Epilepsy Care in Latin America and the Caribbean: Overcoming Challenges and Embracing Opportunities.

The burden of epilepsy in the Latin America and the Caribbean (LAC) region causes a profound regional impact on the health care system and significantly contributes to the global epilepsy burden. As in many other resource-limited settings worldwide, health care professionals and patients with epilepsy in LAC countries face profound challenges due to a combination of factors, including high disease prevalence, stigmatization of epilepsy, disparities in access to care, limited resources, substantial treatment gaps, insufficient training opportunities for health care providers, and a diverse patient population with varying needs. This article presents an overview of the epidemiology of epilepsy and discusses the principal obstacles to epilepsy care and key contributors to the epilepsy diagnosis and treatment gap in the LAC region. We conclude by highlighting various initiatives across different LAC countries to improve epilepsy care in marginalized communities, listing strategies to mitigate treatment gaps and facilitate better health care access for patients with epilepsy by enhancing the epilepsy workforce.

Epilepsy and education: A case-control analysis of the impact of an intensive epilepsy training program on undergraduate medical students.

AIMS: To evaluate the knowledge, attitudes, and practical skills of students submitted to a 6-week intensive training in epilepsy compared to students without any training but mandatory neurology classes. METHODS: It is a case-control study. After completing a 6-week intensive Academic, Clinical, and Research Program in epilepsy, TUMSs answered a validated Knowledge Attitudes and Practices (KAP) questionnaire. The control group, composed of undergraduate students who shared the same age, academic year, and compulsory hours for learning about epilepsy as TUMSs, was also assessed through the KAP instrument. Answers from both groups were submitted to Fisher exact and the χ2 test to observe differences among groups. Descriptive statistics were also performed. RESULTS: TUMSs displayed better results in theoretical knowledge such as the definition and causes of epilepsy, and the application of paraclinical studies essential for diagnosing epilepsy. From their perspective, people with epilepsy encounter restricted opportunities for preserving their social life and employment and they are more prone to workplace accidents. They are convinced that facing epilepsy presents a notable risk due to the difficulties linked with diagnosis, considering epilepsy a challenging disease for general practitioners to identify and follow up. Likewise, they exhibited improvement in treatment adjustment and treatment monitoring of patients with epilepsy, mainly in pregnancy cases. Finally, they had greater knowledge about what to do when they witness a person experiencing a seizure. CONCLUSION: Our study showed that a 6-week intensive education program in epilepsy increased the knowledge and practical skills and changed the attitude toward patients with epilepsy of undergraduate students.

A global survey on the attitudes of neurologists and psychiatrists about functional/psychogenic/dissociative/nonepileptic-seizures/attacks, in the search of its name.

PURPOSE: We conducted an observational study to investigate the opinions of neurologists and psychiatrists all around the world who are taking care of patients with seizures [epilepsy and functional seizures (FS)]. METHODS: Practicing neurologists and psychiatrists from around the world were invited to participate in an online survey. On 29th September 2022, an e-mail including a questionnaire was sent to the members of the International Research in Epilepsy (IR-Epil) Consortium. The study was closed on 1st March 2023. The survey, conducted in English, included questions about physicians' opinions about FS and anonymously collected data. RESULTS: In total, 1003 physicians from different regions of the world participated in the study. Both neurologists and psychiatrists identified "seizures" as their preferred term. Overall, the most preferred modifiers for "seizures" were "psychogenic" followed by "functional" by both groups. Most participants (57.9%) considered FS more difficult to treat compared to epilepsy. Both psychological and biological problems were considered as the underlying cause of FS by 61% of the respondents. Psychotherapy was considered the first treatment option for patients with FS (79.9%). CONCLUSION: Our study represents the first large-scale attempt of investigating physicians attitudes and opinions about a condition that is both frequent and clinically important. It shows that there is a broad spectrum of terms used by physicians to refer to FS. It also suggests that the biopsychosocial model has gained its status as a widely used framework to interpret and inform clinical practice on the management of patients.

MindReader: Unsupervised Classification of Electroencephalographic Data.

Electroencephalogram (EEG) interpretation plays a critical role in the clinical assessment of neurological conditions, most notably epilepsy. However, EEG recordings are typically analyzed manually by highly specialized and heavily trained personnel. Moreover, the low rate of capturing abnormal events during the procedure makes interpretation time-consuming, resource-hungry, and overall an expensive process. Automatic detection offers the potential to improve the quality of patient care by shortening the time to diagnosis, managing big data and optimizing the allocation of human resources towards precision medicine. Here, we present MindReader, a novel unsupervised machine-learning method comprised of the interplay between an autoencoder network, a hidden Markov model (HMM), and a generative component: after dividing the signal into overlapping frames and performing a fast Fourier transform, MindReader trains an autoencoder neural network for dimensionality reduction and compact representation of different frequency patterns for each frame. Next, we processed the temporal patterns using a HMM, while a third and generative component hypothesized and characterized the different phases that were then fed back to the HMM. MindReader then automatically generates labels that the physician can interpret as pathological and non-pathological phases, thus effectively reducing the search space for trained personnel. We evaluated MindReader's predictive performance on 686 recordings, encompassing more than 980 h from the publicly available Physionet database. Compared to manual annotations, MindReader identified 197 of 198 epileptic events (99.45%), and is, as such, a highly sensitive method, which is a prerequisite for clinical use.

A pilot randomized controlled clinical trial of Transcranial Alternating Current Stimulation in patients with multifocal pharmaco-resistant epilepsy.

Transcranial Alternating Current Stimulation (tACS) is a promising noninvasive electrical stimulation therapy for neuropsychiatric diseases. Invasive neuromodulation using alternating current has been efficacious for drug-resistant epilepsy, but it is associated with surgical and medical complications. We aimed to explore the safeness and effectivity on seizure frequency reduction of two tACS protocols against placebo in patients with multifocal refractory epilepsy. This was a randomized, double-blinded, placebo-controlled clinical trial with 3-arm parallel-group (placebo, 30 min/2 mA daily sessions for 3 days [tACS-30], and 60 min/2 mA weekday sessions [tACS-60]). The main outcome was considered a change in reducing seizure frequency at 2 months after the intervention. Secondary outcomes were the apparition of any adverse effects during follow-up. At the second month, we observed a nonsignificant reduction in the seizure frequency in the placebo (7.3 ±â€¯40.4%, p > 0.05) and the tACS-60 (26 ±â€¯37.7%, p > 0.05). While the tACS-30 group showed a nonsignificant increase in seizure frequency (63.6 ±â€¯155.3%, p > 0.05). No changes were statistically different from the placebo group. Otherwise, participants experienced only minor adverse events - the most common being an initial local transient tingling sensation (21%). This pilot study of tACS raises no severe safety issues, but provides negligible evidence for efficacy using this brief treatment protocol. Therefore, more studies are warranted testing different parameters to further verify the safety and effectivity of tACS in multifocal epilepsy.

Intraoperative neurophysiological monitoring in Latin America: A bibliometric analysis.

PURPOSE: Intraoperative Neurophysiological Monitoring (IOMM) has been used worldwide in the attempt to reduce postsurgical neurological deficits, however, most of the publications are from developed countries. There is a global bibliometric analysis of IOMN in spinal surgery, however, the contribution of Latin America (LA) is not mentioned. The aim of this study is to describe scientific productivity, patterns of publications, and thematic trends of IONM in LA. METHODS: Data was collected using Scopus database, by searching scientific articles with LA affiliation, using 18 keywords. We excluded duplicates, not original articles, reviews, surveys, and articles not related to humans. Articles were analyzed and classified as follows: year of publication, language of the original document, journals metrics, country, IONM modality, etiology, location of surgery, medical specialties, and outcome. Descriptive statistics were used. RESULTS: We obtained 8,699 scientific articles of which 41 scientific articles from 7 LA countries were selected. Mexico has the highest number of publications. In most countries, supratentorial location showed the highest frequency. Somatosensory evoked potentials and electrocorticography were the most performed modalities. Neurosurgery was the most involved specialty of our 41 scientific articles, and 95.1% of these publications concluded that IONM is useful to guide surgical procedures. CONCLUSIONS: Mexico and Brazil have led IONM publications in LA. The lower reference in publications of visual evoked potentials and brainstem auditory evoked potentials IONM modalities, could be considered in the future to boost tailored research in LA.

Evidence-Based Guidelines and Secondary Meta-Analysis for the Use of Transcranial Direct Current Stimulation in Neurological and Psychiatric Disorders.

BACKGROUND: Transcranial direct current stimulation has shown promising clinical results, leading to increased demand for an evidence-based review on its clinical effects. OBJECTIVE: We convened a team of transcranial direct current stimulation experts to conduct a systematic review of clinical trials with more than 1 session of stimulation testing: pain, Parkinson's disease motor function and cognition, stroke motor function and language, epilepsy, major depressive disorder, obsessive compulsive disorder, Tourette syndrome, schizophrenia, and drug addiction. METHODS: Experts were asked to conduct this systematic review according to the search methodology from PRISMA guidelines. Recommendations on efficacy were categorized into Levels A (definitely effective), B (probably effective), C (possibly effective), or no recommendation. We assessed risk of bias for all included studies to confirm whether results were driven by potentially biased studies. RESULTS: Although most of the clinical trials have been designed as proof-of-concept trials, some of the indications analyzed in this review can be considered as definitely effective (Level A), such as depression, and probably effective (Level B), such as neuropathic pain, fibromyalgia, migraine, post-operative patient-controlled analgesia and pain, Parkinson's disease (motor and cognition), stroke (motor), epilepsy, schizophrenia, and alcohol addiction. Assessment of bias showed that most of the studies had low risk of biases, and sensitivity analysis for bias did not change these results. Effect sizes vary from 0.01 to 0.70 and were significant in about 8 conditions, with the largest effect size being in postoperative acute pain and smaller in stroke motor recovery (nonsignificant when combined with robotic therapy). CONCLUSION: All recommendations listed here are based on current published PubMed-indexed data. Despite high levels of evidence in some conditions, it must be underscored that effect sizes and duration of effects are often limited; thus, real clinical impact needs to be further determined with different study designs.

Epilepsy diagnosis based on one unprovoked seizure and ≥60% risk. A systematic review of the etiologies.

BACKGROUND: According to the International League Against Epilepsy (ILAE) criteria, epilepsy can be diagnosed after one unprovoked (or reflex) seizure when there is a ≥60% of seizure recurrence in the next decade. The application of this diagnostic criterion, however, is challenging because the risk of recurrence based on different etiologies is not easily retrievable from the literature. OBJECTIVE: To assess etiologies that permit a diagnosis of epilepsy after a single unprovoked seizure. METHODS: We conducted a systematic review of the literature search using PubMed, Scopus, and Cochrane library from January 1950 to December 2020 with the keywords: recurrence, risk of recurrence, absolute risk, risk ratio, risk, seizures, epilepsy, structural, infectious, metabolic, immune, and genetic. We included articles that reported estimates of risks of a subsequent unprovoked seizure. Etiologies were categorized according to the ILAE epilepsy classification. The quality of the evidence was evaluated with PRISMA. Descriptive statistics were used. RESULTS: A total of 25,044 articles resulted from searching three databases. After authors removed duplicates, 18,911 articles remained. We screened by title and abstract, 40 articles were reviewed and finally, two articles were included. The mean follow-up was 8 years and the mean for a risk to present a subsequent unprovoked seizure was 66.6% and included structural etiologies as stroke, traumatic brain injury, cavernous malformation, arteriovenous malformation, and neuroinfections (unspecified agents). Study quality characteristics are classified with low strength of evidence and moderate-quality cohort. CONCLUSIONS: We found that stroke, traumatic brain injury, cavernous or arteriovenous malformations, and unspecified CNS infections can meet the epilepsy diagnosis after one unprovoked seizure based on low strength of evidence and moderate quality of cohorts.

Screening spreading depolarizations during epilepsy surgery.

BACKGROUND: Spreading depolarization (SD) is a fundamental pathophysiological mechanism of both pannecrotic and selective neuronal lesions following deprivation of energy. SD with brain injury has been reported including in one patient during an intracranial operation. However, the incidence of SDs in operative resections is unknown. METHODS: We performed (a) retrospective analysis of intraoperative AC-recordings of 69 patients and (b) a prospective study using intraoperative near-DC recording. All patients had the diagnosis of pharmaco-resistant epilepsy. Both studies were designed to determine the incidence and characteristics of SDs intraoperatively. In the retrospective analysis, we used intraoperative electrocorticography (iECoG) recordings obtained from AC-recording of 69 patients. In the prospective analysis, we used an Octal Bio Amp and Power Lab ECoG recorder with near-DC range. RESULTS: In the retrospective study, we included 69 patients with a mean of 1 h 3 min of iECoG recordings. In the prospective study, we recruited 20 patients with near DC recordings. A total of 35 h 41 min of iECoG recordings with mean of 2 h 32 min/patient were analyzed. We did not find SD in either study. CONCLUSIONS: SDs were not detected during intraoperative recordings of epilepsy surgery using AC- or DC-amplifiers.

Comparative analysis of aneurysm volume by different methods based on angiography and computed tomography angiography.

Endovascular treatment and prognosis of intracranial aneurysms are based on size and volume, which demand more accurate neuroimaging techniques. Aneurysm volume calculation is important to choose endovascular treatment modalities and packing density calculation. Of all these methods, it remains unknown which one is the most accurate to calculate aneurysm volume. The objective of this study is to compare the accuracy of three angiography-based versus three tomographic-based methods which calculate aneurysm volume. A retrospective study which included patients with ruptured and unruptured cerebral aneurysms diagnosed by angiogram and computed tomography angiography (CTA) was done. The accuracy of each method was assessed with an ellipsoid glass model of known volume, which helped us to adjust variation in volumetric measurements done with AngioSuite© and AngioCalc© softwares (based on angiographic and tomographic images), 3D-rotational angiography and 3D-CTA (tridimensional computed tomography angiography), based on measurements of diameters such as maximal width and maximal height. Descriptive statistics, ANOVA for repetitive samples and t test were used. We included 89 patients (126 saccular intracraneal aneurysms). AngioSuite© software (angiography-based) showed more accuracy compared to other methods in our control model. The geometric system (AngioCalc) based on CTA images was statistically different from all other methods studied. AngioCalc (CTA-based) demonstrated a significant difference compared with other methods hence, it may overestimate volume measurements. AngioSuite

New diagnostic criteria for neurocysticercosis: Reliability and validity.

OBJECTIVE: The diagnosis of neurocysticercosis (NCC) remains problematic because of the heterogeneity of its clinical, immunological, and imaging characteristics. Our aim was to develop and assess a new set of diagnostic criteria for NCC, which might allow for the accurate detection of, and differentiation between, parenchymal and extraparenchymal disease. METHODS: A group of Latin American NCC experts developed by consensus a new set of diagnostic criteria for NCC. A multicenter, retrospective study was then conducted to validate it. The reference standard for diagnosis of active NCC was the disappearance or reduction of cysts after anthelmintic treatment. In total, three pairs of independent neurologists blinded to the diagnosis evaluated 93 cases (with NCC) and 93 controls (without NCC) using the new diagnostic criteria. Mixed-effects logistic regression models were used to estimate sensitivity and specificity. RESULTS: Inter-rater reliability (kappa) of diagnosis among evaluators was 0.60. For diagnosis of NCC versus no NCC, the new criteria had a sensitivity of 93.2% and specificity of 81.4%. For parenchymal NCC, the new criteria had a sensitivity of 89.8% and specificity of 80.7% and for extraparenchymal NCC, the new criteria had a sensitivity of 65.9% and specificity of 94.9%. INTERPRETATION: These criteria have acceptable reliability and validity and could be a new tool for clinicians and researchers. An advantage of the new criteria is that they consider parasite location (ie, parenchymal or extraparenchymal), which is an important factor determining the clinical, immunological, and radiological presentation of the disease, and importantly, its treatment and prognosis. Ann Neurol 2016;80:434-442.

Neurophysiological intraoperative monitoring during an optic nerve schwannoma removal.

This paper reports the case of a patient with optic nerve schwannoma and the first use of neurophysiological intraoperative monitoring of visual evoked potentials during the removal of such tumor with no postoperative visual damage. Schwannomas are benign neoplasms of the peripheral nervous system arising from the neural crest-derived Schwann cells, these tumors are rarely located in the optic nerve and the treatment consists on surgical removal leading to high risk of damage to the visual pathway. Case report of a thirty-year-old woman with an optic nerve schwannoma. The patient underwent surgery for tumor removal on the left optic nerve through a left orbitozygomatic approach with intraoperative monitoring of left II and III cranial nerves. We used Nicolet Endeavour CR IOM (Carefusion, Middleton WI, USA) to performed visual evoked potentials stimulating binocularly with LED flash goggles with the patient´s eyes closed and direct epidural optic nerve stimulation delivering rostral to the tumor a rectangular current pulse. At follow up examinations 7 months later, the left eye visual acuity was 20/60; Ishihara score was 8/8 in both eyes; the right eye photomotor reflex was normal and left eye was mydriatic and arreflectic; optokinetic reflex and ocular conjugate movements were normal. In this case, the epidural direct electrical stimulation of optic nerve provided stable waveforms during optic nerve schwannoma resection without visual loss.

Paciente inmunocompetente con criptococosis cerebral: reporte de un caso.

A 14-year-old female, presenting sudden and progressive holocraneal headache along with incoercible vomiting arrived to emergency room. Acute confusional state and meningoencephalitis syndrome where identified. Brain computed tomography-scan with normal results was performed. Lumbar puncture with crystal-clear cerebrospinal fluid was obtained: low glucose, elevated proteins and cell-count of 15/mm. China-Ink and Criptococcus neoformans culture both positive. Viral, lupus-anticoagulant, and HIV tests negative. Fluconazole 200 mg/kg/day, amphotericin-B 0.7 mg/kg/day, dexamethasone 1 mg/kg/day were prescribed. 48-h later evolved to cerebral edema, multiple-organ-failure and death. Hereby we present a Cryptococcus spp. infection case report, addressing the public health challenge and vulnerability of immunocompromised patients in Mexico.

Prevalence of epilepsy, beliefs and attitudes in a rural community in Mexico: A door-to-door survey.

OBJECTIVE: The study aimed to establish the prevalence of seizure history (SH) and epilepsy in a rural community in Hidalgo, Mexico and determine the patients' beliefs and attitudes towards the disease and its initial medical treatment. METHODOLOGY: A transverse, descriptive, door-to-door epidemiological study (April 2011-November 2012) was conducted with 863 inhabitants from Xocotitla, Huejutla, Hidalgo, Mexico (162 housing units). Patients with SH were identified with an adaptation of the WHO protocol for epidemiological studies of neurological diseases. Afterwards, the subjects identified with seizure history (SH) or epilepsy were interviewed with a 20-question Likert type questionnaire regarding the management and belief set of their SH. The interviews were conducted in Spanish and Nahuatl. RESULTS: The prevalence of epilepsy and isolated nonrecurring seizures was 38.2/1000 and 25.4/1000, respectively. Out of the total population of 863 inhabitants, 33/863 were identified with SH: only 39.3% were able to identify an epileptic seizure as such, 48.5% sought medical attention upon the first seizure, 33.3% used a traditional healer, 15.2% took no action, 3% sought a religious representative, 85% lacked any lab analysis, and 60% received no antiepileptic drugs. Only 39% received free local medical attention, 69.7% considered seizures and epilepsy to be a consequence of divine intervention, and 94% reported some type of discrimination. CONCLUSIONS: A high prevalence of epilepsy and SH was found in this rural community in Mexico. Divine/religious beliefs, discrimination, scarce access to basic health services and inadequate medical management of epilepsy and SH persist.

Utility of electrocorticography in the surgical treatment of cavernomas presenting with pharmacoresistant epilepsy.

AIM: To describe the general aspects of cavernomas and epilepsy and review the available literature on the utility of electrocorticography (ECoG) in cerebral cavernoma surgery. METHODS: We searched studies in PubMed, MedLine, Scopus, Web of Science, and Google Scholar (from January 1969 to December 2013) using the keywords "electrocorticography" or "ECoG" or "prognosis" or "outcome" and "cavernomas". Original articles that reported utility of ECoG in epilepsy surgery were included. Four review authors independently selected the studies, extracted data, and assessed the methodological quality of the studies using the recommendations of the Cochrane Handbook for Systematic Reviews of Interventions, PRISMA guidelines, and Jadad Scale. A meta-analysis was not possible due to methodological, clinical, and statistical heterogeneity of included studies. We analysed six articles with a total of 219 patients. RESULTS: The most common surgical approach was lesionectomy using ECoG in the temporal lobe with Engel I outcome range from 72.7 to 100%. CONCLUSIONS: Small controlled studies suggest that ECoG-guided resection offers the best functional results in seizure control for subjects undergoing cavernoma surgery, especially in the temporal lobe.

Electrocorticographic Patterns in Frontal Epilepsy and Long-Term Outcomes.

INTRODUCTION: The prognostic significance of tailored resection guided with intraoperative electrocorticography (iECoG) in frontal lobe epilepsy surgery has not been fully elucidated. OBJECTIVES: To analyze influence of preresection and postresection iECoG patterns on long-term seizure control of adults with frontal lobe epilepsy undergoing epilepsy surgery. METHODS: We retrospectively analyzed 27 patients undergoing epilepsy surgery from two centers with preresection and postresection iECoG and reported clinical variables, preresection and postresection iECoG patterns, and outcome using the Engel Outcome Scale. Descriptive statistics, Kaplan-Meier, the logistic regression model, and analysis of variance tests were used. RESULTS: Fifteen males (55.6%), a mean and mode follow-up after surgery of 43 (range 2-117) and 19 months, respectively. At 6 months, seizure frequency outcome according to Engel Scale was I 74.1% (20/27), II 7.4% (2/27), III 3.7% (1/27), and IV 14.8% (4/27). We found that 51.9% (14/27) and 40.8% (11/27) of patients without residual epileptiform discharges in postresective iECoG become seizure-free at 6 and 12 months of follow-up, respectively, compared with other postresective iECoG patterns. CONCLUSIONS: Disregarding the presence of lack of residual epileptiform discharges (interictal epileptiform discharges) after resection, Engel I outcome was seen between 74.1% and 63% at 6- and 12-month postresection follow-up, suggesting the outcome might be in relation with other factors.

Nonconvulsive Status Epilepticus: Clinical Findings, EEG Features, and Prognosis in a Developing Country, Mexico.

PURPOSE: There is a lack of clinical and epidemiological knowledge about nonconvulsive status epilepticus (NCSE) in developing countries including Mexico, which has the highest prevalence of epilepsy in the Americas. Our aim was to describe the clinical findings, EEG features, and outcomes of NCSE in a tertiary center in Mexico. METHODS: We conducted a retrospective case series study (2010-2020) including patients (≥15 years old) with NCSE according to the modified Salzburg NCSE criteria 2015 with at least 6 months of follow-up. We extracted the clinical data (age, sex, history of epilepsy, antiseizure medications, clinical manifestations, triggers, and etiology), EEG patterns of NCSE, and outcome. Descriptive statistics and multinomial logistic regression were used. RESULTS: One hundred thirty-four patients were analyzed; 74 (54.8%) women, the total mean age was 39.5 (15-85) years, and 71% had a history of epilepsy. Altered state of consciousness was found in 82% (including 27.7% in coma). A generalized NCSE pattern was the most common (32.1%). The NCSE etiology was mainly idiopathic (56%), and previous uncontrolled epilepsy was the trigger in 48% of patients. The clinical outcome was remission with clinical improvement in 54.5%. Multinomial logistic regression showed that the patient's age (P = 0.04), absence of comorbidities (P = 0.04), history of perinatal hypoxia (P = 0.04), absence of clinical manifestations (P = 0.01), and coma (P = 0.03) were negatively correlated with the outcome and only the absence of generalized slowing in the EEG (P = 0.001) had a significant positive effect on the prognosis. CONCLUSIONS: Age, history of perinatal hypoxia, coma, and focal ictal EEG pattern influence negatively the prognosis of NCSE.

The neurophysiological effect of mild hypothermia in gyrencephalic brains submitted to ischemic stroke and spreading depolarizations.

Objective: Characterize the neurophysiological effects of mild hypothermia on stroke and spreading depolarizations (SDs) in gyrencephalic brains. Methods: Left middle cerebral arteries (MCAs) of six hypothermic and six normothermic pigs were permanently occluded (MCAo). Hypothermia began 1 h after MCAo and continued throughout the experiment. ECoG signals from both frontoparietal cortices were recorded. Five-minute ECoG epochs were collected 5 min before, at 5 min, 4, 8, 12, and 16 h after MCAo, and before, during, and after SDs. Power spectra were decomposed into fast (alpha, beta, and gamma) and slow (delta and theta) frequency bands. Results: In the vascular insulted hemisphere under normothermia, electrodes near the ischemic core exhibited power decay across all frequency bands at 5 min and the 4th hour after MCAo. The same pattern was registered in the two furthest electrodes at the 12th and 16th hour. When mild hypothermia was applied in the vascular insulted hemispheres, the power decay was generalized and seen even in electrodes with uncompromised blood flow. During SD analysis, hypothermia maintained increased delta and beta power during the three phases of SDs in the furthest electrode from the ischemic core, followed by the second furthest and third electrode in the beta band during preSD and postSD segments. However, in hypothermic conditions, the third electrode showed lower delta, theta, and alpha power. Conclusion: Mild hypothermia attenuates all frequency bands in the vascularly compromised hemisphere, irrespective of the cortical location. During SD formation, it preserves power spectra more significantly in electrodes further from the ischemic core.

Cluster headache: an update on clinical features, epidemiology, pathophysiology, diagnosis, and treatment.

Cluster headache (CH) is one of the worst primary headaches that remain underdiagnosed and inappropriately treated. There are recent advances in the understanding of this disease and available treatments. This paper aims to review CH's recent clinical and pathophysiological findings, diagnosis, and treatment. We performed a narrative literature review on the socio-demographics, clinical presentations, pathophysiological findings, and diagnosis and treatment of CH. CH affects 0.1% of the population with an incidence of 2.07-9.8/100,00 person-years-habitants, a mean prevalence of 53/100,000 inhabitants (3-150/100,000 inhabitants). The male-to-female ratio remains inconclusive, as the ratio of 4.3:1 has recently been modified to 1.3-2.6, possibly due to previous misdiagnosis in women. Episodic presentation is the most frequent (80%). It is a polygenetic and multifactorial entity that involves dysfunction of the trigeminovascular system, the trigeminal autonomic reflex, and the hypothalamic networks. An MRI of the brain is mandatory to exclude secondary etiologies. There are effective and safe pharmacological treatments oxygen, sphenopalatine, and great occipital nerve block, with the heterogeneity of clinical trial designs for patients with CH divided into acute, transitional, or bridge treatment (prednisone) and preventive interventions. In conclusion, CH remains underdiagnosed, mainly due to a lack of awareness within the medical community, frequently causing a long delay in reaching a final diagnosis. Recent advances in understanding the principal risk factors and underlying pathophysiology exist. There are new therapeutic possibilities that are effective for CH. Indeed, a better understanding of this challenging pathology will continue to be a subject of research, study, and discoveries in its diagnostic and therapeutic approach.