Recent racial inequities as illustrated by the health disparities in COVID-19 infections and deaths, the recent killings of Black men and women by law enforcement, and the widening socioeconomic inequality and have brought systemic racism into a national conversation. These unprecedented times may have deleterious consequences, increasing stress, and trauma for many members of the neurology workforce. The Equity, Diversity, Inclusion and Anti-Racism Committee within our Department of Neurology provides infrastructure and guidance to foster a culture of belonging and addresses the well-being of faculty, staff, and trainees. Here, we present the creation and implementation of our Equity, Diversity, Inclusion, and Anti-Racism (EDIA) Pledge, which was central to our committee's response to these unprecedented times. We outline the process of developing this unique EDIA Pledge and provide a roadmap for approaching these important topics through a Continuing Medical Education Neurology Grand Rounds aimed at fostering a diverse, inclusive, equitable, and antiracist work environment. Through the lived experiences of 4 faculty members, we identify the impact of bias and microaggressions and encourage allyship and personal development for cultural intelligence. We hope that these efforts will inspire neurology departments and other academic institutions across the globe to make a similar pledge.

Introduction: Abdominal epilepsy is an unusual syndrome in which paroxysmal symptoms resembling abdominal pathology result from seizure activity (1, 2). Although abdominal sensations are common manifestations of seizures, symptoms resembling gastrointestinal conditions (such as abdominal pain, vomiting or diarrhoea) are rare ictal symptoms, particularly in adults. Ictal pain is an uncommon ictal symptom, seen in as few as 2 per 1,000 patients (3), and ictal abdominal pain is seen in only 33% of patients with ictal pain (4). The syndrome of abdominal epilepsy is characterized by: a) Otherwise unexplained, paroxysmal gastrointestinal complaints, mainly pain and vomiting; b) Symptoms arise from a central nervous system disturbance; c) Abnormal EEG with findings specific for a seizure disorder; and d) Improvement with anticonvulsant medication (5; 6). A review of the history of this syndrome yielded 36 cases reported in the English literature in the previous 34 years (5). Background Studies: Abdominal epilepsy is well documented among children, but is infrequently recognised in adults (7). The clinical presentation of abdominal epilepsy is characterised by paroxysmal episodes with both gastrointestinal and central nervous system (CNS) manifestations (8, 9). The gastrointestinal manifestations include all or a combination of the following: recurrent abdominal pain, nausea, vomiting, bloating or diarrhea. In our case, we found that the most common presenting ictal symptoms were paroxysmal abdominal pain, speech arrest and visual aura. Although abdominal symptoms may be similar to those of irritable bowel syndrome, abdominal epilepsy may be distinguished from the latter by the presence of altered consciousness during some of the episodes. The key to diagnosis in the present case was provided by symptoms suggestive of functional abdominal pain in association with definite EEG and video-EEG abnormalities. We report here ictal recordings in abdominal epilepsy (figure 2B), which to our knowledge has only been reported once before (10). Previous reports suggest that the most common interictal EEG abnormalities in patients with abdominal epilepsy are bursts of sharp waves or spikes over one or both temporal lobes (1; 7). A video-EEG is a standard nonA¢Â€Âinvasive investigation which may be crucial for the differential diagnosis between gastrointestinal conditions and abdominal epilepsy, as patients with abdominal epilepsy often have ictal EEG abnormalities. Abdominal ictal symptoms such as retching, flatulence and urge to urinate are usually interpreted as insular symptoms arising from the non-dominant hemisphere. However the lateralising value of abdominal pain is less clear. Most series describing abdominal epilepsy do not report the laterality of brain abnormalities. Many patients show bitemporal independent discharges (5). There is one case report of ictal diarrhea arising from the left hemisphere (9). A sustained response to anticonvulsants has been accepted as one of the diagnostic criteria for abdominal epilepsy (7). However, there are no recommendations on the choice of anticonvulsants. Our patient was improved on lamotrigine and lacosamide. Results: The patient is a 26 year-old, Arabic speaking, right handed female. Her birth and initial development were normal. She suffered febrile convulsions at 9 months. She did well at school until grade 6, after which her school performance deteriorated. At age 10, she suffered several complex partial seizures and later started to suffer episodes of head turning to the left and then right, with right arm tonic-clonic convulsions followed by generalization, episodes that later subsided. At present, she suffers the following episodes: 1) Episodes of aggressive behaviour associate with visual perceptions consisting of seeing a black colour and/or figures of “ghosts”. 2) Abdominal pain described as pinching, lasting for approximately 30 seconds, often associated with inability to speak and followed by post-ictal confusion with excessive eating for which she has no recall. This is the most frequent seizure type, occurring almost every day. 3) Episodes of confusion and disorientation. Since investigations for gastrointestinal conditions were normal, epilepsy was suspected. The frequency of episodes reduced by 30% on lamotrigine (400mg/day) and lacosamide (200mg/day). A brain MRI showed left mesial temporal sclerosis. An EEG showed mild diffuse slowing of the background activity and left anterior temporal epileptiform discharges. At present she does not work and spends her time at home with her family. She enjoys reading. Her sleep wake cycle is reportedly reversed, sleeping during the day and remaining awake until late at night, partly due to fear of “ghosts” and the dark. Neuropsychological assessment was not localizing and the patient demonstrated slow processing, with low average performance in both visual and verbal memory, low average visuospatial integration skills, and mild symptoms of depression. The patient was referred to the epilepsy monitoring unit for continuous video-EEG recording and monitored for 4 days. The interictal EEG showed intermittent left temporal slowing and frequent left anterior and posterior temporal epileptiform discharges during sleep and wakefulness, in addition to rare independent right temporal discharges. Three complex partial seizures were recorded which were of similar semiology and consistent with her habitual attacks. During the attacks, she would refer to an aura of abdominal pain, lose awareness and show a distressed look, engage in repetitive moaning and body rocking, followed by motionless staring lasting for approximately one minute. The episodes were followed by brief confusion and relatively quick recovery. The concomitant ictal EEG recordings demonstrated that the attacks were epileptic seizures. Two of the seizures showed a left temporal onset and evolution, whereas the third one appeared to start on right temporal region, evolving later to the left side. The patient also experienced one event with subjective feelings of fear, derealisation and abdominal pain without alteration of language or awareness. There were no concomitant EEG changes during this event which likely represented a simple partial seizure. Conclusion: The present case demonstrates that diagnosis of abdominal epilepsy is particularly challenging: not only ictal symptoms can be vague and non-specific, but also some simple partial seizures may not show clear ictal EEG changes. In addition, the condition is rare and often not thought of, particularly in adults. We suggest that in patients with paroxysms of abdominal pain, nausea or vomiting, with or without CNS manifestations, the possibility of abdominal epilepsy should be considered after exclusion of the most common aetiologies for gastrointestinal conditions. The investigation in these patients should proceed with an EEG and probably ictal video-EEG. Treatment typically begins with anticonvulsant drugs. Lacosamide and lamotrigine appear to be effective anticonvulsants in our case.

Introduction: New-onset refractory status epilepticus (NORSE) is defined as refractory status epilepticus without an obvious cause after initial investigations.. Refractory status epilepticus (SE) is a condition in which patients suddenly experience continuous seizures or a flurry of very frequent seizures that do not respond to standard anticonvulsant medications . Seizures are thought to be due to an excess of pro-inflammatory molecules in the brain, perhaps triggered by a simple viral infection, although no clear cause has ever been demonstrated.

Abdominal epilepsy is often unrecognised as an epilepsy condition, particularly in adults. We present a rare adult patient who suffers daily episodes of abdominal pinching pain described lasting for 30 seconds, often evolving to loss of consciousness. Scalp EEG-video monitoring showed interictal left temporal slowing and frequent left temporal epileptiform discharges. Three stereotypical complex partial seizures consistent with her habitual attacks were recorded. Two seizures showed a left temporal onset and whereas the third one appeared to start on the right temporal lobe. In patients with paroxysms of abdominal pain, nausea or vomiting, abdominal epilepsy should be considered after exclusion of the most common aetiologies for gastrointestinal conditions.

Introduction:The elderly population is increasing around the world, and the prevalence of dementia increases with age.Hence, it is expected that the number of people with dementia will increase significantly in the coming years.The Mini-Mental Status Examination -2 (MMSE-2) and Mini-Cog are widely used tests to screen for dementia.These scales have good reliability and validity and are easy to administer in clinical and research settings.Aim: The purpose of this study was to validate the Arabic versions of MMSE-2 and Mini-Cog.These scales were assessed against the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) criteria for dementia, as the gold standard.Methods: The standard versions of the MMSE-2 and Mini-Cog were translated to Arabic following the back-translation method.Then, a trained rater administered these tests to 134 Arab elderly aged .60 years.A physician, blind to the results of these two tests, assessed the participants for vascular dementia or probable Alzheimer's disease, based on the DSM-IV-TR criteria. Results:The sample included 67.2% Qataris.The mean age was 74.86 years (standard deviation =7.71), and 61.9% did not attend school.The mean of the adjusted scores of MMSE-2 based on age and education level was 19.60 (standard deviation =6.58).According to DSM-IV-TR, 17.2% of the participants had dementia.Sensitivity and specificity of the MMSE-2 and the Mini-Cog together were 71.4% and 61.6%, respectively, which were better than those of each test alone.Conclusion: Together, the Arabic versions of MMSE-2 and Mini-Cog are good screening tools for cognitive impairment in Arabs.

Science is ideally suited to connect people from different cultures and thereby foster mutual understanding. To promote international life science collaboration, we have launched "The Science Bridge'' initiative. Our current project focuses on partnership between Western and Middle Eastern neuroscience communities.

Objective: This study reports the prevalence of Nonconvulsive Status Epilepticus (NCSE) in patients with altered mental status (AMS), and describes the clinical presentation, etiology, neurophysiological findings, neuroimaging, treatment, and outcome of NCSE in Qatar. Recording duration of continuous EEG monitoring was also discussed. Methods: This was a 3-year, prospective, hospital-based study involving patients with AMS and continuous EEG monitoring admitted to the Emergency and ICUs of Hamad Hospital, Qatar. Patients with confirmed diagnosis of NCSE were compared to the patients who did not show EEG and clinical features compatible with NCSE. Descriptive statistics in terms of mean with standard deviation, as well as frequency and percentages for categorical variables, were calculated; Student's t test as well as Chisquare tests or Fisher's exact tests were applied. Logistic regressions NSCE was performed using significance level 0.05 for independent variables at univariate analysis. Results: Number of patients with AMS and continuous EEG monitoring was 250. Number of patients with EEG compatible with NCSE: 65 (age range, 12-79 ys; m, 37; f, 28). Number of controls (defined as patients with EEG not compatible with NCSE): 185 (age range, 12-80 ys; m, 101; f, 84). Rate of occurrence of NCSE in patients with AMS: 26%. NCSE group was younger than controls (p<.001). Twenty patients with NCSE (31%) and 35 patients in the control group (19%) died. Death was more frequent in comatose NCSE compared to controls (p<.0007). NCSE proper and comatose NCSE had longer hospital stays than controls (p<.02 and p<.03, respectively). Complete recovery occurred in 26 NCSE patients (40%) and in 98 controls (53%) (p<.08). Twenty-one patients (31%) presented with refractory NCSE: 12 patients survived, 9 died. Conclusion: This was the first prospective study reporting a high number of NCSE in Qatar, a small country in the MENA region. This prevalence (26%) was in the middle range. NCSE patients did not perform better than controls, outcome being worse with comatose NCSE. NCSE is an emergent condition warranting expedited diagnosis and management. Three days of continuous EEG monitoring were able to diagnose most cases of NCSE.

RationaleEpilepsy is one of the most prevalent neurologic conditions. It is estimated to affect 70 million people worldwide. Epilepsy is an important cause of disability and mortality. It is associated with social stigma and significant economic costs. Although epilepsy is a disease with a worldwide distribution, its prevalence varies between different countries. Very little is known about the epidemiology of epilepsy in Qatar. Qatar's population is a mixture of native citizens and immigrants. We aim at describing the features of epilepsy in Qatar as such information is virtually lacking from the current literature.MethodsA database was created in 2014 to summarize information retrospectively collected on patients with epilepsy seen through the national health system (HMC) adult neurology clinic. For each subject, in addition to the typical demographic variables, we identified the age at onset, seizure types, epilepsy syndrome, etiology, treatment and outcome. Brain imaging and EEG results were also tabulated. All these variables were analyzed using the statistical package for social science (IBM-SPSS, version 20).ResultsOf 504 patients included in the database, 467 with sufficient information were analyzed. Sixty percent were men. The mean age at the last clinic visit was 35. Native Qataris represented 38.5%, Asian subjects 33%, and Middle Eastern/North African (MENA) origin accounted for 25% of the studied population. Generalized tonic-clonic seizures were the most common seizure type, noted in 89% of subjects. Epilepsy was classified as focal in 65.5% of the cases, and generalized in 23%. EEGs were abnormal in 55.5 %, showing epileptiform discharges in 49% of subjects. Imaging studies revealed epileptogenic pathologies in 40% of reports. Common causes of epilepsy were: vascular (11%), hippocampal sclerosis (8%), infectious (6%) and trauma (6%). Sixty six percent of patients were receiving a single antiepileptic drug, and 53% were seizure free at the last follow-up. Overall, the most commonly prescribed drug was Leviteracetam (41%) followed by Valproic Acid (25%) and Carbamazepine (22%). On current therapy, 54% of patients were seizure-free, 41% had a partial response and five percent were refractory. When the patients were divided by geographical background, some differences were noted. Remote infections caused the epilepsy in 15% of Asian patients (with neurocysticercosis accounting for 10%), but only in 1% of Qatari and 3% of MENA subjects (with no reported neurocysticercosis) (p

Stroke is a global health problem. However, very little is known about stroke care in low-to middle-income countries. Obtaining country-specific information could enable us to develop targeted programs to improve stroke care. We surveyed neurologists from 12 countries (Chile, Georgia, Nigeria, Qatar, India, Lithuania, Kazakhstan, Indonesia, Denmark, Brazil, Belgium, and Bangladesh) using a web-based survey tool. Data were analyzed both for individual countries and by income classification (low income, lower middle income, upper middle income, and high income). Six percent (n = 200) of 3123 targeted physicians completed the survey. There was a significant correlation between income classification and access and affordability of head computed tomography scan (rho = .215, P = .002), transthoracic echocardiogram (rho = .181, P = .012), extracranial carotid Doppler ultrasound (rho = .312, P <= .000), cardiac telemetry (rho = .353, P < .000), and stroke treatments such as intravenous thrombolysis (rho = .276, P <= .001), and carotid endarterectomy (rho = .214, P <= .004); stroke quality measures suchas venous thromboembolismprophylaxis duringhospital stay (rho = .163, P <= .022), discharge from hospital on antithrombotic therapy (rho = .266, P <= .000), consideration for acute thrombolytic therapy (rho = .358, P <= .000), and antithrombotic therapy prescribed by end of hospital day 2 (rho = .334, P <= .000). However, there was no significant correlation between income classification and the access and affordability of antiplatelet agents, vitamin K antagonists and statins, anticoagulation for atrial fibrillation/flutter, statin medication, stroke education, and assessment for rehabilitation. Our study shows that it is possible to get an overview of stroke treatment measures in different countries by conducting an internet-based survey. The generalizability of the findings may be limited by the low survey response rate. (C) 2015 by National Stroke Association

April 21, 2015April 6, 2015Free AccessMapping Epilepsy in Qatar (P3.206)Ayman Al Jurdi, Abdullah El Zafarany, Faten Aqeel, Abuhadra Nour, Mujahed Laswi, Yasser Alsamman, Basim Uthman, … Show All … , Dirk Deleu, Hassan Jassim Al Hail, Boulenouar Mesraoua, Naveed Akhtar, Ziyad Mahfoud, Gayane Melikyan, and Naim Haddad Show FewerAuthors Info & AffiliationsApril 6, 2015 issue84 (14_supplement)https://doi.org/10.1212/WNL.84.14_supplement.P3.206 Letters to the Editor

OBJECTIVE:To introduce a Neuroscience curriculum with in a Middle East medical college capable of preparing its students for US and foreign Clinical Neuroscience residency training programs. BACKGROUND:In 2008 Weill Cornell Medical College in Qatar (WCMC-Q) graduated 15 physicians. This was the first time medical students studying outside of the United States had received a US medical degree. The curriculum consists of 2 years of pre-medical education followed by a 4-year medical program that mirrors the one in New York (WCMC) in content, sequence of lectures, and other teaching activities. Instruction is carried out by on-site WCMC-Q faculty, visiting faculty from the WCMC mother campus, and video streaming using state-of-the-art teleconferencing technology. DESIGN/METHODS:The Neuroscience curriculum in the preclinical years draws faculty from Neurology, Neuroscience, Neuroanatomy, Pathology, Pharmacology, Physiology & Biophysics, Psychiatry, and Radiology. The teaching modalities emphasize active student participation. Important features include problem-based analysis of classical neurological and psychiatric disorders, and the opportunity to examine both standardized and individual patients in clinical settings. Information is provided in the form of lectures, patient presentations and small-group tutorials, as well as laboratory sessions on neuroanatomy, gross anatomy of the head and neck, and neuropathology. Journal club sessions that review papers from the current Neuroscience literature, foster an understanding of contemporary research ideas and techniques. In conjunction with our clinical teaching facility in Qatar, Hamad Medical Corporation (HMC), clinical training have two clerkships are required in neurology (4 weeks) and psychiatry (6 weeks) during the third and fourth years of medical school. Here students practice the rudiments of the neuropsychiatric evaluation of patients. WCMC-Q provides trained medical interpreters for students to elicit neurologic histories as accurately as possible. CONCLUSIONS:At WCMC-Q, we believe it is possible to conduct a continuum of neuroscience education necessary to prepare international medical students for their graduation to US and foreign residency training programs. Support:Sponsorship from Qatar Foundation with clinical support of Hamad Medical Corporation and staff. Disclosure: Dr. Streletz has nothing to disclose. Dr. Haddad has nothing to disclose. Dr. Kronfol has nothing to disclose. Dr. Safdieh has nothing to disclose. Dr. Uthman has nothing to disclose.

Hypertensive encephalopathy typically presents with headache, confusion, and bilateral parietooccipital vasogenic edema. Brainstemedema in hypertensive encephalopathy usually occurs in association with typical supratentorial parieto-occipital changes and is usually asymptomatic. We report here a patient with hypertensive encephalopathy, with isolated brain stem involvement on magnetic resonance imaging (MRI). Rapid treatment of hypertension resulted in clinical and radiological improvement. Prompt recognition of the condition and aggressive treatment of hypertension in such patients is crucial to relieve edema and prevent lifethreatening progression.

Abstract Objective: Some patients with epilepsy require treatment with >1 adjunctive antiepileptic drug (AED) to achieve adequate seizure remission. The purpose of this analysis was to evaluate the efficacy and safety of adding adjunctive pregabalin to an AED regimen that included levetiracetam in patients with refractory partial-onset epilepsy. Research design and methods: Data from the pregabalin and placebo arms of two placebo-controlled, double-blind, randomized studies of pregabalin in patients who received adjunctive treatment with levetiracetam in addition to ≥1 other AEDs were pooled for this post hoc analysis. Patients (aged ≥18 years) had ≥4 partial-onset seizures and no 28-day period free of seizures during baseline. Efficacy outcomes included Response Ratio (RRatio), change from baseline in seizure frequency, proportion of patients with ≥50% reduction in seizure frequency, and 28-day seizure-freedom rate. Safety was evaluated using adverse events (AEs). Results: In total, 138 patients were included in the analysis (placebo, n = 47; pregabalin, n = 91). Pregabalin was significantly better than placebo for difference in least squares mean of the RRatio (−16.4; 95% confidence interval [CI]: −28.5, −4.5; p = 0.0085), median of the difference in percentage change from baseline in seizure frequency (−22.3; 95% CI: −40.1, −7.2; p = 0.0095), and proportion of 50% responders (36.3 vs. 17.0; odds ratio, 3.2; 95% CI: 1.3, 8.3; p = 0.018), but not 28-day seizure-freedom rate (7 [7.7%] vs. 2 [4.3%]; p = 0.353). The most common AEs when adding pregabalin were dizziness/vertigo, fatigue, somnolence, blurred vision, and increased weight that were not proportional to the number of concomitant AEDs. Conclusions: In this population of patients with refractory partial-onset seizures, adding pregabalin to an AED regimen with levetiracetam produced further seizure reductions. The safety profile of pregabalin in patients receiving levetiracetam and ≥1 other AEDs did not appear to be compromised by the number of concomitant AEDs.

Characteristic movements of human body parts ranging from eye twitches to limbs jerky movements have been used for decades by physicians as clinical indicators of certain neurological disorders. Through a multidisciplinary research approach, our team, composed of medical experts, signal-processing specialists, wireless sensing experts, and computer scientists, aims at developing a sophisticated framework for automatic characterization of certain clinical conditions via identification of a proposed unique sequence (a signature pattern) of limb movements in relation to other body parts. We argue that a set of movement data collected from human subjects via strategically located movement sensors fused with other supporting data, such as gyroscopic movements and relative locations of sensors, can be processed by advanced intelligent signal processing techniques. Using medical expert systems fed with knowledge provided by the contributing medical experts this can be used to characterize and classify typical and atypical human movements. The collected data is then processed using machine learning algorithms which is trained to automatically detect and characterize a set of movement disorders and classify them into specific clinical diagnosis such as specific types of seizures. In particular, our work ambitiously aims at developing a prototype proof-of-concept seizure remote monitoring and detection system. This would demonstrate the applicability of our developed methodology in real-life scenarios, using commercial of-the-shelf wireless sensing platforms coupled to our intelligent expert-based signal-processing platform. We believe that the outcomes of this applied research will pave the roads for new methods in clinical diagnosis of various neurological diseases and monitoring progress and outcome of treatment that will, in turn, reduce human suffering and medical costs. Further, when coupled with our wireless technology and positioning methods, DC-MOVE can initiate or trigger an alerting response that could be life-saving.

The unified myoclonus rating scale (UMRS) has been utilized to assess the severity of myoclonus and the efficacy of antiepileptic drug (AED) treatment in patients with Unverricht Lundborg disease (ULD). Electroencephalographic (EEG) recordings are normally used as a supplemental tool for the diagnosis of epilepsy disorders. In this study, mutual information and nonlinear interdependence measures were applied to the EEG recordings in an attempt to identify the effect of treatment on the coupling strength and directionality of mutual information and nonlinear interdependences between different brain cortical regions. Two 1-h EEG recordings were acquired from four ULD subjects; one prior and one after a minimum of 2 months treatment with an add-on AED. Subjects in this study were siblings of same parents and suffered from ULD for approximately 37 years. Our results indicated that the coupling strength was low between different brain cortical regions in the patients with disease of less severity. Adjunctive AED treatment was associated with significant decrease of the coupling strength in all subjects. The mutual information between different brain cortical regions was also reduced after treatment. These findings could provide a new insight for developing a novel surrogate outcome measure for patients with epilepsy when clinical tools or observations could potentially fail to detect a significant difference.

SummaryPurpose: Distinguishing nonconvulsive status epilepticus (NCSE) from some nonepileptic encephalopathies is a challenging problem. In many situations, NCSE and nonepileptic encephalopathies are indistinguishable by clinical symptoms and can produce very similar electroencephalography (EEG) patterns. Misdiagnosis or delay to diagnosis of NCSE may increase the rate of morbidity and mortality.Methods: We developed a fast‐differentiating algorithm using quantitative EEG analysis to distinguish NCSE patients from patients with toxic/metabolic encephalopathy (TME). EEG recordings were collected from 11 patients, including 6 with NCSE and 5 with TME. Three nonlinear dynamic measures were used in the proposed algorithm: the maximum short‐term Lyapunov exponent (STLmax), phase of attractor (phase/angular frequency), and approximate entropy (ApEn). A further refined metric derived from STLmax and phase of attractor (the mean distance to EEG epoch samples from their centroid in the feature space) was also utilized as a criterion. Paired t tests were carried out to further clarify the separation between the EEG patterns of NCSE and TME.Results: Computational results showed that the performance of the proposed algorithm was sufficient to distinguish NCSE from TME. The results were consistent in all subjects in our study.Conclusions: The study presents evidence that the maximum short‐term Lyapunov exponents (STLmax) and phase of attractors (phase/angular frequency) can be useful in assisting clinical diagnosis of NCSE. Findings presented in this article provide a promising indication that the proposed algorithm may correctly distinguish NCSE from TME. Although the exact mechanism of this association remains unknown, the authors suggest that epileptic activity is highly associated with and can be modeled by dynamic systems.