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Nodding syndrome (NS) is a poorly understood form of childhood-onset epilepsy that is characterized by the pathognomonic ictal phenomenon of repetitive vertical head drops. To evaluate the underlying ictal neurophysiology, ictal EEG features were evaluated in nine participants with confirmed NS from South Sudan, Tanzania, and Uganda and ictal presence of high frequency gamma oscillations on scalp EEG were assessed. Ictal EEG during the head nodding episode predominantly showed generalized slow waves or sharp-and-slow wave complexes followed by electrodecrement. Augmentation of gamma activity (30-70 Hz) was seen during the head nodding episode in all the participants. We confirm that head nodding episodes in persons with NS from the three geographically distinct regions in sub-Saharan Africa share the common features of slow waves with electrodecrement and superimposed gamma activity. ANN NEUROL 2022;92:75-80.

Objective: To analyse the cumulative incidence of febrile seizures, to evaluate the accuracy of our screening questionnaire and to describe clinical characteristics of children with febrile seizure in an urban population in Tanzania.Methods: A large random cluster sampled population was screened for a febrile seizure history as part of a larger epilepsy study using a standardised questionnaire in a two-stage door-to-door survey in Tanzania. A subset of screen positive participants was further examined for confirmation of diagnosis and evaluation of clinical characteristics.Results: Overall, 49 697 people were screened for a febrile seizure history of whom 184 (0.4%) screened positive. Women more commonly screened positive than men (112 [0.4%] vs. 72 [0.3%]). There was no marked difference between age groups or education. The positive predictive value of the screening tool was 37% (95% CI 24-51%) but its accuracy varied with the age of interviewed individuals. Cumulative incidence rates were estimated between 1.1% and 2.0% after adjusting for the inaccuracy of the screening tool. Most febrile seizures occurred before the age of two (65%) and most children had more than one episode (80%). A large proportion of children had complex febrile seizure (65%), often caused by malaria or respiratory infections.Conclusions: The community-based cumulative incidence of a febrile seizure history in an urban Tanzanian population was similar to rates reported from other rural populations after adjusting for the inaccuracy of our screening tool. Based on the integrated nature of the febrile seizure questionnaire, screening positivity rates may have been too low. This has implications for the design of future studies. The majority of cases had complex febrile seizures often associated with malaria. This has implications for clinical case management. [ABSTRACT FROM AUTHOR]

Objectives Nodding syndrome ( NS), a new epilepsy disorder of sub-Saharan Africa, has only recently been classified. In a study conducted in southern Tanzania in 2005, 62 patients with NS were analyzed in great detail. The present study, a follow-up investigation, was conducted to evaluate the progression of NS over time and to obtain serial electroencephalography ( EEG) data. Methods Of the 62 NS patients, 53 (85.5%), the majority of whom were currently on some form of antiepileptic treatment, could be reevaluated in 2009 with a standardized questionnaire. A subset of these patients (25/53) underwent EEG investigation. Results In patients with 'head nodding ( HN) only' in 2005, 10 (43.5%) of 23 remained with the same diagnosis, whereas 5 (21.7%) of 23 had developed ' HN plus' (i.e., HN and generalized tonic-clonic seizures). Six patients (26.1%) had seizures other than HN only, and two patients (8.7%) had fully recovered. In the ' HN plus' group of 2005, 9 (30.0%) of 30 patients remained ' HN plus,' and 15 patients (50.0%) had seizures other than HN only. Four patients (13.3%) reverted to ' HN only,' and two patients (6.7%) stopped all seizures. In 11 (44.0%) of 25 patients, electroencephalography ( EEG) showed generalized slowing. Six (54.6%) of these 11 abnormal EEG studies further showed generalized epileptiform discharges: (1) ictal electroencephalographic pattern with generalized 2.5 Hz spike and waves in two patients and (2) interictal bursts of 1.5-2 Hz spike and waves in four patients. Significance This follow-up study confirms that HN represents an epilepsy disorder, possibly of the atypical absence type with dynamic development over time. [ABSTRACT FROM AUTHOR]

The main aim of this door-to-door-study was to determine the prevalence, incidence, and clinical characteristics of epilepsy in northern Tanzania. A total of 7,399 people were screened with a standardized questionnaire using “multistage random sampling.” The prevalence rate of epilepsy was 11.2/1,000 [95% confidence interval (CI) 8.9–13.9/1,000] and the age-adjusted prevalence rate was 13.2/1,000. The prevalence of active epilepsy was 8.7/1,000 (95% CI 6.7–11/1,000). There was a preponderance of women. The average retrospective incidence including the last 5 years was 81.1/100,000 (95% CI 65–101/100,000). Fifty-four percent (45 of 83) of the people with epilepsy had generalized seizures without any identifiable cause; 71% (59 of 83) of the epilepsy patients had not visited health institutions prior to the study and 76% (63 of 83) had never received treatment. Our study shows that the prevalence and incidence of epilepsy in northern Tanzania are higher compared to developed countries and that the majority of people with epilepsy do not access treatment. [ABSTRACT FROM AUTHOR]

In developing countries, neurocysticercosis (NCC) is a common cause of epilepsy. Most of the work on NCC and epilepsy has been compiled in Latin America. To date, comprehensive neuroimaging studies are missing in sub-Saharan Africa. In our study, we interviewed 212 people with epilepsy (PWE) and performed cerebral computed tomography (CT) at the Haydom Lutheran Hospital in northern Tanzania. Control cerebral CT scans were selected from 198 consecutive individuals without epilepsy. Sera of PWE with lesions indicating NCC (n = 20), PWE without NCC lesions (n = 20), and healthy individuals (n = 20), as well as cerebrospinal fluid (CSF) samples of PWE with NCC lesions (n = 11) were investigated for anticysticercal antibodies. Definite NCC lesions were present in five (2.4%), lesions highly suggestive of NCC in 24 (11.3%), and lesions compatible with NCC in nine (4.2%) PWE. This compares to two (1.0%) people with definite NCC lesions, two (1.0%) with lesions highly suggestive of, and six (2.9%) with lesions compatible with NCC in the control group. NCC lesions were significantly more frequent in PWE compared to controls (p < 0.0001). CT results, and serum and CSF analysis taken together, we diagnosed 22 (10.4%) individuals with probable and 7 (3.3%) with definitive NCC in our cohort of PWE. For the first time in sub-Saharan Africa, we give evidence within a large-scale neuroimaging study that NCC, a so far neglected infectious disease, represents a major cause of epilepsy. [ABSTRACT FROM AUTHOR]

In the 1960s in Tanzania, L. Jilek-Aall observed a seizure disorder characterized by head nodding (HN). Decades later, “nodding disease,” reminiscent of what was seen in Tanzania, was reported from Sudan. To date this seizure disorder has not been classified and possible causes still remain obscure. In a prospective study in southern Tanzania, we evaluated 62 patients with HN. Selected patients underwent blood (n = 51) and cerebrospinal fluid (CSF) (n = 48) analyses. Others were chosen for MRI (n = 12) and EEG (n = 10). Seizure type was classified as “head nodding only” and “head nodding plus,” the latter being combined with other types of seizure (n =34). During HN, consciousness was impaired in 11 patients (17.7%) and supportive signs of epileptic seizures were described by 15 (24.2%) patients. Precipitating factors were confirmed by 11 (17.7%) patients. Fifty-six (90.3%) patients had at least one relative with epilepsy. EEG confirmed interictal epileptic activity in two patients and unspecific changes in four patients. MRI showed hippocampus pathologies (n = 5) and gliotic changes (n = 5). Skin polymerase chain reaction (PCR) positivity for Onchocerca volvulus was significantly associated with lesions on MRI. However, PCR of the CSF was negative in all cases. We present a comprehensive clinical description of the “HN syndrome,” possibly a new epilepsy disorder in sub-Saharan Africa. MRI lesions and their association with positive skin PCR for O. volvulus despite negative PCR of the CSF is intriguing and deserves attention. Furthermore, the high prevalence of hippocampus sclerosis and familial clustering of epilepsy may point toward other potential pathogenetic mechanisms. [ABSTRACT FROM AUTHOR]

Summary: In developing countries, especially Latin America, neurocysticercosis (NCC) is a common cause of epilepsy. Recently, neurotoxocariasis has also been implicated in the pathogenesis of epilepsy. In sub-Saharan Africa data on parasitic disease and epilepsy are scarce. We therefore conducted a study in a rural hospital in northern Tanzania and analysed serum samples for anticysticercal and antitoxocaral antibodies for 40 people with epilepsy (PWE), 20 of whom had confirmed NCC on cranial computed tomography (CT) and 20 healthy individuals. Cerebrospinal fluid (CSF) of 11 PWE with NCC lesions on cranial CT was also investigated. Antibodies were determined using ELISA and Western blot. Six PWE with NCC lesions showed anticysticercal antibodies in serum. Of those, five had active lesions. Anticysticercal antibodies were significantly more frequent in PWE with active NCC than in those with inactive NCC (P <0.01). CSF samples were positive for anticysticercal antibodies in five patients, of whom four had active lesions on cranial CT. Antitoxocaral antibodies were detected in sera of 11 (55%) PWE with NCC lesions, of eight (40%) PWE without lesions on cranial CT and of eight (40%) controls. In our study anticysticercal antibodies in both serum and CSF were associated with active NCC in PWE, whereas there was no relationship between antitoxocaral antibodies and epilepsy. [Copyright &y& Elsevier]

Background: In a resource-poor environment such as rural East Africa, expensive medical devices such as computed tomographic (CT) scanners are rare. The CT scanner at the rural Haydom Lutheran Hospital (HLH) in Tanzania therefore offers a unique chance to observe possible differences with urban medical centers in the disease pattern of trauma-related cranial pathologies. The purpose of this study was to compare traumatic brain injuries (TBIs) between a rural and an urban area of Tanzania. Methods: HLH has 350 beds and one CT scanner. The urban Aga Khan Hospital is a private hospital with 80 beds and one CT scanner. This was a retrospective study. Data of 248 patients at HLH and of 432 patients at Aga Khan Hospital with TBI could be collected. Results: The prevalence of TBI was significantly higher in the rural area compared to the urban area (34.2% vs. 21.9%, P < 0.0001). TBI due to violence was noted to occur more frequently at HLH, whereas road traffic accidents were more frequent at the Aga Khan Hospital. The number of patients showing a normal CT result was significantly higher in the urban area (53.0% vs. 35.9%, P < 0.0001). Bone fractures (35.9% vs. 15.7%, P < 0.0001) and pneumocephalus (6.9% vs. 0.9%, P < 0.0001) were diagnosed significantly more frequently in the rural survey. Soft tissue swelling (11.6% vs. 1.2%, P < 0.0001) and frontal sinus injuries (7.4% vs. 0.4%, P < 0.0001) were observed significantly more often in the urban setting. Conclusions: This study documents the burden of TBI and the differences in TBI-related CT diagnoses and their incidence between urban and rural areas in Eastern Africa. These results are important as they demonstrate that patients with severe TBI are not a primarily urban concern. Management of TBI should be included in the training curricula for health personnel alike irrespective of whether their workplace is primarily urban or rural. [Copyright &y& Elsevier]

Abstract: Background: Empirical knowledge suggests that altered states of consciousness are common in sub-Saharan Africa. However, to date prevalence studies are scarce. Methods: The study was conducted at the Haydom Lutheran Hospital in northern Tanzania. Over a period of eight months all patients with altered states of consciousness were seen prospectively by a neurologist. The study population was subdivided into patients with acute confusional states (ACS) and those with impairment of consciousness (IOC). Results: Out of 768 patients with neurological/psychiatric diagnoses 464 patients (60.4%) with altered states of consciousness were admitted. 159 patients had ACS (20.7%) and 447 IOC (58.2%). The diagnoses were not mutually exclusive. The most frequent aetiologies were of non-infectious origin. In patients with ACS, non-infectious encephalopathy, psychiatric disorder and dementia made up for 13.8%, 7.6% and 6.9%, respectively. In 25.2% of the cases with ACS, the reason remained obscure. In patients with IOC, the leading causes were epileptic seizures (febrile seizures 20.6% and epilepsy 13.9%) and head trauma 13.9%. Both ACS and IOC carried a bleak prognosis with 26% and 27% in-hospital mortality, respectively. Interpretation: The above data emphasize that altered states of consciousness contribute substantially to morbidity and mortality in a rural African hospital. In our study sample, non-infectious causes represented the leading aetiologies although HIV testing was not available at the time of the study. [Copyright &y& Elsevier]

Objectives Restless legs syndrome (RLS) is one of the most common neurological disorders in Caucasian populations with prevalence rates between 5% and 15%. A recent study conducted in rural northern Tanzania documented a prevalence of only 0.013%. This result requires further investigation of the epidemiology of RLS in Africa, as prevalence rates seem to vary among different ethnicities. Patients/methods We conducted a community-based door-to-door study in an urban environment in eastern Africa (Kinondoni district, Dar es Salaam, Tanzania), where 35.008 people aged 14 years and above were screened for RLS according to the essential diagnostic criteria. Sampling was performed by the method of cluster sampling with probability-proportional-to-size. Results One hundred and sixty-four people screened positively for RLS (0.47%). Ninety-two of those were subject to detailed history taking and physical examination. Four people could finally be diagnosed with RLS, yielding a RLS prevalence rate of 0.037% (95% CI 0.015%; 0.059%) among the people in Kinondoni. Conclusion These results support previous findings that RLS has a very low prevalence in Tanzania despite the fact that only part of the questionnaire-positive RLS people could be interviewed face-to-face, and show that this is independent of whether assessed in a rural or an urban population. According to our results it seems that indigenous Tanzanian people (which are considered representative for the population of Eastern Africa) are less prone to RLS compared to Caucasian populations. Whether the reasons for this discrepancy in prevalence are primarily genetic, environmental or have a cultural/social component remains to be determined. In addition, the study points to a limited application of the essential diagnostic criteria in settings of non-Caucasian populations. Irrespective of ethnic origin, we support the necessity of detailed history and physical examination as performed in the second part of our study to exclude RLS mimics and verify the diagnosis of RLS. [ABSTRACT FROM AUTHOR]

Abstract: The social stigma toward people with epilepsy (PWE) varies greatly between cultures. In this study, 167 people (59 PWE, 62 relatives, 46 villagers) in a rural area of northern Tanzania were interviewed at the hospital and in the community regarding their prevailing beliefs about epilepsy and attitudes toward PWE. Seventy-eight of those interviewed (46.7%) thought that epilepsy was due to supernatural causes, but 86 (51.5%) assumed that epilepsy is caused by brain disorders or is inherited. According to the interviewees, epilepsy impacts on the lives of affected people. 65.3% (n=109) thought that PWE should not attend school or go to work and 38.3% (n=64) were of the opinion that PWE had decreased chances of getting married. A minority (11.4%; n=19) thought that epilepsy was a reason not to have children. In summary, supernatural and more scientific ideas about the causes of epilepsy seem to coexist. Nevertheless, there is considerable stigma toward PWE, which needs to be interpreted within the sociocultural context of the study. [ABSTRACT FROM AUTHOR]

Background/Objectives: The prudent allocation of neurosurgical resources and training efforts requires an understanding of prevalence and clinical pattern of neurosurgical disorders in a particular region. The aim of our study was to assess the hospital-based prevalence of neurosurgical disease in the setting of rural sub-Saharan Africa. Methods: The study was conducted at Haydom Lutheran Hospital in northern Tanzania. Over a period of 8 months, all patients suspected of having neurologic or neurosurgical disorders were seen by a neurologist in consecutive order. Patients were assessed clinically and with plain radiographs, a computed tomography scanner was not available. Results: Of 8676 admissions, 151 patients (1.7%) were given a neurosurgical diagnosis. The most frequent diagnoses were traumatic brain injury (n=90), followed by tuberculosis of the spine (n=22), spina bifida (n=14), space-occupying cerebral lesion (n=13), and hydrocephalus (n=12). The overall mortality was 10.6%; it was especially high in patients with hydrocephalus (25%), space-occupying cerebral lesions (54%), and spina bifida (29%). Conclusions: Initial neurosurgical training and resource allocation in sub-Saharan Africa should focus on neurotrauma, spinal infections, congenital malformations, and hydrocephalus. [ABSTRACT FROM AUTHOR]