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Neurology Update in Kazakhstan 2021

By Aida Kondybayeva, MD, PhD

Aida Kondybayeva

Aida Kondybayeva

The International Educational Online Forum: Neurology Update in Kazakhstan was held April 23-24, 2021. Forums of this scale in Kazakhstan are held every two years, and this forum was being held online for the first time. The event was attended by 985 doctors, including neurologists, internists, GPs, rehabilitation specialists, and intensive care specialists from Kazakhstan, Kyrgyzstan, Uzbekistan, Belarus, and Ukraine.

At the first day within the framework of the International Educational Online Forum: Neurology Update in Kazakhstan, the EAN-Day in Kazakhstan was held. This event was held with the joint work of the European Academy of Neurology, Kazakh National Association of Neurologist Neuroscience, and al-Farabi Kazazakh National University.

Welcoming speeches to the participants were given by Prof. Saltanat Kamenova, president of KNANN; Nadezhda Petuhova, chair of the Public Council of the Ministry of Health of the Republic of Kazakhstan; Prof. Raushan Isayeva, director of High School of Medicine, Faculty of Medicine and Health, al-Farabi Kazazakh National University; and Mikhail Mazurchak, vice president of KNANN. They noted the special significance of the EAN-Day in Kazakhstan for all practicing doctors who took part in this event.

The speakers of the EAN-Day in Kazakhstan were Prof. Aksel Siva from the Department of Neurology of Istanbul University, Cerrahpaşa School of Medicine (Istanbul Turkey); Prof. Erik Taubøll from the Department of Neurology Oslo University Hospital (Oslo, Norway); and Prof. Maxwell Simon Damian, Department of Medicine, Cambridge University (Cambridge, UK).

The professors presented reports on the situation with MS, epilepsy, and neuromuscular diseases before and during the COVID-19 pandemic; these presentations aroused great interest among all participants of the event.

Luca Caffaro, the youngest speaker of this event, presented an interesting report on the work of the Residents and Research Fellows Section (RRFS) of the EAN, and on professional development opportunities for young neurologists and residents. EAN-Day in Kazakhstan received positive feedback from all registered participants of the event.

In the second half of the event, workshops were held, in which speakers presented analyses of difficult clinical cases and the possibilities of their resolution. The second day, the forum was no less eventful, and included reports of doctors from Spain (Jerzy Krupinski-Bilecki), Afghanistan (Ayesha Khaideri), Ukraine (Sergey Moskovko), Russia (Dmitry Kasatkin, Evgeny Evdoshenko, and Natalia Khachanova), and Kazakhstan (Gulsum Duschanova, Saltanat Kamenova, Gulnar Kabdrakhmanova, Mikhail Mazurchak, Maksharip Martazanov, Karlygash Kuzhibaeva, Aida Kondybayeva, and Asel Aralbayeva). Topics including MS, pain, neuromuscular diseases, and epilepsy were discussed. •

Aida Kondybayeva, MD, PhD, is a neurologist and chair of the Educational Committee at Kazakhstan National Association of Neurologist “Neuroscience” Institutional Delegate of the European Academy of Neurology from Kazakhstan.

 

Cerebral Venous Thrombosis After Vaccination Against SARS-CoV-2

With Information on the International Consortium on CVT Registry

By José M. Ferro, MD, PhD

The public and the global medical community have been exposed since early March 2021, both from the media, the official agencies, and the medical literature, to multiple and often contradictory information, concerning the risk of “uncommon” thrombosis occurring after vaccination against SARS-CoV-2. Most of the news concerned the vaccine manufactured by AstraZeneca and more recently the vaccine from Johnson and Johnson/Janssen. The uncommon thromboses were splanchnic and cerebral venous thrombosis (CVT), mostly the latter.

Mass vaccination is currently humanity’s great hope to control the pandemic. Vaccines were developed, tested, and approved in an incredibly fast pace, about one year since the onset of the pandemic. Administration of a vaccine simultaneously to millions of persons in multiple locations of the world was never done before in human history. Not surprisingly, extremely uncommon side effects of the vaccine, which were not detected in randomized trials of hundreds or thousands of subjects, can emerge when a much larger sample of millions is exposed to the vaccine.

COVID-19 Infection and CVT

CVT was known to occur as a rare complication (0.08%) of COVID-19, accounting for 4.2% of all acute cerebrovascular disease occurring during COVID-19 infection. Several case reports, case series, and systematic reviews of CVT associated with COVID-19 infection have been reported since the beginning of the pandemic 1,2. Both a systematic review2 and a large study based on administrative data from a hospital network3 indicate than the incidence of CVT increased with COVID-19 infection.

CVT can be the initial clinical manifestation of the infection, but the majority of CVTs develop within 13 days of onset of COVID-19 symptoms. Recognized risk factors for CVT are present in only one third of the patients. The main pathophysiological mechanism is related to the hypercoagulable state seen in moderate/severe COVID-19 disease. In fact, CVT patients often have very high D-Dimers, low fibrinogen levels, and low platelet counts. The prognosis is less favorable; namely case fatality (40%) is higher than the non-COVID-19 CVT (5-10%). Management is similar, namely on what concerns the use of parenteral heparin in the acute phase of CVT.

Case Reports and Case Series of CVT Occurring After Vaccination Against SARS-CoV-2

The European Medicines Agency (EMA) approved four vaccines against SARS-CoV-2: two mRNA vaccines from Pfizer and Moderna and two adenovirus vector DAN vaccines from AstraZeneca (AZ) and Johnson & Johnson/Janssen (JJ). The AZ vaccine is not yet approved for use in the United States.

Shortly after the onset of mass vaccination with those vaccines in Europe and in several other countries around the world, there were signals and thereafter publications of case reports and small case series of severe CVT occurring in young women within days of vaccination with the AZ vaccine 4-8. The growing number of those events led several countries to contraindicate the AZ vaccine in young and middle-aged adults, despite the total number of signaled cases being low (<200) as well as the estimated absolute risk of CVT (5 per million vaccinated individuals). In April, a small number of similar cases were reported in the U.S. after the JJ vaccine 9, leading the authorities to temporarily pause the use of that vaccine. A few individuals developed immune thrombocytopenia (ITP) 10 without thrombosis after receiving the mRNA vaccines. There are a few CVTs also reported, but the percentage of CVT occurring after mRNA vaccination is much smaller than for the adenovirus vector DNA vaccines

A striking feature of those cases was the high frequency of thrombocytopenia, which is uncommon in pre-COVID-19 CVT (<10% of the cases). Some other patients had only thrombocytopenia, splanchnic venous thrombosis, or hemorrhagic phenomena, or a combination of those, eventually with CVT. Although most of the emphasis has been placed in the thrombocytopenia, the most serious event, which may be fatal, is CVT. CVT is obviously also the most relevant event to the neurology community.

From the published cases and those signaled to the EMA’s Pharmacovigilance Risk Assessment Committee (PRAC), a clinical profile of CVT associated with the AZ vaccine can be extracted:

  • CVTs occur almost exclusively in women below age 60.
  • Only about one third has traditional risk factors for CVT, such as thrombophilia or use of estrogenic contraceptives.
  • CVT occurs up to 20 days after the administration of the first dose of the vaccine.
  • A high percentage (up to two thirds) has thrombocytopenia; some have high D-Dimers and low fibrinogen.
  • The clinical picture is often of a malignant CVT, with multiple sinus and veins thrombosis, cerebral hemorrhages and oedema, causing herniation, often requiring decompressive craniectomy, as a live-saving intervention.
  • The mortality is high (~25%).
  • Patients with traditional risk factors for CVT do not appear to have an increased risk of CVT after vaccination.

Possible Pathophysiological Mechanisms

Chance association or undetected recent COVID-19 infection are possible, but unlikely, explanations for CVT occurring after AZ and JJ vaccines. They cannot account for the different risk of CVT after each type of vaccine, not for the distinct clinical laboratory profile, as described in the previous section. Moreover, SARS-CoV-2 PCR nasopharyngeal swabs were negative in all the patients, in whom that test was performed (or reported to be performed), and patients only displayed antibodies against the virus spike protein antigen (most probably a vaccine effect) and not against other antiviral antibodies, as expected if they were recently infected.

Shortly after the notice of the first cases of venous thromboses with thrombocytopenia, a group of researchers from Germany, Ontario, and Vienna under the leadership of Andreas Greinacher identified the mechanism of the thrombotic complications of AZ vaccine, which they called “thrombotic thrombocytopenia.” Unfortunately, this label underscores the fact that the main feature of the syndrome is CVT, with the consequent risk of death and disability. Their patients tested positive on a screening platelet factor 4 (PF4)-heparin immunoassay. None of the patients had received heparin before blood for the tests was drawn. Patients also tested positive on a platelet-activation assay in the presence of PF4 independent of heparin. Platelet activation was inhibited by high levels of heparin and immunoglobulin4. They concluded that the vaccine resulted in a rare thrombotic thrombocytopenia mediated by platelet-activating antibodies against PF4, which clinically mimics autoimmune heparin-induced thrombocytopenia (HIT). In recent years, it has been recognized that triggers other than heparin (polyanionic medications, infections, surgery) can also cause a HIT-like coagulopathy, which can also be spontaneous. The pivotal observations of Greinacher et al 4 were confirmed by other researchers11. This post-vaccinial entity is now named vaccine-induced prothrombotic immune thrombocytopenia (VIPIT) or vaccine immune thrombotic thrombocytopenia (VITT).

A similar laboratory observation was found in the cases reported after the JJ vaccine. This finding raises the suspicion that the adenovirus vector could be the initial trigger of antibody production. The adenovirus vector carries negatively charged DNA, which binds to the positively charged PF4. An alternative explanation is the strong inflammatory stimulus of the vaccination or cross-reaction of antibodies produced by the vaccine and PF44. RNA is charged positively, so this immune response is unlikely to occur after mRNA vaccines.

Management of Cerebral Venous Thrombosis Occurring After Vaccination Against SARS-CoV-2

The risk of CVT following AZ vaccine being estimated as only five cases per million vaccinated people, it is evident that no randomized trials are possible to inform management decisions. Evidence comes from case series, analogy with HIT management, and expert consensus statements, and therefore is of low quality. Strong recommendations are not possible and the most sensible option is to produce guidance documents that will be periodically updated, as new evidence is produced.

Vaccinated persons should be informed that they may experience a transient headache a few days after vaccination. If the headache persists or is unusually severe, or they have any other neurological symptom, they should seek urgent medical advice. These patients should be examined by a neurologist.

If the clinical picture is suspicious of CVT, cerebral CT with venography or MR with MR venography should be performed to confirm, or not, the diagnosis of CVT. Meanwhile, a complete blood cell count and film, coagulation tests (INR, APTT, fibrinogen, D-Dimers) and COVID antibodies are obtained.

If CVT is confirmed and platelet count is below 150×109/L, VITT is a possibility. However, if the results of coagulation tests, fibrinogen, and D-Dimers are normal, VITT is unlikely, and the patient can be managed accordingly to the current CVT Guidelines12, namely be treated with low molecular or unfractionated heparin in the acute phase.

On the contrary, if any of those tests is abnormal, VITT is suspected and a HIT Elisa test (capable of detecting PF4 antibodies) should be performed. Consultation with a hematologist is advisable to guide on further testing (e.g., functional HIT assays) and discuss management. Meanwhile, platelet transfusions should be avoided, IV immunoglobulin (e.g., 1 mg/kg for 2 days) be administered, and a non-heparin anticoagulant (argatroban, danaparoid, or direct oral anticoagulants) be used instead of heparin4,11. Endovascular treatment of CVT can also be an option.

The International Consortium on CVT Initiative

From the available evidence so far, it is apparent that CVT after SARS-CoV-2 vaccines can be a heterogeneous group of patients. While most appear to have an immune mechanism (VITT), a few other cases may be coincidental, related to the usual CVT risk factors or even to recent COVID-19 infection. Therefore, a detailed analysis of non-selected CVT cases who developed after any COVID-19 vaccination needs to be performed.

The International Cerebral Venous Thrombosis Consortium (ICVTC) is an existing, global collaboration by academic researchers with the primary aim to perform investigator-initiated research on the epidemiology, manifestations, and outcome of patients with CVT.

Currently, 32 hospitals are participating in the consortium and have already collected data of 1,308 patients with CVT, prior to the COVID pandemic. ICVTC recently launched a prospective registry to report clinical manifestations, laboratory findings, management and outcome of patients with CVT after any COVID-19 vaccination. The registry will include CVT patients with radiologically confirmed CVT, with onset of CVT symptoms within four weeks of COVID-19 vaccination, and informed consent. Principal investigator is Jonathan Coutinho from the Amsterdam University Medical Centers (j.coutinho@amsterdamumc.nl).

Conclusion

Medicine should follow the ethical principle of “Primum non nocere” (first do not harm). However, ethics should also be applied with justice. We must consider that the individual risk of CVT following COVID infection is much higher (6x) than that following any anti-SARS-CoV-2 vaccine3, even without considering the indirect effect of the infection through contagium. Therefore, the fundamental message for the public should focus on the urgent need, safety, and confidence on vaccines.

Epidemiological, clinical, and laboratory research will unveil the multiple remaining unanswered questions on the occurrence of CVT after anti-SARS-CoV-2 vaccines. Meanwhile, neurologists and other health care workers must be aware of this very rare complication of the AZ and JJ vaccines. Management of the occasional CVT patient occurring after those vaccines should follow the most recent guidance statements from national13 and international official agencies and from scientific societies14, which are likely to be updated as evidence grows. Inclusion of those cases in the ongoing International Consortium on Cerebral Vein Thrombosis registry is welcome. •

From the Serviço de Neurologia, Centro Hospitalar Lisboa Norte; J Ferro Lab, Instituto de Medicina Molecular João Lobo Antunes, Faculdade de Medicina, Universidade de Lisboa; Lisboa, Portugal. jmferro@medicina.ulisboa.pt

Inclusion Criteria for the International Consortium on CVT Registry

Patients with cerebral venous thrombosis with:

  • Radiologically confirmed CVT
  • Onset of CVT symptoms within 4 weeks of any COVID-19 vaccination
  • Informed consent, according to local law

For more information, contact Dr. Jonathan Coutinho at j.coutinho@amsterdamumc.nl.

 

References

  1. Dakay K, Cooper J, Bloomfield J, Overby P, Mayer SA, Nuoman R, Sahni R, Gulko E, Kaur G, Santarelli J, Gandhi CD, Al-Mufti F. Cerebral Venous Sinus Thrombosis in COVID-19 Infection: A Case Series and Review of The Literature. J Stroke Cerebrovasc Dis. 2021 Jan;30(1):105434. doi: 10.1016/j.jstrokecerebrovasdis.2020.105434
  2. Baldini T, Asioli GM, Romoli M, Carvalho Dias M, Schulte EC, Hauer L, Aguiar De Sousa D, Sellner J, Zini A. Cerebral venous thrombosis and severe acute respiratory syndrome coronavirus-2 infection: A systematic review and meta-analysis. Eur J Neurol. 2021 Jan 11:10.1111/ene.14727. doi: 10.1111/ene.14727
  3. Taquet M, Husain M, Geddes JR, Luciano S, Harrison PJ. Cerebral venous thrombosis: a retrospective cohort study of 513,284 confirmed COVID cases and a comparison with 489,871 people receiving a COVID-19 mRNA vaccine. In press
  4. Greinacher A, Thiele T, Warkentin TE, Weisser K, Kyrle PA, Eichinger S. Thrombotic Thrombocytopenia after ChAdOx1 nCov-19 Vaccination. N Engl J Med. 2021 Apr 9. doi: 10.1056/NEJMoa2104840
  5. Castelli GP, Pognani C, Sozzi C, Franchini M, Vivona L. Cerebral venous sinus thrombosis associated with thrombocytopenia post-vaccination for COVID-19. Crit Care. 2021 Apr 12;25(1):137. doi: 10.1186/s13054-021-03572-y
  6. Schultz NH, Sørvoll IH, Michelsen AE, Munthe LA, Lund-Johansen F, Ahlen MT, Wiedmann M, Aamodt AH, Skattør TH, Tjønnfjord GE, Holme PA. Thrombosis and Thrombocytopenia after ChAdOx1 nCoV-19 Vaccination. N Engl J Med. 2021 Apr 9. doi: 10.1056/NEJMoa2104882
  7. Mehta PR, Mangion SA, Benger M, Stanton BR, Czuprynska J, Arya R, Sztriha LK. Cerebral venous sinus thrombosis and thrombocytopenia after COVID-19 vaccination – a report of two UK cases. Brain Behav Immun. 2021 Apr 12:S0889-1591(21)00163-X. doi: 10.1016/j.bbi.2021.04.006
  8. Muir K-L, Kallam A, Koepsell SA, Gundabolu K. Thrombotic Thrombocytopenia after Ad26.COV2.S Vaccination. N Engl J Med. 2021 Apr 14. doi: 10.1056/NEJMc2105869.
  9. Franchini M, Testa S, Pezzo M, Glingani C, Caruso B, Terenziani I, Pognani C, Bellometti SA, Castelli G. Cerebral venous thrombosis and thrombocytopenia post-COVID-19 vaccination. Thrombosis Research (2021), https://doi.org/10.1016/j.thromres.2021.04.001
  10. Lee EJ, Liu X, Hou M, Bussel JB. Immune thrombocytopenia during the COVID-19 pandemic. Br J Haematol. 2021 Apr 14. doi: 10.1111/bjh.17457
  11. Scully M, Singh D, Lown R, Poles A, Solomon T, Levi M, Goldblatt D, Kotoucek P, Thomas W, Lester W. Pathologic Antibodies to Platelet Factor 4 after ChAdOx1 nCoV-19 Vaccination. N Engl J Med. 2021 Apr 16. doi: 10.1056/NEJMoa2105385.
  12. Ferro JM, Bousser MG, Canhão P, Coutinho JM, Crassard I, Dentali F, di Minno M, Maino A, Martinelli I, Masuhr F, Aguiar de Sousa D, Stam J; European Stroke Organization European Stroke Organization guideline for the diagnosis and treatment of cerebral venous thrombosis – endorsed by the European Academy of Neurology. Eur J Neurol. 2017 Oct;24(10):1203-1213. doi: 10.1111/ene.13381
  13. Pai M, Grill A, Ivers N, et al. Vaccine-induced prothrombotic immune thrombocytopenia VIPIT following AstraZeneca COVID-19 vaccination: lay summary. Science Briefs of the Ontario COVID-19 Science Advisory Table. 2021;1(16). https://doi.org/10.47326/ocsat.2021.02.16.1.0
  14. Oldenburg J, Klamroth R, Langer F, Albisetti M, von Auer C, Ay C, Korte W, Scharf RE, Pötzsch B, Greinacher A. Diagnosis and Management of Vaccine-Related Thrombosis following AstraZeneca COVID-19 Vaccination: Guidance Statement from the GTH. Hamostaseologie. 2021 Apr 1. doi: 10.1055/a-1469-7481

President Praises WFN Performance During the Pandemic

By Prof. William Carroll, WFN President

William Carroll, MD

Against the backdrop of what is without a doubt medical history – the vaccination of the world against SARS-Cov-2 virus (COVID-19) – it is appropriate to review our performance. That the vaccination rollout is bumpy is to be expected. That the world has developed a multitude of vaccines and that the process is under way in just over a year is outstanding.

What about the WFN? This assessment of the WFN is focused on the component parts of our organization rather than by overall achievement. In so doing, I hope to illustrate the effort and output of each.

  • Member Societies
  • Regional Organizations
  • Individuals
  • Related Organizations
  • London Office
  • Trustees

It is my personal perspective, and any errors or omissions are mine.

Member Societies

The member societies are the neurological bodies representing neurologists in each jurisdiction and are the core of the WFN. All have had to deal with the impact of the pandemic on their organization, function, and educational activities. In most instances, they have been successful. Members have continued to serve and care for neurological disorders, be involved in educational activities and training, and in many cases supported the World Brain Day campaign of 2020 and the first electronic Annual General Meeting of the Council of Delegates. Collectively, these efforts have assisted the WFN’s mission to foster brain health and quality neurology worldwide.

Member societies are the neurological bodies representing neurologists in each jurisdiction and are the core of the WFN.

117 of 122 member societies responded to the Needs Registry.

In addition, member societies have participated in the program to update communicability with the London Office, an essential element for our global organization. During this program, they have engaged in Zoom conversations to communicate their views on WFN activities and how they might be further engaged.

A pleasing 117 societies responded to the Needs Registry, which will provide data for the development of targeted campaigns to improve services and resources in all socioeconomic strata. Member societies in Africa and Mexico have, where possible, maintained WFN Training Programs.

Some member societies have seized the opportunity presented by the pandemic to upgrade their electronic educational program. Especially notable has been the efforts of the Indian Academy of Neurology in its highly regarded neuroinfections series of 2020, where it partnered with the Tropical and Geographical Neurology Specialty Group.

More recently, the IAN has begun a series highlighting the contribution made by inspiring leaders in neurology. (Please see WFN website.)

Regional Organizations

These six organizations through their presidents have attended the biennial WFN Strategy Meeting in 2020 at the time of the onset of the pandemic. Most of the six have continued their regular congresses.

Most of the six regional organizations have continued their regular congresses.

The EAN and AAN held successful virtual congresses in 2020 and plan to do so again in 2021. Both have also maintained close organizational ties through regular leadership meetings with the WFN.

The AOAN had to defer its 17th Congress from August 2020. It held a successful, highly regarded meeting in early April 2021, which was the first regional hybrid meeting. AFAN has deferred its scheduled biennial meeting from 2021 to October 2022 to be held in Cameroon.

With the WFN, AFAN held a valuable e-Learning Day on stroke in 2020, which included two parallel sessions in French. A similar e-Learning Day will be held in November 2021 on epilepsy.

PAUNS held its biennial Congress in February 2020 (at the onset of the pandemic) and will do the same in 2022.

PAFNS held its Congress in conjunction with the Brazilian Academy of Neurology in 2019 and plans its next congress for 2023.

Regional organizations are supporting efforts by a subgroup of trustees and office staff to improve communications.

Individuals

Neurologists are the core of each member society and the advocates and supporters for them and the WFN. They continue to participate in all regular activities of diagnosis, treatment, and care. In a number of instances, neurologists and neurological infrastructure have been drafted to COVID duties.

Many individuals have made, and are continuing to make, important contributions to national, regional, global, and disease-specific COVID-19 data collection efforts on topics ranging from the impact of COVID-19 on the provision of neurological services generally, the documentation of neuro-COVID phenotypes, and contributed to the development of the WHO Case Report Form to provide more uniform data collection. Many have also participated in activities overseen by the WHO Neuro-COVID Global Forum, the COVID-19 Neuroresearch Coalition, the EAN ENERGY Registry, the NINDS NeuroCOVID project, and the WFN Environmental Neurology Specialty Group’s list of registries.

Many neurologists continue to make important contributions to COVID-19 data collection and maintain neurological services.

Related Organizations

Members of the Global Neurology Alliance (GNA) have supported the WFN World Brain Day campaigns, especially the International Parkinson’s Disease and Movement Disorder Society (2020) and the Multiple Sclerosis International Federation (2021). Recently, GNA members have played a major role in the constructive assessment and advice to the WHO on its discussion plan for the preparation of the Intersectoral Global Action Plan for Epilepsy and Neurological Disorders. Notable here were the International League Against Epilepsy (ILAE,) International Bureau for Epilepsy (IBE), International Child Neurology Association (ICNA), World Stroke Organization (WSO), International Headache Society (IHS), the International Parkinson’s Disease and Movement Disorder Society (IPD&MDS), Alzheimer’s Disease International (ADI), the World Federation of Neuro-Rehabilitation (WFNR), World Psychiatry Association (WPA), and Multiple Sclerosis International Federation (MSIF).

A number of WFN Specialty Groups have also made valuable contributions to the WFN goals. I have already mentioned the Tropical and Geographical Neurology Specialty Group’s series on neuroinfections where they partnered with the Indian Academy of Neurology. The Migrant Neurology Specialty Group has produced an excellent comprehensive reference book on “Neurology for Migrants.”

The Rare Neurological Diseases Specialty Group is conducting a survey on these and their resourcing around the world. The new ALS/MND Diagnostic Criteria were published by the ALS/MND Specialty Group, and the Neuromuscular Disease Specialty Group held its 2020 Congress virtually.

London Office

If member societies are the core of the WFN, the London office is the heart. The WFN employed a second senior manager, Kimberly Karlshoej, in February 2020 with the primary role of overseeing new WFN initiatives, such as the Needs Registry and enhancing the relationship between the WFN and the WHO.

Within weeks, she joined the other London staff in lockdown. Despite the tribulations of the pandemic on London residents, the office staff have exceeded everyone’s expectations, including their own. They have maintained the routine day-to-day management of the federation, such as receiving and responding to email from member societies, calendar organization, financial, and membership records.

Where necessary, they have joined conference calls and provided audio recording for the production of accurate minutes despite an array of different time zones through countless Zoom, GoTo, Teams, and Webex meetings.

They guided a flawless Council of Delegates Annual General Meeting, including the inaugural electronic trustee election. They have orchestrated improved electronic communicability with member societies, specialty groups, WFN committees, and the Global Neurology Alliance, increased the social media posts, and assisted the regular website updates, including the COVID-19 and World Neurology page. These tasks, and there are many that I may have omitted, have all been performed with a cheerful professional disposition which has facilitated business operations in this unprecedented environment. I am sure I speak for all the trustees when I say that we are indebted to our office.

The London Office guided a flawless 2020 Council of Delegates Annual General Meeting, including the inaugural electronic trustee election.

The most important initiative they have been engaged in is the updating of member society contacts and the development of its enduring continuity.

Trustees

The pandemic began one month after the 2020 Trustees and Regional Presidents’ Strategy Meeting. At this time, Jean Marc Leger stepped down as co-opted trustee, and his place was taken soon after by Marianne de Visser. Both Leger and de Visser added invaluable depth to trustee discussions and decisions.

The expiration of Riadh Gouider’s stellar term as trustee at the 2020 AGM was also marked by the election of Morris Freedman. Freedman has begun to develop a WFN e-learning pilot program. Gouider continues to oversee the WFN/AFAN e-learning Day. Throughout 2020 and to date, each and every one of the trustees have combined energetically in the collective effort of the WFN. All have recognized the importance that they represent all member societies, and that decisions made by them, as trustees, are all gauged by their worth for the whole federation.

Trustees all recognize that they represent all member societies and that decisions made by them are gauged by their worth for the whole federation

It has been a pleasure to witness the careful consideration given by all in discussing a matter of weight before arriving at the most optimal decision. I have no doubt that the present composition of four officers, three elected trustees, and two co-opted trustees is the most efficient for a number of reasons.

First, a nine-person group is simply workable. Each can contribute readily both in discussion and in the preparation of papers for specific proposals. Second, the ability to co-opt two trustees provides flexibility for particular skillsets and diversity. Third, the staggered rotation of the elected trustees provides additional corporate memory to that of the executive officers. Fourth, a board of nine persons is a number that the London office can support efficiently. An increased number would likely require an increase in staff. Leanness and flexibility are two desirable virtues on which the WFN depends.

Current trustee structure is fit for purpose.

  • A nine-person group is simply workable. Each can contribute readily both in discussion and in the preparation of papers for specific proposals.
  • The ability to co-opt two trustees provides flexibility for particular skillsets and diversity.
  • The staggered rotation of the elected trustees provides additional corporate memory to that of the executive officers.
  • A board of nine persons is a number that the London office can support efficiently.

Conclusion

I am then unashamedly proud of the WFN and its robust advancement on all fronts despite the COVID-19 pandemic. As I have tried to illustrate above, every part of the organization, its governance, and the processes have performed admirably. I, as the president, and we all as the WFN, know that from individual neurologists, who have continued to function as neurologists in the care of people with neurological illness, through to the London office should share a sense of achievement for what has been done.

There is still some way to go to a post-COVID normal but we can appreciate that we will continue to prosecute our mission to foster brain health and quality neurology through and beyond the end of this pandemic. •

The Format of World Congress of Neurology 2021 in Rome Finalized

By Ryuji Kaji, Chair Congress Committee, First Vice President of the WFN

Ryuji Kaji

The Congress Committee met on April 19, and the format of WCN2021 was finalized. Considering the global outlook of the COVID-19 pandemic and the decisions of other international meetings, we had to conclude that WCN2021 shall be held all online.

Despite being fully virtual, we will try our best for all of the participants to amply experience the atmosphere of Rome using state-of-the-art technology. The registration fee was revised and discounted to a large extent to facilitate attendance of many delegates, young neurologists, and medical students (see box at right), and the contents will be held available on the web for three months after the meeting for the registered participants.

The deadline of abstract submission was May 3, and we received over 2,000 abstracts. More bursaries than usual (200) will be provided to encourage young neurologists in the form of waiving registration fees. The early registration fees will apply until July 13, and we sincerely ask more neurologists than ever to make our virtual meeting one of the best WCNs in the new style of holding an academic meeting during the pandemic.

We are also soliciting nominations of the names for WFN medals for 2021 ( https://wfneurology.org/activities/education-grants-and-awards/wfn-awards ).

See you all virtually in Rome! •

Registration Fees Euros
Full Participants Int’l – Early 300
Full Participants Int’l – Late 350
Full Participants – Italians Early 200
Full Participants – Italians Late 250
Low/Lower Middle Income Countries – Early* 150
Low/Lower Middle Income Countries – Late* 200
Allied Health Professionals – Early + Late ** 100
Undergraduate Medical Students – Early + Late ** Waived
*Low/Lower Middle Income countries are defined according to the World Bank Country Classification. Participants from Low/Low Middle Income Countries must submit a copy of their passport

**Allied Health Professionals include Residents, Fellows, Nurses, Physical Therapist, Occupational Therapist, and Speech Therapist. Status must be certified by an official letter from the institution signed by the head of the department

Special Issue on Tropical Neurology

By John D. England, MD

John D. England, MD

During the World Congress of Neurology in 2017 in Kyoto, Japan, Profs. Marco Medina, Chandrashekar Meshram, Raad Shakir, and I proposed to publish a special issue on tropical neurology in the Journal of the Neurological Sciences. The selection of topics and authors was coordinated with the Tropical and Geographical Specialty Group of the World Federation of Neurology (WFN).  Because of the high incidence and prevalence of neglected tropical diseases (NTD) that affect the nervous system, this project was given high priority by the journal’s editorial board.

Almost half of the world’s population (approximately 3.3 billion) resides in the tropics. Taken together, NTDs affect close to 1 billion people each year. At present, these diseases affect the majority of Latin America, Asia, and Africa. Due to global climate change, these diseases are predicted to affect an ever-increasing number of people. We hope this special issue will bring greater attention to these important and highly prevalent diseases.

Because the special issue is an online product, articles are added as they are accepted for publication. Currently, nine articles covering the topics of CNS fungal infections, onchocerciasis, ebola, chikungunya, leprosy, tuberculosis, brucellosis, COVID-19, and environmental neurology are published; others covering neurocysticercosis, dengue, and zika will follow.

The articles in the special issue are available by accessing:

https://www.sciencedirect.com/journal/journal-of-the-neurological-sciences/special-issue/10NG1VC7F2Z •

John D. England, MD, is editor-in-chief of the Journal of the Neurological Sciences, the official journal of the WFN.

 

 

 

 

Brain Health Initiative in India

By Drs. Chandrashekhar Meshram, JMK Murthy, Nirmal Surya and U. Meenakshisundaram.

The Tropical and Geographical Neurology Specialty Group of the WFN joined hands with the Indian Academy of Neurology (IAN) to celebrate the Brain Health initiative on Jan. 11, 2021, to raise awareness for the importance of brain health.

A public education and awareness activity in the form of a panel discussion was planned through virtual meeting. The theme of the session was brain health and what happens if brains are not healthy. Dr. Chandrashekhar Meshram, chief coordinator of the program, released the press note.

Dr. JMK Murthy, president of Indian Academy of Neurology and clinical director and chair of the Department of Neurology, CARE Hospitals Hyderabad, inaugurated the event.

Dr. Meshram, in his introductory remarks, emphasized the relevance of this initiative by the World Federation of Neurology. Dr. Sarosh Katrak, past president of IAN, explained the importance of the brain, explained its functions and discussed why brain health is the priority.

IAN Secretary Dr. U. Meenakshisundaram spoke about various brain diseases and when people should consult a neurologist. Dr. Subhash Kaul, past president of IAN, mentioned various risk factors for brain diseases and how a change in lifestyle is important for prevention of neurological disorders.

Marathon runner and neurologist Dr. Anuradha explained how regular physical exercises improve brain health. Dr. Meshram highlighted the misconceptions about diet and stressed the need to shift to a low carbohydrate diet. He said that wrong diet is responsible for the pandemic of metabolic syndrome all over the world.

Dr. Gagandeep Singh, past secretary of IAN, informed about the current status of COVID vaccine. Dr. Sudhir Kothari said that developing hobbies is a good idea to maintain brain health and suggested that there is no age bar to learning new things. Dr. Sudhir Shah explained the positive effects of meditation and yoga on brain health. Dr. Sumit Singh stressed the effects of air pollution on brain health and discussed the sources of air pollution.  Dr. Sudhir Bhave explained the need for sleep hygiene and the role of positive thinking.

The emphasis was on maintaining brain health and prevention of brain diseases.

Dr. Nirmal Surya, IAN president-elect, was the moderator, and he interacted with the panelists. Participants enjoyed the session and the opportunity to interact with the experts during the question-and-answer session. •

Selçuk University Hospital: One Year Later

By Ani-Osheku Ifeyinwa, Nigeria

Neurology Grand Rounds

In December 2019, I had the utmost privilege to spend four weeks at the neurology department of the Selçuk University in Konya, Turkey. It remains one of the most gratifying moments in my career as a young neurologist.

It has been over a year, yet the memories are ever so fresh. I clearly remember the feeling of excitement as I walked into the massive Selçuk University Hospital and made my way to the “nöroloji poliklinik” where I was greeted with so much warmth by the entire neurology staff. I met Prof. Şerefnur Öztürk, my supervisor, who provided me with the itinerary and a road map of what I was to expect in the coming weeks.

Indeed, it was a four-week period of intense learning in a relaxed and friendly environment. I had the privilege of exploring the world of the practice of neurology by the Turks under the able guidance and excellent mentorship of the neurology team of the Selçuk University Hospital.

Certificate presentation and the new year celebration.

Case after case, I witnessed the translational art of the pathological basis of neurologic diseases from therapeutic theorem to practical strategies using cut-edge technology and evidence-based medicine in the management of various neurologic conditions, including stroke, movement disorders, demyelinating disease (especially multiple sclerosis), neuromuscular diseases, and seizure disorders.

Prof. Öztürk shared with me priceless clinical pearls especially in the area of vascular neurology during the daily morning rounds in the neuro-intensive service as well as in the outpatient service. Her depth of knowledge combined with her wealth of experience has inspired me to push the limits of my career.

It was intriguing watching Prof. Gökhan Özdemir navigate stenosed and occluded vessels inserting stents and retrieving clots and ultimately achieving revascularization.

My experience with the neurophysiology laboratories left quite an impression on me that instinctively I knew I would pursue a fellowship in this area. I participated in carrying out and interpreting several EEGs, needle EMGs, and nerve conduction studies under the supervision of Profs. Gökhan Özdemir, Haluk Gümüş, and Dr. Hakan Ekmekci.

I learned the techniques of peripheral nerve blockade in the management of headaches and this service is one of the treatment modalities currently offered to patients with headache disorders in our neurology clinic. The ease of application coupled with the dramatic improvement has been a rewarding experience.

Lunch with neurology residents

I joined the neurosurgical team in the collaborative management of patients especially those with movement disorders, where I witnessed the usefulness of deep brain stimulation in advanced Parkinson’s disease.

One of the highlights of my stay was the opportunity to speak on “Nigeria, Its People, and Its Health Care System: A Focus on Neurological Diseases.” This lecture was delivered on Dec. 25,  2019, in the Dekanlik Donem 2 Amfisi, and I tagged it “A Christmas to Remember!”

The rich cultural heritage of the Turks makes the city a tourist’s delight. I savored the tastebud tantalizing Turkish foods and enjoyed the sceneries of some of the city’s famous sites, like the famous Mevlâna Museum and Alaaddin Cami.

Despite the numerous challenges the novel Covid-19 pandemic brought, redefining interactions in the health care sector along with restrictions in movements that put a hold on dreams for the physical quest in knowledge acquisition, I have continued to cascade the knowledge so acquired in my time in Selçuk in order to positively impact the lives of patients with neurological needs in Nigeria. I am currently working on various projects that include the transfer of skills acquired, especially relating to headache management and protocols for managing various neurology conditions.

Dr. Ani-Osheku Ifeyinwa giving a lecture

My profound gratitude to the WFN/TNS for this wonderful and innovative collaboration to give young neurologists like me the opportunity to experience the practice of neurology in an advanced society and a chance to improve our skills and broaden our horizons. Plenty of thanks to Mrs. Jade Levy and Mr. Burak for the seamless facilitation of my trip and stay in Konya. My deep appreciation to Selçuk University and  the dean of the College of Medicine for providing the enabling environment for my visit. To Prof. Şerefnur Öztürk, you inspire me in numerous ways to be the best version of myself. Finally, to the exceptional team at the Selçuk neurology department that showed me true friendship, generosity, and ensured I was well integrated, I say thank you!

I had the most amazing time in Konya and established alliances that I believe will go a long way. The lessons learned from my four weeks to Selçuk University will always be a reference point in my career development. •

Prospects for 2021

By William M. Carroll, president of the World Federation of Neurology

An Important Conjunction

William Carroll, MD

As this column goes to press in the first issue of World Neurology for 2021, it is surprising to see the energy and the activities the WFN will be involved in after such a trying 2020. I will enlarge on the role of the WFN in the COVID-19 pandemic, but first I wish to highlight two important events that occurred late last year and early this year.

The first was the adoption by the World Health Organization (WHO) of resolution WHA 73.10. As was communicated to all member societies in November and again in my column in December, this particular resolution was a landmark event. For the first time, neurological disorders were recognized by the WHO for what they are: a looming threat to individuals and societies, including both economic and personal burdens.

In common language, the WHO plans to develop an all-encompassing action plan to mitigate the effects of neurological disorders on brain health throughout life. This plan has become known as the Intersectoral Global Action Plan (IGAP) for epilepsy and similar neurological disorders.

Early in resolution WHA73.10, neurological disorders are described as “conditions of the central and peripheral nervous system that include epilepsy, headache disorders, neurodegenerative disorders, cerebrovascular diseases, including stroke, neuroinfectious/neuroimmunological disorders, neurodevelopmental disorders and traumatic brain and spinal cord injuries.” Subsequently, these disorders do occur as comorbidities of epilepsy and that many may benefit from similar public health measures to be developed for epilepsy.

Since this development, the WFN has been engaged with the International League Against Epilepsy, the International Bureau for Epilepsy, and the International Child Neurology Association in preparing the broader neurological fraternity, including members of the Global Neurology Alliance to be ready to contribute to the proposed plans if requested by the WHO.

The second important event has been the launch of the WFN Brain Health Initiative (BHI). The BHI arose through the perceived need to promote brain health more generally and more widely. This ambitious initiative is aimed at the global population and not just the WFN and its specialty constituents. Many members of the Global Neurology Alliance (GNA) have their own educational advocacy programs. Indeed, the WFN does this also through its biennial WCN and the annual disease specific World Brain Day (WBD), lately always partnered with a GNA member.

In this initial phase, the BHI will comprise five separate but sequential modules. The first two, titled “An Introduction to Brain Health” and “What Happens When Brains Are Not Healthy” were launched on Jan. 11 and the parallel webinar Feb. 17. The webinar also included contributions from each of the WFN regional organizations.

Modules 3 to 5 will follow soon with a launch webinar that will hopefully feature a wider collaboration from member societies.

The reason for highlighting the fortunate conjunction of these two crucial events is that there is an evolving momentum on the importance of brain health. Triggered in part by the Global Burden of Disease (GBD) study of 2016 showing neurological non-communicable disorders (nNCD) are the leading cause of disability and the second leading cause of death, a growing number of organizations and people are recognizing that brain health is not only a natural gift but that for some its attainment requires active, effortful participation as does the maintenance of optimum brain health.

It is hoped that along with improvement in health standards generally there will be increasing emphasis on the importance of brain health. People, societies, health care practitioners and governments need to advocate in concert for measures that reduce the risk of brain ill-health and injury.

Brain Health Initiative and COVID-19

From the above, it is clear that the WFN will be focusing its virtual efforts on brain health including the Brain Health Initiative.

It is opportune to compare the preparations for this challenge with that which the world has had to undertake for the challenge of COVID-19. Although over a much shorter time frame, the world has begun to introduce a viable response to the pandemic. With the same energy and commitment, the world will meet the challenge of the increasing burden of neurological disorders.

Through 2020, the WFN has participated with two groups developing means to capture, measure, and treat any neurological state generated by the COVID-19 pandemic.

Both the WHO Global Forum on Neuro-COVID-19, headed by Tarun Dua (WHO Brain Health Unit) and the Neuro Covid-19 Coalition inaugurated by Andrea Winkler (University of Munich), have worked in parallel to assess the acute effects and the late effects of COVID-19 infection.

The development of the WHO Global COVID-19 Clinical Case Record Form (CRF) provides a uniform CRF that can be employed in the acute and importantly the post-infective stage of COVID-19 illness and will ensure as far as possible that the data collected from anywhere will be viable and informative. Thanks go to Richard Stark and Alla Guekht for their efforts on our behalf with these groups. It is envisaged that the WFN will continue to be associated with these two groups through 2021.

World Brain Day

Following on from the successful collaborations with the International Headache Society in 2019 and the International Parkinsons Disease and Movement Disorders Society through the peak of the pandemic in 2020, the WFN will likely partner with the Multiple Sclerosis International Federation in 2021.

The WFN decision on this topic was made only after careful consideration. Multiple sclerosis (MS) and other immune-mediated CNS inflammatory disorders have an important success story to disseminate, share a link with severe and often fatal COVID-19 disease, have caused concern among those with MS with regard to treatments and COVID-19 vaccination and highlight again the risk the pandemic poses to ongoing neurological management through the diversion of resources.

The success story for MS is that with the continuing development of effective therapies and the post-marketing observations, it has become evident that the accrual of disability from MS has been dramatically reduced and even more so if treatment is begun early. Furthermore, there are now therapies arriving that promise to slow the later, progressive phase of MS.

Communication

Thanks to the efforts of member societies and the London office staff of the WFN, we now have the ability to communicate rapidly and with high fidelity. Efforts now will be centered on maintaining this facility as is it clearly to the benefit of us all. Thanks also to those who maintain the WFN website, a never-ending task. The recent update of the homepage to accommodate the Brain Health Initiative is a case in point.

Needs Registry

Another crucial example of the benefits of reliable communications is the completion of the Needs Registry survey by some 115 of the 122 member societies. The data is now undergoing preliminary statistical evaluation, and it is hoped that this will be able to be shared with members soon. It is likely that the Needs Registry survey data will also be helpful for the IGAP.

World Congress of Neurology and Council of Delegates Meeting

Planning and organization of the 25th WCN will be a major effort through this year. Ryuji Kaji, chair of the WCN Congress Committee, reports on the progress of this WCN in this issue. At this time, it appears quite unlikely that this congress will be a wholly physical or face-to-face meeting. Kenes, the WFN professional conference organizer (PCO), has experience and expertise to hold a hybrid meeting or a totally virtual meeting, whatever eventuates. The WFN, the Society of Italian Neurologists and Kenes hope to hold off a final decision on the format of the WCN until April, some six months before the WCN. Given the uncertainties about the pandemic and the likelihood of a hybrid meeting, the trustees have determined to again conduct the scheduled elections electronically as was done successfully in 2020. In this regard, I draw your attention to the notice of elections and the call for nominations for those elections. •

From the editors

By Steven L. Lewis, MD, Editor,
and Walter Struhal, MD, Co-Editor

Steven L. Lewis, MD, Walter Struhal, MD

Welcome to the February 2021 issue of World Neurology. This issue begins with the news that Prof. Raad Shakir, immediate past president of the World Federation of Neurology (WFN), has been made a Commander of the British Empire (CBE) in the U.K. New Year Honors List, with a commentary on this remarkable honor provided by WFN President William M. Carroll.

Next. Dr. Carroll updates us on the many activities planned for the WFN in 2021, including plans with the World Health Organization (WHO) and the WFN regional organizations, the Brain Health Initiative (BHI) and COVID-19, the WFN Needs Registry, the World Congress of Neurology (WCN) and the upcoming Annual General Meeting (AGM) of Council of Delegates meeting COD meeting planned for WCN 2021.

With regard to the WCN, WFN Vice President Ryuji Kaji reminds all readers to submit abstracts to the WCN 2021 in Rome. Dr. Kaji also announces the creation of a new award for service to the WFN. In his column on the WFN Committees and Specialty Groups, WFN Secretary-General Wolfgang Grisold reports on the many activities of the WFN Tropical and Geographical Neurology Specialty Group and Standards & Evaluations Committee.

Drs. Chandrashekahr Meshram, JMK Murthy, Nirmal Surya, U Meenakshisundaram and Gagandeep Singh report on the many activities that recently occurred around National Brain Week in India, revolving around the theme of preventive aspects of the neurological diseases. Dr. Meshram also reports on the new monthly webinar series, “Inspiring People in Neurosciences,” with an exciting schedule of remarkable neurologists speaking about inspirational neurologists, a free educational series for which neurologists around the world and at all stages of their career should find of great interest.

In this issue’s WFN Training Center report, Drs. Olivier Kapto and Ratsitohara Santatra Razafindrasata, from Burkina Faso and Madagascar, respectively provide a nicely illustrated report of their successful year of specialty training at the WFN Training Center in Rabat, Morocco.

The history column by Peter J. Koehler provides his insights into the potential neurological origins of visions reported by a classic figure from the Middle Ages.

Finally, this issue also details the notice of elections for open positions in 2021 to be voted on at the AGM of the COD meeting at the WCN in October 2021.

Thanks to all readers for your interest in World Neurology. We look forward to continued submissions from neurologists and neurological societies worldwide to inform all neurologists about the remarkable variety of activities and opportunities available to enhance the field of neurology and our care of neurological patients around the globe. •

Submit Abstracts and Join Us at WCN 2021 in Rome

By Ryuji Kaji MD, WFN First Vice President

As the chair of the Congress Committee, I cordially invite you to join the 25th World Congress of Neurology (WCN) to be held Oct. 3-7, 2021, in Rome, Italy. Since the pandemic of COVID-19 will not completely fade out by then, we are most likely to have a hybrid-type congress, providing you the option of attending in person or virtually. The committee has decided that we will remain flexible until the end of March as to what extent the meeting can be held online.

The world is now suffering from COVID-19, which is comparable to Spanish flu or the influenza pandemic that occurred 100 years ago. At that time, peculiar neurological conditions were reported. These included encephalitis lethargica or von Economo’s encephalitis, which is now hypothesized as a sequela of the pandemic. Similarly, there are various neurological manifestations of COVID-19, such as anosmia, stroke, so-called “brain fog” and others. Despite the difficulties of having WCN 2019 at this time, it is a unique opportunity to discuss various consequences of the pandemic not only scientifically but also in terms of its impact on neurological education and patients’ care during the crisis to put our best pieces of knowledge together.

We will have the most updated sessions on COVID-19 and the nervous system, including a plenary session, so that we can share the strategies to fight against the virus. Also, we welcome abstract submissions on any advances in the other subspecialties of neurology. Our strengths include the worldwide links among membership societies and research groups, and we expect a number of breakthroughs in neurology to be presented at this meeting.

On behalf of our Italian colleagues, we welcome those who will be physically able to visit Rome and enjoy the most historic place in Europe: Inspired by the past to build the future of neurology. For those who are unable to come, you will also be able to present your paper online.

Please submit your abstracts now. The deadline is April 5, 2021. •

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