Background Neurological care in rural areas such as Tena, Ecuador, remains critically low due to geographic, economic, and systemic barriers. Tena, located in the Amazon region, has limited access to specialized neurological services, creating significant health disparities. Since 2009, the International Neurology Foundation (INF) has partnered with the Hospital José María Velasco Ibarra to address these challenges. Methodology This retrospective analysis summarizes data from the INF medical service relief trip (MSRT) conducted in Tena from 2021 to 2023. Clinical records, interviews with providers, and MSRT reports were reviewed to assess patient demographics, diagnoses, treatments, and interventions. Descriptive statistics and thematic analysis were used to identify trends and insights. Results Over three years, 751 patients were treated, with epilepsy being the most common diagnosis (265 cases). Children under the age of 10 years represented the largest patient group. Key achievements included the donation of electroencephalography equipment, enabling local epilepsy diagnostics, and training local healthcare providers. Persistent challenges included limited imaging resources, inconsistent medication supply, and barriers related to language and transportation. Conclusions INF's initiatives have significantly improved access to neurological care in Tena, enhancing diagnostic capabilities and providing critical training. Sustainable progress requires investment in infrastructure, expanded training programs, and consistent medication availability. The Tena experience serves as a model for reducing health disparities and improving neurological care in resource-limited settings, aligning with global health equity priorities.

Introduction Ischemic stroke is among the leading causes of death and disability. Approximately 50% of cryptogenic strokes are embolic strokes of undetermined source (ESUS). The most common cause of ESUS is atrial fibrillation. Therefore, the detection of atrial fibrillation with long-term implantable devices is needed. Neurologists are directly involved with acute and post -acute stroke care and have direct access to the management of stroke patients. Therefore, there is a need for neurologists to recommend, implant, and monitor cardiac implantable devices in patients with ESUS. Methods From November 2022 to October 2023, our group implanted 32 ESUS patients with Confirm RxTM insertable cardiac monitors (Abbott, USA). Atrial fibrillation detection was supervised and monitored daily. Results In 24 months, atrial fibrillation was detected in 12.5% of patients (four patients), sinus bradycardia in 6.25% of patients (two patients), paroxysmal supraventricular tachycardia in 9.4% of patients (three patients), and asystole in one patient. Conclusion Our study shows that neurologists involved in the treatment of stroke care can safely implant, monitor, and detect atrial fibrillation accurately. Our rate of detection of atrial fibrillation in patients with ESUS was 12.8%, which is consistent with prior studies.

Since the first case of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was reported in Wuhan, China, in December 2019, Coronavirus - 19 (COVID-19) has become a global pandemic with multiple neurological complications. In December 2020, two vaccines have been approved in the United States for the prevention of COVID-19. We report a case of Guillain-Barre Syndrome (GBS) after receiving the first dose of Pfizer - COVID-19 vaccine.

We reviewed the evidence on proton pump inhibitors (PPIs) and dementia. PPIs are among the most widely utilized drugs in the world. Dementia affects roughly 5% of the population of the United States (US) and world aged 60 years and older. With respect to PPIs and dementia, basic research has suggested plausible mechanisms but descriptive and analytic epidemiological studies are not inconsistent. In addition, a single large-scale randomized trial showed no association. When the evidence is incomplete, it is appropriate for clinicians and researchers to remain uncertain. Regulatory or public health authorities sometimes need to make real-world decisions based on real-world data. When the evidence is complete, then the most rational judgments for individual patients the health of the general public are possible At present, the evidence on PPIs and dementia suggests more reassurance than alarm. Further large-scale randomized evidence is necessary to do so.

Introduction: Worldwide, more than 5.7% of the population reside above 1,500 m of elevation. It has been hypothesized that acute short-term hypoxia exposure could increase the risk of developing a stroke. Studies assessing the effect of altitude on stroke have provided conflicting results, some analyses suggest that long-term chronic exposure could be associated with reduced mortality and lower stroke incidence rates. Methods: An ecological analysis of all stroke hospital admissions, mortality rates, and disability-adjusted life years in Ecuador was performed from 2001 to 2017. The cases and population at risk were categorized in low (<1,500 m), moderate (1,500–2,500 m), high (2,500–3,500 m), and very high altitude (3,500–5,500 m) according to the place of residence. The derived crude and direct standardized age-sex adjusted mortality and hospital admission rates were calculated. Results: A total of 38,201 deaths and 75,893 stroke-related hospital admissions were reported. High altitude populations (HAP) had lower stroke mortality in men [OR: 0.91 (0.88–0.95)] and women [OR: 0.83 (0.79–0.86)]. In addition, HAP had a significant lower risk of getting admitted to the hospital when compared with the low altitude group in men [OR: 0.55 (CI 95% 0.54–0.56)] and women [OR: 0.65 (CI 95% 0.64–0.66)]. Conclusion: This is the first epidemiological study that aims to elucidate the association between stroke and altitude using four different elevation ranges. Our findings suggest that living at higher elevations offers a reduction or the risk of dying due to stroke as well as a reduction in the probability of being admitted to the hospital. Nevertheless, this protective factor has a stronger effect between 2,000 and 3,500 m.

Background: Globally, more than 5.7% of the population reside above 1,500 m of elevation. It has been hypothesized that acute short-term hypoxia exposure could increase the risk of developing a stroke. Studies assessing the effect of altitude on stroke have provided conflicting results, some analysis suggest that long-term chronic exposure could be associated with reduced mortality and lower stroke incidence rates. Methods: An ecological analysis of all stroke hospital admissions, mortality rates and disability adjusted life years in Ecuador was performed from 2001-2017. The cases and population at risk were categorized in low (<1,500 m), moderate (1,500-2,500 m), high (2,500-3,500 m) and very high altitude (3,500-5,500 m) according to place of residence. The derived crude and direct standardized age-sex adjusted mortality and hospital admission rates were calculated. Results: A total of 38,201 deaths and 75,893 stroke-related hospital admissions were reported. High-altitude populations (HAP) had lower stroke mortality in men (RR: 0.91 [0.88 - 0.95]) and women (RR: 0.83 [0.79 - 0.86]). In addition, HAP had a significant lower risk of getting admitted to the hospital when compared with the low altitude group in men (RR: 0.55 [CI95% 0.54 - 0.56]) and women (RR: 0.65 [CI95% [0.64 - 0.66]). Conclusions: This is the first epidemiological study that aims to elucidate the association between stroke and altitude using four different elevation ranges. Our findings suggest that living at higher elevations offers a reduction or the risk of dying due to stroke as well as a reduction in the probability of being admitted to the hospital. Nevertheless, this protective factor has the stronger effect between 2,000 m to 3,500 m.

The proverbial “zebras” in neurology are often times missed due to their low prevalence and incidence in the community. The number of misdiagnoses and improper therapeutic interventions that occur are further increased when patients with these rare diseases present with signs and symptoms of more common disorders. One such disease is sporadic Creutzfeldt-Jakob disease (sCJD), a prion disease that causes neuronal derangement and classically presents as a rapidly progressing dementia with extrapyramidal signs, ataxia, behavioural problems, and myoclonus in the advanced stage. It falls into the category of neurodegenerative disease, which also includes Alzheimer's disease, Huntington's disease, Parkinson's disease, and other Parkinson-related diseases. Though these diseases have overlapping symptomologies - such as cognitive impairment and neuromuscular dysfunction - they can be differentiated from one another based on the time course of the illness and the specific constellation of signs and symptoms. Our case report describes a patient who was found to have sCJD after months of treatment for Parkinson's disease and trigeminal neuralgia. Thus, we are highlighting the importance of recognizing rare diseases so that proper management can be initiated in a timely manner. Furthermore, we review the current literature on the diagnosis and management of sCJD.

Objective To assess the cognitive function, prevalence, and risk factors associated with cognitive decline and dementia in people above 65 years of age in Santa Cruz Island, Galápagos, Ecuador. Methods This is a cross-sectional observational study that was carried out in adults over 65 years of age in Santa Cruz Island, Galápagos, Ecuador. The mini-mental state examination (MMSE) and ascertain dementia eight-item informant questionnaire (AD8)-validated Ecuador Spanish versions were used to assess cognition. Results There were a total of 80 participants, 55 (67%) women and 25 (31.2%) men. The majority of participants were Mestizos (85.3%), with the remainder classified as White (4.8%), Afro-Ecuadorians (2.4%), or Indigenous (3.6%). The prevalence of cognitive impairment is 30.0%-43.7%. The MMSE results showed that older age and lack of education are risk factors for cognitive decline (p < 0.01). There was high correlation between MMSE and AD8 scores. The AD8 showed that older age, widowhood, and living in Santa Rosa were risk factors for cognitive decline (p < 0.01). According to the AD8, the group with the highest education (six years or more) had the lowest risk of cognitive decline and dementia (p < 0.01). Conclusions The main risk factors for cognitive decline and dementia in individuals above 65 years old in Santa Cruz Island, Galápagos, Ecuador are increased age, lack of education, and widowhood. The prevalence of cognitive impairment is similar to previous studies in Ecuador.

Tras el diagnóstico de la primera persona infectada con el coronavirus SARS-CoV-2 este ha llegado a expandirse por todo el mundo, ocasionando una pandemia y poniendo en alerta a los sistemas de salud. Actualmente, la evidencia indica que los efectos de este coronavirus en humanos no siempre se limitan al tracto respiratorio, pueden invadir el sistema nervioso central ocasionado dolor de cabeza, convulsiones y alteraciones de conciencia. Por esta razón, se recomienda pensar en una infección con SARS-CoV-2 como un diagnóstico diferencial en pacientes que presentan manifestaciones neurológicas.

Leber hereditary optic neuropathy (LHON) is a genetic condition that typically presents with unilateral, painless, sub-acute central vision loss followed by contralateral vision loss after a few weeks to months. It is a rare disease that typically affects young adults - men more than women - and is a relatively common cause of blindness. It is due to a mutation in mitochondrial DNA (mtDNA). The majority (more than 95%) of patients have one of three mtDNA point mutations: m.14484T→C, m.3460G→A, or m.11778G→A. These mutations lead to disruption of the mitochondrial respiratory chain activating pro-apoptotic pathways. For reasons unknown, this insult tends to affect the retinal ganglion cells more than any other cell in the body, leading to the disease state. Due to its low prevalence in the United States (1:50,000), this diagnosis is often overlooked, misdiagnosed, and mismanaged, which may exacerbate symptoms. It is essential then for physicians to recognize the presentation of and understand the diagnostic work-up for LHON. In this case report, we present the diagnostic challenges of a patient who presented with progressive vision loss, discuss the various differential diagnoses, review the literature on LHON, and propose an explanatory model for vision loss in patients with LHON.

The neurological complications of coronavirus disease 2019 (COVID-19) are being better understood as the pandemic progresses. We report a second case of a patient who presented with COVID-19 infection and encephalopathy to our institution. In addition, we report MRI brain and cerebrospinal fluid data. COVID-19 does not seem to cross the blood-brain barrier. The exact mechanisms of encephalopathy and pathological response of COVID-19 are unknown.

Coronavirus disease 2019 (COVID-19) is a pandemic. Neurological complications of COVID-19 have not been reported. Encephalopathy has not been described as a presenting symptom or complication of COVID-19. We report a case of a 74-year-old patient who traveled from Europe to the United States and presented with encephalopathy and COVID-19.

Moyamoya disease, well described in literature, is a chronic cerebrovascular occlusive disorder. It is characterized by progressive stenosis/occlusion of the terminal portions of the internal carotid arteries (ICA) and the proximal portions of the middle cerebral arteries (MCA). Less frequently described is Moyamoya syndrome, the name given to radiographic findings consistent with Moyamoya disease, but with an identifiable cause. The diseases associated with Moyamoya Syndrome include Sickle Cell Disease (SCD), Thalassemias, and Down's Syndrome to name a few. Common complications of Moyamoya include both ischemic and hemorrhagic strokes. Upon literature review, Moyamoya syndrome caused by SCD is not well described. When it is, the discussion is centered around the pediatric patient population and surgical management. Our case report describes a 22-year-old African American female with SCD who initially presented with Acute Chest Syndrome. Her hospital course was complicated by development of overt debilitating neurologic deficits. Subsequently, she was found to have Moyamoya Syndrome on neuroimaging. She was successfully treated with medical management without any surgical intervention. This case highlights the necessity of thorough examination, differential diagnosis, imaging findings, and consideration of predisposing syndromes in the work-up for Moyamoya syndrome; especially individuals with Sickle Cell Disease. Disclosures No relevant conflicts of interest to declare.

Since the diagnosis of the first person infected with SARS-Cov-2, it has quickly spread throughout the world causing a pandemic and putting healthcare systems on maximal alert Currently, evidence indicates that SARS-Cov-2 infection is not a disease limited to the respiratory system but it can also affect the central nervous system, causing anosmia, headache, seizures, stroke and altered mental status For this reason, it is important to be aware of the neurological complications associated SARS-CoV-2 infection © 2020 Fundacion para la difusion neurologica en Ecuador - FUNDINE All rights reserved

Elevated blood pressure (BP) is a major avoidable cause of premature morbidity and mortality in the United States (US) and worldwide, due primarily to increased risks of stroke as well as myocardial infarction. While there are therapeutic lifestyle changes and adjunctive pharmacologic medications of proven benefit, recent interest has increasingly focused on Complementary and Alternative Medicine, in particular, Mind-Body Interventions. With respect to BP, it is tempting to speculate that mindfulness with paced breathing will have beneficial effects in the short run that may translate into lowered risks of stroke in the long run. Paced breathing is deep diaphragmatic breathing with typical rates equal to or less than 5-7 breaths per minute compared with the usual rate of 12-14. One plausible mechanism of benefit is that paced breathing stimulates the parasympathetic nervous system which alters neuronal function in specific areas of the brain and reduces stress chemicals. The hypothesis that mindfulness with paced slow breathing reduces BP could be directly tested in randomized trials designed a priori to do so. Subsequently, a finding that mindfulness with paced breathing reduces BP would also lead to direct tests in randomized trials of reductions of carotid atherosclerosis and, if so, a larger scale trial to test whether there is a direct impact of mindfulness with paced breathing on reducing the risks of stroke and MI. If rigorous testing of this medical hypothesis led to positive results this would have large and important clinical and policy implications in the US and worldwide.

Aneurysmal subarachnoid hemorrhage is a life-threatening event that can cause permanent disability. This life-threatening event can be further complicated by subsequent cardiac and pulmonary disability. The presence of a neurogenic cardiomyopathy and pulmonary edema increases the morbidity and mortality of patients who suffer from aneurysmal subarachnoid hemorrhage. In this paper, we discuss a 39-year-old woman who presented to the emergency department (ED) with a chief complaint of a pounding headache with associated nausea and vomiting for the past three days. She had a past medical history significant only for migraines. During her stay in the ED, she began to exhibit signs of altered consciousness, hemoptysis, and respiratory compromise. Neuroimaging showed evidence of subarachnoid hemorrhage. The exact source of her subarachnoid hemorrhage could not be located with neuroimaging or angiography. Her clinical course was complicated by pulmonary edema and neurogenic stunned myocardium, and is still ongoing.

Anti-glutamic acid decarboxylase (GAD) antibodies have been discovered in a variety of neurological syndromes with unique presentations. These syndromes include limbic encephalitis (LE), stiff person syndrome (SPS), opsoclonus-myoclonus-ataxia syndrome, cerebellar ataxia, status epilepticus, and palatal myoclonus among others. We present two patients who presented with Guillain-Barré (GBS) and myasthenia gravis (MG) like syndromes, who were found to have anti-GAD antibodies. These case reports highlight the complex presentation of patients with neurological disorders associated with anti-GAD antibodies. The proper identification of anti-GAD antibody’s presence has proven to be beneficial in treatment and provide enhanced quality of life.

OBJECTIVE:Traumatic brain injury (TBI) is a public health problem worldwide. Information regarding TBI from low- and middle-income countries is scarce. The objectives of this study are to determine the incidence, mortality and geodemographic distribution of TBI in Ecuador.METHODS:A population-based analytical study from 2004 to 2016 was conducted in Ecuador. Men and women with a diagnosis of TBI from all ages (0-110 years) were included. Data was obtained from official hospital-discharges records and retrieved from the National Institute of Statistics and Census (INEC) Database. We analyzed data by region, province and canton with a monthly resolution. The incidence, mortality, case fatality rates and the risk of developing TBI within the population were calculated based on the last 13 years of available data.RESULTS:A total of 124,576 hospital admissions and 5,264 deaths due to TBI were registered in Ecuador from 2004 to 2016. The overall TBI-related hospital admission rate was 70.68 per 100,000. The sex- and age-specific rate was 90.1 per 100,000 for men and 64.1 per 100,000 for women. Mestizos' population has the highest adjusted incidence rate of 195.6 per 100,000, followed by the indigenous with 61.4 per 100,000 and Afro-Americans with 14.2 per 100,000. The overall annual mortality rate during the study ranged from 2.11 to 3.35 per 100,000. Case fatality rates were significantly higher in older populations, becoming fatal in up to 27% of men >90 years/old and in 15% of women older than 90 years/old.CONCLUSION:This is the first recorded epidemiological study of the socio-demographic distribution of TBI in Ecuador to date. The study found that young men were almost 4 times more likely to be hospitalized due to TBI than women of this age. Fatalities due to TBI were less likely to occur among younger age groups, increasing significantly among the elderly population. The national incidence rate of TBI has been decreasing since 2011, which coincides with the introduction of stricter alcohol regulation, suggesting that this measure might have played a role in this reduction.