Amantadine for Traumatic Brain Injury-Supporting Evidence and Mode of Action.

Traumatic brain injury (TBI) is an important global clinical issue, requiring not only prevention but also effective treatment. Following TBI, diverse parallel and intertwined pathological mechanisms affecting biochemical, neurochemical, and inflammatory pathways can have a severe impact on the patient's quality of life. The current review summarizes the evidence for the utility of amantadine in TBI in connection to its mechanism of action. Amantadine, the drug combining multiple mechanisms of action, may offer both neuroprotective and neuroactivating effects in TBI patients. Indeed, the use of amantadine in TBI has been encouraged by several clinical practice guidelines/recommendations. Amantadine is also available as an infusion, which may be of particular benefit in unconscious patients with TBI due to immediate delivery to the central nervous system and the possibility of precise dosing. In other situations, orally administered amantadine may be used. There are several questions that remain to be addressed: can amantadine be effective in disorders of consciousness requiring long-term treatment and in combination with drugs approved for the treatment of TBI? Do the observed beneficial effects of amantadine extend to disorders of consciousness due to factors other than TBI? Well-controlled clinical studies are warranted to ultimately confirm its utility in the TBI and provide answers to these questions.

Consensus Guideline on the Management of Epilepsy in Egypt: A National Delphi Consensus Study.

OBJECTIVE: In epilepsy, early diagnosis, accurate determination of epilepsy type, proper selection of antiseizure medication, and monitoring are all essential. However, despite recent therapeutic advances and conceptual reconsiderations in the classification and management of epilepsy, serious gaps are still encountered in day-to-day practice in Egypt as well as several other resource-limited countries. Premature mortality, poor quality of life, socio-economic burden, cognitive problems, poor treatment outcomes, and comorbidities are major challenges that require urgent actions to be implemented at all levels. In recognition of this, a group of Egyptian epilepsy experts met through a series of consecutive meetings to specify the main concepts concerning the diagnosis and management of epilepsy, with the ultimate goal of establishing a nationwide Egyptian consensus. METHODS: The consensus was developed through a modified Delphi methodology. A thorough review of the most recent relevant literature and international guidelines was performed to evaluate their applicability to the Egyptian situation. Afterward, several remote and live rounds were scheduled to reach a final agreement for all listed statements. RESULTS: Of 278 statements reviewed in the first round, 256 achieved ≥80% agreement. Live discussion and refinement of the 22 statements that did not reach consensus during the first round took place, followed by final live voting then consensus was achieved for all remaining statements. SIGNIFICANCE: With the implementation of these unified recommendations, we believe this will bring about substantial improvements in both the quality of care and treatment outcomes for persons with epilepsy in Egypt. PLAIN LANGUAGE SUMMARY: This work represents the efforts of a group of medical experts to reach an agreement on the best medical practice related to people with epilepsy based on previously published recommendations while taking into consideration applicable options in resource-limited countries. The publication of this document is expected to minimize many malpractice issues and pave the way for better healthcare services on both individual and governmental levels.

Changes in Vital Signs During Epileptic and Psychogenic Nonepileptic Attacks: A Video-EEG Study.

INTRODUCTION: Epilepsy is a common disorder. Psychogenic nonepileptic attack (PNEA) is one of the epilepsy mimics. Video EEG is still the gold standard tool that differentiates between epileptic seizures (ES) and PNEA. Oxygen saturation (SaO2) and ictal vital signs, including heart rate (HR), respiration rate (RR), body temperature, systolic blood pressure (SBP), and diastolic blood pressure show crucial changes during ES and PNEA. PURPOSE: To analyze, compare, and find relationships of changes in ictal vital sign during ES and PNEA. METHODS: Ninety-four adults had video EEG monitoring. SaO2, HR, RR, body temperature, SBP, and diastolic blood pressure were obtained at baseline and during the attacks. RESULTS: The 49 patients with ES and 45 patients with PNEA had nearly similar baseline vital sign. Epileptic seizures yielded a higher ictal HR (p = 0.003) and lower ictal SaO2 (p = 0.04) than PNEA. Ictal RR and ictal SBP of patients with PNEA were higher than those of patients with ES (p = 0.02 and P = 0.04, respectively). For ES, ictal HR inversely correlated with ictal SaO2 (P = 0.003). In PNEA, ictal HR directly correlated with ictal SBP (P = <0.005). CONCLUSIONS: There are statistically significant differences between pre-ictal and ictal SaO2, HR, SBP, and diastolic blood pressure in both ES and PNEA groups. The inverse relationship between ictal SaO2 and ictal HR in ES suggests severe cardiorespiratory dysfunction. The significantly elevated ictal HR, ictal RR, and ictal SBP during PNEA demonstrates the risk of those attacks if not stopped.

Prognostic Value of "A" Waves in Patients With Guillain Barre Syndrome.

INTRODUCTION: The "A" wave is a compound action potential evoked consistently from a muscle by submaximal electric stimulation to the nerve. "A" waves were usually associated with the presence of conduction block and abounded in lower limbs more than in upper limbs. Guillain Barre syndrome is an autoimmune polyradiculoneuropathy that usually follows respiratory or gastrointestinal infections. PURPOSE: To study the prognostic value of "A" waves in patients with Guillain Barre syndrome with different recovery patterns. METHODS: In this study, 50 patients with GuillainBarreSyndrome were enrolled. They were divided into two groups based on the presence or absence of "A" waves in their neurophysiologic study at onset of illness. Strength of limb muscles of the involved patients was assessed at onset of the study and 6 weeks later (short-term clinical recovery) using the Medical Research Council Scale. RESULTS: Patients with waves (29 patients: 58%) showed poorer short-term follow-up parameters than those without "A" waves (21 patients: 42%). CONCLUSIONS: Presence of "A" waves is usually associated with conduction block and marked degree of demyelination. "A" waves carry poor prognostic value in short-term follow-up parameters in patients with Guillain Barre syndrome.

Sympathetic skin response in patients with systemic sclerosis and rheumatoid arthritis.

BACKGROUND: Sympathetic skin response (SSR) is a technique to assess the sympathetic cholinergic pathways. Sympathetic dysfunction may participate in the development of pain, which is the major complaint in patients with systemic sclerosis (SSc) and rheumatoid arthritis (RA). OBJECTIVES: In this study, we aimed to assess the autonomic dysfunction in patients with (SSc) and (RA) using SSR as a simple neurophysiologic test. METHODS: Palmar SSR to median nerve electrical stimulation was recorded in 21 patients with SSc, 39 patients with RA, and in 60 healthy age and sex-matched control subjects. RESULTS: Palmar SSR to median nerve stimulation (of SSc patients and RA patients) shows significantly delayed latency and reduced amplitude in comparison to the control group. SSR of SSc patients has significantly delayed latency and reduced amplitude when compared to RA patients. Moreover, six SSc patients have delayed SSR in spite of the absence of manifestations of polyneuropathy. CONCLUSIONS: Patients with SSc and RA have features of autonomic dysfunction with more affection of SSc patients.

Construction of an Arabic computerized battery for cognitive rehabilitation of children with specific learning disabilities.

PURPOSE: The aim of this study was to design an Arabic computerized battery of cognitive skills for training children with specific learning disabilities (SLD). SUBJECTS AND METHODS: Nineteen students from fourth grade primary schools in Assiut, Egypt, who were previously diagnosed with SLD, agreed to participate in the rehabilitation program. The study passed through four stages: first stage, detailed analysis of the cognitive profile of students with SLD (n=19), using a previously constructed diagnostic cognitive skill battery, to identify deficits in their cognitive skills; second stage, construction of an Arabic computerized battery for cognitive training of students with SLD; third stage, implementation of the constructed training program for the students, each tailored according to his/her previously diagnosed cognitive skill deficit/deficits; and fourth stage, post-training re-evaluation of academic achievement and cognitive skills' performance. RESULTS: Students with SLD have a wide range of cognitive skill deficits, which are more frequent in auditory cognitive skills (68.4%) than in visual cognitive skills (64.1%), particularly in phonological awareness and auditory sequential memory (78.9%). Following implementation of the training program, there was a statistically significant increase (P<0.001) in the mean scores of total auditory and visual cognitive skills, as well as in academic achievement (P<0.001) of the study group. CONCLUSION: Remediation-oriented diagnosis of cognitive skills, when tailored according to previously diagnosed cognitive deficits, leads to the improvement in learning abilities and academic achievement of students with SLD.

Steroid/Antiviral for the treatment of Bell's palsy: Double blind randomized clinical trial.

BACKGROUND: A large number of patients with Bell's palsy fail to recover facial function completely after steroid therapy. Only a few small trials have been conducted to test whether outcomes can be improved by the addition of antiviral therapy. OBJECTIVE: To evaluate the efficacy of treatment with steroid alone versus steroid + antiviral in a group of patients with moderately severe to severe acute Bell's palsy. METHODS: Fifty eligible patients out of a total of 65 with acute onset Bell's palsy were randomized to receive the two treatments. Evaluation was performed before starting treatment, after 2 weeks of treatment and 3 months after onset, using the House and Brackmann facial nerve grading system (HB) and the Sunnybrook grading system.This study was registered with ClinicalTrials.gov, number NCT02328079. RESULTS: Both treatments had comparable demographics and clinical scores at baseline. There was greater improvement in the mean HB and Sunnybrook scores of the steroid + antiviral group in comparison to steroid group at 3 months. At the end of the 3rd month, 17 patients (68%) had good recovery and 8 patients (32%) had poor recovery in the steroid group compared with 23 patients (92%) and 2 (8%) respectively in the steroid and antiviral group (p = 0.034). CONCLUSION: The combination of steroid and antiviral treatment increases the possibility of recovery in moderately severe to complete acute Bell's palsy.

Spectrum of epilepsy - prevalence, impact, and treatment gap: an epidemiological study from Al-Quseir, Egypt.

BACKGROUND: Epidemiology continues to be an important research tool in the study of epilepsy and related disorders, providing a better understanding of the frequency, causes, and natural history of the disorder. OBJECTIVE: To estimate the prevalence of epilepsy in Al-Quseir, Red Sea Governorate, Egypt, and its magnitude of treatment gap. METHODS: The study was part of a door-to-door study, including every door, to screen all inhabitants in Al-Quseir (33,818 inhabitants) by three specialists of neurology and 15 female social workers (for demographic data collection) using a standardized screening questionnaire. All suspected cases were subjected to detailed history, clinical examination, and electroencephalogram. Neuroimaging studies and estimation of serum drug level were done in select cases if needed. RESULTS: The study revealed that the lifetime prevalence rate of epilepsy in Al-Quseir is 5.5/1,000, with the highest peak during early childhood, while that of active epilepsy is 3.3/1,000 population. The annual incidence rate is 48/100,000, and the age-specific incidence rate has a U-shaped pattern with two peaks of incidence in early infancy and elderly life. Localization-related epilepsy is the most frequently encountered type (58.8%). The treatment gap of epilepsy in Al-Quseir is 83.8%. CONCLUSION: The lifetime prevalence of epilepsy in Al-Quseir city, Red Sea Governorate, was 5.5/1000.

Prevalence of multiple sclerosis in Al Quseir city, Red Sea Governorate, Egypt.

BACKGROUND: Multiple sclerosis (MS) is a chronic and disabling disorder with considerable social effects and economic sequelae. It is one of the major causes of disability in young adults. OBJECTIVES: This study aimed at detecting the prevalence of MS among the population of Al Quseir city. METHODS: This study is a part of door-to-door survey of major neurological disorders that was conducted in Al Quseir city, Red Sea Governorate, Egypt. The sample size was 33,285 persons. The youngest patient was 17 years old. The number of people at and above 17 years of age was 21,827. They were screened by three neurologists. Then, the positive cases were subjected to meticulous clinical evaluation by three staff members of Department of Neurology, Assiut University Hospital, Egypt. Essential investigations were done. RESULTS: A total of three cases of MS were diagnosed with an age-specific prevalence ≥17 years of 13.7/100,000.

Epidemiology and clinical presentation of stroke in Upper Egypt (desert area).

BACKGROUND: Stroke is a common cause of morbidity and mortality worldwide. Four out of five strokes occur in the low- and middle-income countries. This study aims to find lifetime prevalence of stroke in Upper Egypt and to identify clinical presentations and possible risk factors of stroke in this population. METHODS: This is a door-to-door (every door) study conducted on all inhabitants in Al Kharga district (representative of western desert) and Al Quseir city (representative of eastern desert). The study was conducted in two stages, and every stage consisted of three phases (screening, diagnostic, and investigatory). RESULTS: The total lifetime prevalence of stroke was 8.5/1,000 in the population aged 20 years and more. It increased with advancing age and was higher among males than females among all age groups except in the childbearing period (20 years to <40 years of age). Lifetime prevalence of ischemic stroke (7.2/1,000) was higher than hemorrhagic stroke (1.1/1,000). Hemiparesis and hemiplegia were the commonest presentation of stroke. Headache, vomiting, and vertigo were found to be significantly more common accompaniments of hemorrhagic stroke. The most common risk factor was hypertension, followed by hyperlipidemia and diabetes mellitus. CONCLUSION: The total lifetime prevalence of stroke in the population aged 20 years and more in Upper Egypt (desert area) lies within the range that is recorded in developing countries. Clinical presentation and risk factors are similar to those recorded from developing and developed countries.

Different types of headache in patients with systemic lupus erythematosus.

BACKGROUND: Headache in patients with systemic lupus erythematosus (SLE) is considered a common neurological finding, although the relationship is unclear. AIM: In this study, we aimed to evaluate frequency and characteristics of different types of headache in patients with SLE. METHODS: 40 SLE patients were chosen from those referred to the out patient clinic using the American College of Rheumatology (ACR) criteria for the diagnosis of SLE. Headache classification was done regarding the ICD-II criteria in the patients. Headache severity was assessed by visual analog scale (VAS), and subjects with VAS ≥4 were included in the study. RESULTS: 30 patients out of 40 SLE patients (75%) have different headache types: tension type in 37.5% (n = 15) and migraine in 30% (n = 12), cluster 2.5% (n = 1), and intracranial hypertension 5% (n = 2) of all patients. CONCLUSION: Headache is frequent in SLE especially tension and migraine types, but overall, it is not associated with disease activity.

Changes in motor cortical excitability in patients with Sydenham's chorea.

BACKGROUND AND PURPOSE: The neurophysiological characteristics of motor cortex have been well characterized in patients with Huntington's disease. We present the first data on cortical excitability in patients with Sydenham's chorea. METHODS: Motor cortex excitability was examined using transcranial magnetic stimulation in 16 patients in the early clinical stages of Sydenham's chorea and in 17 age- and sex-matched control subjects. Investigations included resting and active motor threshold, motor evoked potential, input-output curves, contralateral silent period, and transcallosal inhibition. RESULTS: Resting and active motor threshold were significantly higher and motor evoked potentials were significantly smaller in patients in comparison with controls. The input-output curves were shallower in both hemispheres of patients with chorea compared with controls. No significant differences were seen in silent period or transcallosal inhibition duration. CONCLUSION: Sydenham's chorea is characterized by reduced excitability of corticospinal output similar to that observed in Huntington's disease.

Cerebral palsy in Al-Quseir City, Egypt: prevalence, subtypes, and risk factors.

Cerebral palsy (CP) is the most frequent cause of motor handicap. The present door-to-door survey was conducted in Al-Quseir City, Egypt, to investigate the epidemiology of CP. All inhabitants were screened by three neurologists. Medical and neurological examinations were performed for all residents and suspected cases of CP were confirmed by meticulous neurological assessment, brain magnetic resonance imaging, electroencephalography, and testing with the Stanford-Binet Intelligence Scale. Forty-six of 12,788 children aged ≤18 years were found to have CP, yielding a childhood prevalence of 3.6 (95% confidence interval 1.48-2.59) per 1,000 live births. Five adults (aged 19-40 years) among 13,056 inhabitants had CP, giving an adult prevalence of 0.4 (95% confidence interval 0.04-0.72) per 1,000. The risk factors for CP identified in this study were premature birth, low birth weight, neonatal jaundice, neonatal seizures, and recurrent abortion in mothers of children with CP.

Epileptic and cognitive changes in children with cerebral palsy: an Egyptian study.

BACKGROUND: Cerebral palsy (CP) is the most frequent cause of motor handicap among children. AIM OF THE STUDY: We aim to study the relation of epilepsy in children with CP to various risk factors that affect the development of seizures. PATIENTS AND METHODS: In a cross-sectional, descriptive, population-based, case-control study, 98 children with CP (48 children with CP with epilepsy, and 50 children with CP without epilepsy) were compared with 180 children without CP or seizures. The children lived in two regions in Egypt: the Al-Kharga District-New Valley and El-Quseir city-Red Sea. These cases were subjected to meticulous neurological assessment, brain magnetic resonance imaging, electroencephalography, and Stanford-Binet (4th edition) examination. Multinomial logistic regression was used to assess the risk factors. RESULTS: Epilepsy was diagnosed in 48.9% of all cases of CP. Mental subnormality was observed more frequently in children with epilepsy than in those without epilepsy (84.6% versus 66.7%). The frequency of epilepsy was highest in patients with the spastic quadriplegic type of illness (58.3%). Multinomial logistic regression revealed that prematurity (<32 weeks of pregnancy), low birth weight (<2.5 kg at birth), neonatal seizures, jaundice, and cyanosis were significantly associated with CP with epilepsy. CONCLUSION: CP is associated with a high percentage of seizure disorders. Prematurity, low birth weight, neonatal seizures, cyanosis, and jaundice are significant risk factors among patients with CP with epilepsy compared to patients with CP without epilepsy or a healthy control group.

Selenium and antioxidant levels decreased in blood of children with breath-holding spells.

We hypothesize that the imbalance between oxidant and antioxidant systems might be involved in the pathophysiology of breath-holding spells. The aim of this study is to evaluate the oxidant-antioxidant status in children with breath-holding spells compared to healthy children. In a case control study, 67 children with breath-holding spells were compared with 60 healthy children. Malondialdehyde values of the patients were significantly higher than those in control. Levels of selenium, glutathione peroxidase, and superoxide dismutase of the patient group are significantly lower than those in control. The present study gives helpful data about oxidant-antioxidant systems alterations in breath-holding spells in such a large patient group. These data give support to the hypothesis of the imbalance between oxidant and antioxidant systems, and selenium deficiency might be involved in the pathophysiology of breath-holding spells, suggesting the role of this system dysregulation in breath-holding spells.

Turner syndrome: review of clinical, neuropsychiatric, and EEG status: an experience of tertiary center.

We reviewed the clinical, neuropsychiatric, and EEG status of 53 turner syndrome (TS) females, aged 3-16 years, in Assiut university hospitals, Upper Egypt. The diagnosis and care of patients with TS in Egypt is still in the developing stage. Hence this study was undertaken to review the details of patients with TS with respect to the pattern of cognitive, psychiatric, and motor dysfunction. We aimed to provide a comprehensive data about the experience of our center comparable to previous studies, which have been published in this field. This will contribute to a better definition of the neuropsychiatric features that may be specific to TS that allows early and better detection and management of these cases. We found FSIQ and verbal IQ that seem to be at a nearly normal level and a decreased performance IQ. ADHD and autistic symptoms were found in 20.70 and 3.77 % of our cohort, respectively. The motor performance in TS was disturbed, with some neurological deficits present in 17 % (reduced muscle tone and reduced muscle power). In addition, females with TS in our study exhibit social and emotional problems, including anxiety (5.66 %) and depression (11.30 %). The EEG results revealed abnormalities in seven patients (13.20 %). One patient presenting with generalized tonic-clonic seizures showed generalized epileptiform activity, and six patients presenting with intellectual disabilities showed abnormal EEG background activity.

Trace element, oxidant, and antioxidant enzyme values in blood of children with refractory epilepsy.

PURPOSE: The aim of this study is to evaluate the serum levels of some trace elements, oxidants, and antioxidants in children with intractable epilepsy compared to healthy children. PATIENTS AND METHODS: In a case-control study, 40 children (24 males and 16 females) suffering from refractory generalized epileptic seizures were compared with 40 sex- and age-matched healthy children serve as a control group. Serum selenium (Se), zinc (Zn), copper (Cu), and plasma malondialdehyde (MDA) as well as erythrocyte glutathione peroxidase (GSH-Px) and superoxide dismutase (SOD) values were measured in the patients and controls. RESULTS: Plasma MDA values of the patient group were significantly ( p < 0.001) higher than those in control. Serum Zn, Se, and erythrocyte GSH-Px values of the patient group are significantly ( p < 0.001) lower than those in control, although there is no statistical difference in Cu and SOD values. CONCLUSION: Plasma MDA, erythrocyte GSH-Px, and trace elements Zn and Se may play an important role in the pathogenesis of intractable epilepsy in children.

Prevalence of dementia in Al-Quseir city, Red Sea Governorate, Egypt.

Dementia is one of the most important public health problems as a result of the rapid increase in the number of elderly persons worldwide. Improvement of prevention strategies and caring for people with dementia should be undertaken. We performed a door-to-door study to screen all subjects aged 50 years and older (n=4,329 of 33,285 inhabitants) in Al-Quseir city. The screening was performed by 3 neuropsychiatrists, using a modified form of the Mini-Mental State Examination. Suspected cases were subjected to case ascertainment according to Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, diagnostic criteria for dementia; full clinical assessment; psychometric assessment using Cognitive Abilities Screening Instruments, Hachinski Ischaemic Score, Instrumental Activities of Daily Living Scale and the Geriatric Depression Scale; neuroimaging (computed tomography and/or magnetic resonance imaging); and laboratory investigations for selected patients when indicated. The prevalence of dementia was 2.01% for participants aged 50 years or older and 3.83% for those aged 60 years or older. It increased steeply with increasing age to a maximum of 13.5% for those aged 80 years or older. Alzheimer's dementia (48.3%) was the most common subtype, followed by vascular dementia (36.8%), dementia resulting from general medical conditions (11.5%), and last, dementia resulting from multiple etiologies (3.4%).

Epidemiology of non-fatal cerebrovascular stroke and transient ischemic attacks in Al Quseir, Egypt.

BACKGROUND AND PURPOSE: Stroke is a medical emergency that can cause permanent neurological damage, complications, and disability. We aim to determine the epidemiology of non-fatal cerebrovascular stroke (CVS) and transient ischemic attacks (TIAs) in Al Quseir City, Red Sea, Egypt. METHODS: The total population (n=33,285) was screened through a door to door study by three specialists of neurology and 15 female social workers (for demographic data collection). All suspected stroke patients were subjected to a full clinical examination, computerized tomography (CT) and/or magnetic resonance imaging (MRI) of their brain, blood sugar, lipogram, serum uric acid, complete blood cells, blood urea, and serum creatinine, as well as evaluated by Barthel Index and Scandinavian Stroke Scale. Carotid doppler, echocardiography, and thyroid functions were done for selected cases. RESULTS: CVS was recorded among 130 patients out of 19,848 subjects aged 20 years and more, yielding a total prevalence of 6.55/1,000 population. From June 1, 2010 to May 31, 2011, 36 patients were recorded to have stroke within 1-year, yielding an incidence rate of 1.81/1,000. Prevalence and incidence rates were higher among males than females, and both indices increased steadily with advancing age to reach the highest prevalence (37.02/1,000) and incidence rate (9.5/1,000) among aged persons 60 years and more. CONCLUSION: The prevalence of non-fatal stroke in Al Quseir city (6.55/1,000) was at the lower range of that recorded in developing countries (5-10/1,000) and slightly higher than that recorded in industrialized countries (5/1,000 population). Ischemic stroke is the most common type of stroke. The prevalence of TIAs was 0.15/1,000.