengths and competencies, we can jointly advance the treatment of illnesses and our patients’ well-being. A cornerstone of my presidency will be to strengthen collaboration with WHO, the global neurology network, and scientific societies to successfully advance our initiatives.

My second goal is to increase the impact of the WFN. As per our mission, we strive to enhance high-quality neurology and brain health worldwide. Our focus is to make neurology accessible in all parts of the world and for all patients in need. To this end, I see high-quality education as the backbone as it empowers regions to consolidate, advance and adapt their education and treatment strategies.

Among other activities, I intend to drive the development of training centers and department visits, integrating  emerging opportunities of virtual education. I am confident we can increase our impact by training and empowering aspiring neurologists. My plan is to design a global training charter to establish standardized neurology training, and establish fellowship, advocacy, and leadership programs.

My third goal is to ensure coherence and continuity. The WFN has launched several successful initiatives targeting all aspects of brain health. One prominent example is World Brain Day, which has significantly helped raise public awareness about neurological diseases. We are fortunate to launch new initiatives and programs, but can only make a sustainable impact where there is continuity and coherence across projects.

One way to increase coherence and continuity is to smooth transitions between administrations. I envision the immediate past-president and president-elect serving in overlapping periods to ensure an efficient, transparent handover.

Importantly also, I will endeavor to balance the gender distribution in leadership roles and give patients a voice in WFN.

I am applying for the presidency of the WFN because I see many promising opportunities that we can achieve together over the next four years. At the heart of my agenda is the will to “strengthen the strengths” of our organizations and further improve outreach and impact of our programs for neurology and neurological patients.

It would be my sincere pleasure to work with you on these programs in the next four years. •

Youssef Al-Said

As the current Saudi Neurology Society President (SNS), it would give me great pleasure and be an honor to represent the World Federation of Neurology (WFN) and therefore am submitting my name as a nominee for the position of president.

As an experienced senior professional in neurology and epilepsy, administrative MBA graduate and the executive director of medical and clinical affairs at one of the leading hospitals in Saudi Arabia, I believe I embody the vision and mission of WFN on a daily basis to raise professional and academic proficiency in neuroscience.

My goal is to always lead with movement to action through results-oriented execution. Using this kind of leadership,neuroscience will reach new heights within the kingdom and see real time results.

Neuroscience is not just my career; it is my passion, and I would like to continue to share my knowledge with those entering in the field and contribute to the development of our youth as well as expand and improve the services throughout the kingdom and worldwide.

This year, 2021, is a year of inspiration as we transform to a new norm. Let’s go forward and try to reach a brighter future.

In closing, it would be a pleasure to be considered as the president so that I may help lead from the front as an action-centered leader for neuroscience.

I look forward to hearing from you. •

By Prof. Mustapha El Alaoui-Faris, WFN Rabat Training Center

Mustapha El Alaoui-Faris

After the accreditation of the Rabat Training Center in September 2013, the WFN signed a contract with the Mohammed V University of Rabat to train neurologists from Sub-Saharan Africa in Morocco. It was decided to start with complementary training in clinical neurophysiology for neurologists who have already completed their studies. They receive a grant of 13,000 Euros from the WFN covering travel and living expenses in Rabat for 10 months. The internship includes training in the performance and interpretation of EMG and EEG and in the management of patients suffering from neuromuscular diseases or epilepsy.

During their training, neurologists participate in the various teaching activities of the Department of Neurology of Rabat and attend the meetings of the Moroccan Society of Neurology in Morocco and in the Maghreb. Neurologists from Burkina Faso, Chad, Guinea, Madagascar, Mali, and Senegal have benefited from this training, which has allowed them to consolidate their EMG and EEG practices. In this regard, I would like to thank Prof. Reda Ouazzani, head of the clinical neurophysiology department, and his team, in particular Prof. Nazha Birouk, for their commitment and their availability during the African neurologists’ internship.

During the eight years of training for French-speaking African neurologists, the Rabat Center has received eight diligent trainees committed to expanding their knowledge and improving their expertise. They all have a good knowledge in general neurology, whatever their country of origin. This is due to the heritage of excellence of the French neurological school in these countries.

Currently, 14 French-speaking countries organize training of neurologists on-site, but due to lack of financial resources, they only train one to five neurologists per cohort. At this rate and given the glaring lack of neurologists in sub-Saharan Africa (barely 0.03 neurologists per 100,000 inhabitants, whereas the WHO calls for 1/100,000), it would take decades to reach a sufficient number of neurologists in these countries.

It is therefore important to explore the different possibilities to increase the number of neurologists in sub-Saharan Africa, while being aware that the majority of African neurologists trained in Europe and North America do not return to their countries.

Currently, the WFN has four accredited training centers in Africa, each center receives approximately one neurologist per year, often for additional training. Alternatively, neurologists can be trained in their own countries with the possibility that the last year of training be done in a training center approved by the WFN in Africa. This might be cost-effective for French-speaking African countries with good neurology training centers and affordable costs of living.

At the Rabat Center, we are willing to provide full training in neurology (4 years), in addition to continuing the annual training in clinical neurophysiology sponsored by the WFN and by the ICNMD Congress.

To ensure continuing education of French-speaking neurologists, the WFN in collaboration with the African Academy of Neurology (AFAN) can organize virtual courses in neurology in French. The courses could be made available on the WFN website. The lack of neurologists in Africa will not be filled any time soon, so it would be desirable in the era of video conferences that the WFN could provide education on “neurology for non-neurologists” for general practitioners in sub-Saharan Africa.

Finally, to accelerate the training of African neurologists, it would be desirable for the WFN to develop a true “Alliance for Neurology in Africa” by involving the AAN, the EAN, and other partners of the World Brain Alliance for its financing. This will improve the care of millions of African patients suffering from neurological disorders. •