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Previous studies have described the association of onchocerciasis (caused by Onchocerca volvulus) with epilepsy, including nodding syndrome, although a clear etiological link is still missing. Cases are found in different African countries (Tanzania, South Sudan, Uganda, Democratic Republic of the Congo, Central African Republic and Cameroon). In our study we investigated immunological parameters (cytokine, chemokine, immunoglobulin levels) in individuals from the Mahenge area, Tanzania, presenting with either epilepsy or nodding syndrome with or without O. volvulus infection and compared them to O. volvulus negative individuals from the same endemic area lacking neurological disorders. Additionally, cell differentiation was performed using blood smears and systemic levels of neurodegeneration markers, leiomodin-1 and N-acetyltyramine-O, β-glucuronide (NATOG) were determined. Our findings revealed that cytokines, most chemokines and neurodegeneration markers were comparable between both groups presenting with epilepsy or nodding syndrome. However, we observed elevated eosinophil percentages within the O. volvulus positive epilepsy/nodding syndrome patients accompanied with increased eosinophilic cationic protein (ECP) and antigen-specific IgG levels in comparison to those without an O. volvulus infection. Furthermore, highest levels of NATOG were found in O. volvulus positive nodding syndrome patients. These findings highlight that the detection of distinct biomarkers might be useful for a differential diagnosis of epilepsy and nodding syndrome in O. volvulus endemic areas. Trial-registration:NCT03653975. Author summary: A lot of epidemiological studies suggest that an infection with the filarial nematode Onchocerca volvulus is a risk factor for a certain form of epilepsy which includes the nodding syndrome. The seizures occur suddenly in previously healthy children between the ages of 3 and 18 years and the disease is an important public health problem in onchocerciasis-endemic regions with inadequate or lacking onchocerciasis elimination programmes. So far, no exact pathophysiological mechanisms were detected that shed light on how the parasite can trigger the seizures, although many factors have been investigated. However, most studies lack an accurate determination of an active/chronic O. volvulus infection; rather, they rely on the presence of circulating antibodies, which is only evidence of previous exposure to the parasite (and therefore positive in most people living in endemic areas. Within our study, we included participants from the Mahenge area, Tanzania, who were displaying epilepsy/nodding syndrome in absence or presence of a PCR-determined O. volvulus infection. We could show that the group of O. volvulus infected patients displayed higher levels of eosinophils, antigen-specific immunoglobulin levels as well as increased levels of a worm-related metabolic product (NATOG), which might be used as a potential diagnostic biomarker of the disease in future studies. [ABSTRACT FROM AUTHOR]

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 [ABSTRACT FROM AUTHOR]

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]

Objective: Febrile seizures may contribute to epilepsy later in life, but data in sub-Saharan Africa are scarce. We, therefore, conducted a hospital-based study on clinical characteristics of children with febrile seizures.Methods: Over 2 years, we screened all pediatric admissions of Haydom Lutheran Hospital, northern Tanzania, and recruited 197 children with febrile seizures.Results: The incidence of febrile seizures was 4% of all admitted children aged <10 years, with a mortality of almost 4%. The peak age at the first febrile seizure was 2 years. One of five children experienced repeated episodes, and the majority of children showed features of complex seizures. Approximately 20% of children had a positive family history of febrile seizures or epilepsy.Conclusion: Febrile seizures represent a frequent cause for admission of children, bearing a rather high mortality. Most children exhibit complex febrile seizures, which may contribute to the development of epilepsy later in life. [ABSTRACT FROM AUTHOR]

Objective.- One goal of the campaign 'Lifting the burden: The global campaign against headache' is to highlight existing evidence about headache worldwide. In this context, the aim of our study was to report the migraine-related headache burden in northern Tanzania. Methods.- From December 2003 until June 2004 a community-based door-to-door survey was undertaken in northern Tanzania, using multistage cluster sampling. Based on the criteria of the International Headache Society, 7412 individuals were enrolled in this survey. Results.- Migraine patients' average annual attack frequency was 18.4 (n = 308, standard deviation [SD] ± 47.4) with a mean duration of 16.4 hours (SD ± 20.6). The average headache intensity per patient was 2.65 (SD ± 0.59) with a calculated loss of 6.59 (SD ± 26.7) working days per year. Extrapolation of data to the investigated population (n = 7412) resulted in annual migraine burden of 281.0 migraine days per 1000 inhabitants. Conclusions.- To our knowledge, this study reports for the first time the burden that arises from migraine headache in a rural population of sub-Sahara Africa (SSA). As the presented migraine-related burden is considerable, we hope that our data will increase the awareness among local decision makers in allocating resources for treatment and research on headache. [ABSTRACT FROM AUTHOR]

The prevalence of Parkinson’s disease (PD) in sub-Saharan Africa is still a matter of debate. The few studies that have been conducted have shown prevalences lower than those in the western world. Whether this represents a genuine finding is unclear to date. In northern Tanzania, we have conducted a hospital-based evaluation and a community-based door-to-door study to assess the prevalence of Parkinsonism, including that of PD. Over a period of 8 months, all patients admitted to a mid-size rural hospital were screened for PD. In parallel, 1,569 people aged ≥50 years were recruited from the communities and assessed for PD with standard questions. Sampling was performed according to the method of “multistage cluster sampling.” The questions had previously been tested in a pilot study prior to the survey. People who screened positive were examined by a specialist neurologist. In the hospital, eight of 740 people with neurological diagnoses had Parkinsonism, of whom three patients had a diagnosis of PD. In the community-based study, 18 people answered positively to least one of the 12 screening questions. However, the diagnosis of PD could not be confirmed by further examination in any of them. The prevalence of PD in northern Tanzania was found to be very low. This result would need confirmation in studies with larger populations, ideally of different African ethnicities. [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]

The classification of epilepsy, which represents the commonest neurological disorder throughout the developing world, has been difficult due to lack of diagnostic tools. Adapted to the circumstances of an epilepsy clinic in northern Tanzania, we grouped people with epilepsy (PWE) according to an adjusted version of the International Classification of Epileptic Seizures with the main groups being: generalized types of seizures (206 PWE) divided into those starting within (147 PWE) and those starting outside (59 PWE) a specific age range (6-25 years); and partial types of seizures (102 PWE) with subgroups of generalized seizures with diffuse brain damage (41 PWE), those with predominantly focal signs (60 PWE) and complex partial seizures (1 PWE). Clinical implications are discussed. [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]

Objective: A door-to-door survey was carried out to assess the prevalence of active epilepsy in the rural population within the catchment area of the Mnero Diocesan Hospital in Southern Tanzania. Methods: A total of 4,905 individuals living in 1,047 households were enrolled in a study, consisting of a screening dialogue with a representative family member followed by a face-to-face interview with the affected subject. The diagnosis of epilepsy followed clinical guidelines proposed by the International League Against Epilepsy (ILAE). Results: We detected 42 cases (21 males and 21 females) of active epilepsy (8.6/1,000; 95% CI: 6.0/1,000–11.1/1,000; age-adjusted prevalence ratio: 7.4/1,000). Thirty of them met the case definitions of generalized seizures, whereas 12 patients reported partial seizures. The peak prevalence was found in both sexes in the second decade of life (f: 16.9/1,000; m: 15.8/1,000; t: 16.4/1,000), with a second peak in the group aged 30–39 years (f: 10.4/1,000; m: 8.8/1,000; t: 9.7/1,000). Eleven patients (26.2%) were classified as “strongly suspected of symptomatic” epilepsy, the remaining 31 patients (73.8%) as possibly being idiopathic, symptomatic, or cryptogenic epilepsy cases. Discussion: This study provides baseline data about the active epilepsy prevalence in a rural African population. Compared to western countries, our study confirmed a pattern toward higher prevalence of epilepsy in tropical countries. As shown in previous studies, we observed a higher prevalence of epilepsy in children and adolescents, followed by a steady decline with increasing age. Reasons for this type of frequency could be ascribed to malnutrition, trauma, genetic conditions, antenatal and prenatal care, diseases resulting in febrile convulsions, cerebral infections and may even result in death in specifically diseased individuals. [ABSTRACT FROM AUTHOR]

We have previously described a seizure disorder characterized by head nodding (HN). In a prospective study in southern Tanzania, we evaluated 62 patients with HN. Here,we report the patients' clinical characteristics and those of their seizures, which indicate high seizure frequency, unsatisfactory seizure control, a high burden of cognitive impairment and disease-associated barriers to education. [ABSTRACT FROM AUTHOR]

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]

• This study shows that the continuous presence of a trained neurologist is associated with a lower seizure frequency in people with epilepsy. • The continuous presence of a neurologist is also associated with a higher likelihood of reporting and detecting side effects. • Investing in specialist services in addition to primary healthcare may reduce brain health inequities faced by PWE in Africa. With an estimated lifetime prevalence of epilepsy of 7.6 per 1,000 people, epilepsy represents one of the most common neurological disorders worldwide, with the majority of people with epilepsy (PWE) living in low-income and middle-income countries (LMICs). Adequately treated, up to 70 % of PWE will become seizure-free, however, as many as 85% of PWE worldwide, mostly from LMICs, do not receive adequate treatment. To assess the impact of the presence of a neurologist on the management of PWE in Tanzania. Two epilepsy clinics in rural Tanzania, one continuously attended by a neurologist, and one mainly attended by nurses with training in epilepsy and supervised intermittently by specialist doctors (neurologists/psychiatrists) were comparatively analyzed by multivariable linear and logistic regression models with regard to the outcome parameters seizure frequency, the occurrence of side effects of antiepileptic medication and days lost after a seizure. The presence of a neurologist significantly reduced the mean number of seizures patients experienced per month by 4.49 seizures (p < 0.01) while leading to an increase in the occurrence of reported side effects (OR: 2.15, p = 0.02). The presence of a neurologist may play a substantial role in reducing the burden of the disease of PWE in LMICs. Hence, specialist training should be encouraged, and relevant context-specific infrastructure established. [ABSTRACT FROM AUTHOR]

Introduction The spectrum of meningitis pathogens differs depending on the age of patients and the geographic region, amongst other. Although meningitis vaccination programs have led to the reduction of incidence rates, an imbalance between low- and high-income countries still exists. Methods In a hospital-based study in rural northern Tanzania, we consecutively recruited patients with confirmed meningitis and described their clinical and laboratory characteristics. Results A total of 136 patients with meningitis were included. Fever (85%), meningism (63%) and impairment of consciousness (33%) were the most frequent clinical symptoms/signs. Nearly 10% of all patients tested were positive for malaria. The majority of the patients with bacterial meningitis (39%), especially those under 5 years of age, were confirmed to be infected with Haemophilus influenzae (26%), Streptococcus pneumoniae (19%) and Neisseria meningitidis (15%). Haemophilus influenzae represented the dominant causative organism in children under 2 years of age. Conclusion Our study emphasizes the importance of recognizing warning symptoms like fever, meningism and impairment of consciousness, implementing laboratory tests to determine responsible pathogens and evaluating differential diagnoses in patients with meningitis in sub-Saharan Africa. It also shows that Haemophilus influenza meningitis is still an important cause for meningitis in the young, most probabaly due to lack of appropriate vaccination coverage. [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: Neurocysticercosis (NCC), a zoonotic disease caused by the pork tapeworm T. solium, represents one of the most common causes of secondary epilepsy but remains often undiagnosed due to lack of awareness and diagnostic facilities., Methodology: We pooled data from four cross-sectional studies on epilepsy and NCC in eastern Africa. Study sites were in Uganda, Malawi and in Tanzania (Dar es Salaam and Haydom). The study in Uganda and Malawi were community-based, the two studies in Tanzania were hospital-based. The same questionnaire was used for assessment of clinical characteristics of patients with epilepsy. Computed tomography (CT) scans and serological testing were performed in order to diagnose NCC., Results: Overall, 1,179 people with epilepsy were included in our analysis. Of those, 941 PWE underwent CT scanning and were pooled for NCC analysis. Seventy patients were diagnosed with NCC, but NCC prevalence differed considerably between sites ranging from 2.0% (95%CI 0.4% to 3.6%) in Dar es Salaam to 17.5% (95%CI 12.4% to 22.6%) in Haydom. NCC prevalence did not show any association with sex but increased with age and was higher in rural than urban settings. In addition, being a farmer, non-Muslim, eating pork and living with pigs close by was associated with a higher NCC prevalence. PWE with NCC experienced their first epileptic seizure around 3 years later in life compared to PWE without NCC and their epileptic seizures seemed to be better controlled (p&lt;0.001). There was no difference between focal onset seizures and focal signs on neurological examination in both groups (p = 0.49 and p = 0.92, respectively). The rT24H-EITB had a sensitivity for the detection of NCC of 70% (95% confidence interval [CI] 51 to 84%), the LLGP of 76% (95%CI 58 to 89%) and the antigen ELISA of 36% (95% CI 20 to 55%)., Conclusions: NCC is prevalent among PWE in eastern Africa, although it may not be as common as previously stated. Demographic characteristics of PWE with NCC differed from those without NCC, but semiological characteristics and results on neurological examination did not differ compared to PWE without NCC. Interestingly, seizures seemed to be less frequent in PWE with NCC. Being aware of those differences and similarities may help triaging PWE for neuroimaging in order to establish a diagnosis of NCC., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2022 Stelzle et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Epilepsy is one of the most common neurological disorders worldwide. Yet, its treatment gap is large in some areas and especially in sub-Saharan Africa data on clinical, radiological and semiological characteristics, as well as on treatment of persons with epilepsy (PWE) are still scarce., Methods: We pooled data from four cross-sectional studies on epilepsy in eastern Africa. Two studies from Malawi and Uganda were community-based; two studies in Tanzania (urban Dar es Salaam and rural Haydom) were hospital-based. Clinical characteristics of PWE were assessed by the same questionnaire. Additionally, data on treatment were collected and computed tomography (CT) scans were performed., Results: Overall, 1179 PWE were included in our analysis (581 (49.3%) female, median age 22 years (IQR 15-32 years)). Up to 25% of the patients had focal onset seizures. Those showed a higher rate of remarkable CT scan findings, with especially post-ischaemic and neurocysticercosis-associated lesions, compared to PWE with generalized onset seizures (35.1% vs. 20%). The majority of the patients experienced tonic-clonic seizures (70-85%). Only 67-78% of PWE received anti-seizure medication (ASM) treatment in the community-based studies, mostly monotherapy with phenobarbital, phenytoin or carbamazepine. Yet, underdosage was frequent and a large proportion of PWE received alternative non-ASM treatment consisting of herbal treatment (up to 83%) and/or scarification (up to 20%)., Conclusions: Epilepsy is common in sub-Saharan Africa, often caused by neurocysticercosis or ischaemic strokes. PWE suffer from high seizure rates and subsequent injuries, as well as from socio-economic consequences due to insufficient ASM treatment. This pooled analysis illustrates the need for structural programmes for adequate identification, education, assessment and treatment of PWE in sub-Saharan Africa., (© 2022. The Author(s).)

Background: The prevalence of febrile seizures (FSs) and epilepsy are often reported to be higher in sub-Saharan Africa. Furthermore, several studies describe complex features of FSs as risk factors for the development of subsequent epilepsy., Methods: During the period from 2002 to 2004 door-to-door studies with supplementary data collection were conducted in three different areas of Tanzania, examining the prevalence of FSs in 7,790 children between the age of 2 mo and 7 y at the time of the interview. The information on the presence of FSs of 14,583 children, who at the time of the interview were younger than 15 y, was collected in order to describe reported seizures, if any., Results: Overall, 160 children between 2 mo and 7 y with a prevalence rate of 20.5/1,000 (95% confidence interval: 17.5-23.9/1,000) met the criteria for FSs. The average age at onset was 2.2 (SD: 1.8) y and ~42% had complex FSs. Respiratory tract infections and malaria were the most frequent concomitant diseases., Conclusion: Our findings do not confirm the assumption of an increased prevalence of FSs in sub-Saharan Africa. However, the elevated number of complex FSs emphasizes the necessity of more reliable studies about FSs and its consequences.

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., (Copyright © 2014. Published by Elsevier B.V.)

Background: Nodding syndrome (NS) is a seemingly progressive epilepsy disorder of unknown underlying cause. We investigated association of pyridoxal-phosphate serum levels and occurrence of anti-neuronal antibodies against N-methyl-D-aspartate (NMDA) receptor and voltage gated potassium channel (VGKC) complex in NS patients., Methods: Sera of a Tanzanian cohort of epilepsy and NS patients and community controls were tested for the presence of anti-NMDA-receptor and anti-VGKC complex antibodies by indirect immunofluorescence assay. Furthermore pyridoxal-phosphate levels were measured., Results: Auto-antibodies against NMDA receptor or VGKC (LG1 or Caspr2) complex were not detected in sera of patients suffering from NS (n=6), NS plus other seizure types (n=16), primary generalized epilepsy (n=1) and community controls without epilepsy (n=7). Median Pyridoxal-phosphate levels in patients with NS compared to patients with primary generalized seizures and community controls were not significantly different. However, these median pyridoxal-phosphate levels are significantly lower compared to the range considered normal in Europeans., Conclusions: In this pilot study NS was not associated with serum anti-NMDA receptor or anti-VGKC complex antibodies and no association to pyridoxal-phosphate serum levels was found.

The prevalence of spinal pathologies in sub-saharan Africa has received little attention so far. The aim of the survey was to investigate and compare the prevalence pattern of spinal lesions in two different populations of Tanzania, one coming from the urban and semi-urban catchment area of Aga Khan Hospital in Dar es Salaam and the other coming from the rural catchment area of Haydom Lutheran Hospital in Mbulu, northern Tanzania. At the Aga Khan Hospital a total number of 1163 patients were included in the survey. In 50 cases (4.3%) no radiological findings were available and 150 patients (12.9%) showed no pathological abnormality. 90.4% (n = 1051) of screened population were classified in the category of extradural-extramedullary pathologies. Intradural-extramedullary lesions were observed in only three cases (0.3%). Intramedullary pathologies accounted for 2.1% (n = 24). Mean age of the screened population was 46.6 years, male-female ratio 1.08:1. At the Haydom Lutheran Hospital 105 cases were included into the study. Twenty-six patients (24.8%) showed no pathological abnormalities. Extradural-extramedullary pathologies occurred in 72.4% (n = 76) of overall cases. However, intradural-extramedullary pathologies were not seen in Haydom. Intramedullary pathologies were diagnosed in two patients (1.9%). Mean age was with 39.8 years clearly younger compared to urban areas, male-female ratio being 1.21:1, only non-significantly higher than in the Aga Khan Hospital's population. Beside this, one of the main goals of this study was to assess the frequency of infections to the spinal cord and vertebral column in rural and urban Tanzania. Surprisingly there were only few radiological findings at the Aga Khan Hospital, which suggested diagnoses consistent with tropical diseases, a striking difference from rural Haydom Lutheran Hospital, where nearly 30% of all patients showed changes on radiograph consistent with infections/infestations.

The prevalence of neurological diseases and cranial pathologies in sub-Saharan Africa remains a very little investigated field. This study aims at providing an imaging-based overview of cranial pathologies in two Tanzanian hospitals and at identifying possible differences in the spectrum of diseases between rural and urban African populations. At rural Haydom Lutheran Hospital (Manyara region) the data of 726 patients were included in a retrospective survey. At urban Aga Khan Hospital (Dar es Salaam) the data of 1975 patients who had undergone Computed Tomography (CT) and of 537 Magnetic Resonance Imaging (MRI) patients were obtained. All three surveys showed a clear male preponderance within the populations. The median age of the patients was higher in the city (urban CT 48 years; range 0-95/MRI 39 years; 0.1-89; rural CT 32 years; 0-102). In the urban series stroke, extracranial infections, cerebral atrophy and tumours formed the main groups of diagnoses. Amongst rural patients traumatic pathologies, followed by stroke and cerebral infections/infestations were the most common diagnoses. The most striking differences were noticed with cases compatible with cerebral infections/infestations and hydrocephalus being reported more frequently in the rural population. On the other hand stroke and cerebral atrophy were more frequent amongst urban patients. In the rural catchment area the data of 51 HIV-positive CT patients could be obtained, showing a clear female preponderance. Within the urban HIV-positive subgroup of CT patients (n = 57), the gender distribution was almost equal. Furthermore, in both HIV-positive populations the proportion "compatible with cerebral infections/infestations" was higher than amongst the overall study populations. In conclusion, cranial pathologies seem to differ widely in rural and urban areas of Tanzania in particular with respect to cerebral infections and vascular disease.

Restless legs syndrome (RLS) is a highly prevalent movement disorder. However, prevalences seem to vary amongst different ethnicities. To date, no community-based prevalence studies on RLS have been reported from the African continent. We have conducted a community-based, door-to-door study in northern Tanzania. Over a period of 16 months, 7,654 people aged 14 years and older were screened for the RLS Essential Diagnostic Criteria. Sampling was performed according to the method of "multistage cluster sampling." People who screened positive where reinterviewed and physically examined by a specialist neurologist. During the screening phase, 10 people answered "yes" to at least one of the screening questions. After reinterviewing those people, the result was confirmed in five people only. After careful re-evaluation of the results, only one person was diagnosed with RLS. Because of methodological limitations a definite prevalence may only be calculated from larger population-based studies of different African ethnicities with screening questions adapted to the cultural context., ((c) 2010 Movement Disorder Society.)

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., (Copyright © 2010 Elsevier Inc. All rights reserved.)

Most people with epilepsy (PWE) live in developing countries with limited access to health care facilities. In sub-Saharan Africa with approximately 12 million PWE, 90% do not receive adequate medical treatment. In this context, traditional medicine, being easily accessible, plays an important role. However, in sub- Saharan Africa, studies on the attitude of people (both affected and not affected by epilepsy) towards traditional medicine for treatment of epilepsy are scarce. In this study, 167 people (59 PWE, 62 relatives, 46 villagers) were interviewed at the hospital and in the community with a semi-structured validated questionnaire regarding the prevailing attitude towards traditional medicine for treatment of epilepsy in a rural area of northern Tanzania. Various traditional healing methods (THM) could be ascertained, i.e. traditional herbal medicine, spiritual healing, scarifications and spitting. 44.3% (n=74/167) of the interviewed people were convinced that epilepsy could be treated successfully with THM. Interestingly, 34.1% (n=57/167) thought that Christian prayers could cure the cause and/or treat symptoms of epilepsy. Significantly more PWE and their relatives were in favour of THM compared to villagers not knowing about epilepsy or not being immediately affected by epilepsy (χ(2)-test, p=0.004). Further factors influencing people's attitudes towards THM were gender, tribe, religion and urbanity of people's dwellings. Our study demonstrates that not only THM but also prayers in the Christian sense seem to play an important role in people's beliefs regarding successful treatment of epilepsy. Factors influencing this belief system have been identified and are discussed.

Empirical knowledge suggests that neurological disorders are common in sub-Saharan Africa. The aims of our study were to assess the hospital-based prevalence of neurological disorders in a rural African setting and to suggest a systematic approach to disease classification. Of 8676 admissions (over a period of eight months) 740 patients (8.5%) were given a neurological diagnosis; cases were grouped according to diagnostic certainty. We suggest three major categories for neurological disorders (group 1=no diagnostic uncertainties; group 2=minor diagnostic uncertainties; group 3=major diagnostic uncertainties) with clinical implications.

Background: Rapid diagnosis and adequate therapy are crucial to prevent development of severe disease and death in children suffering from malaria. A reliable but easy system for disease severity assessment would help to fast track seriously ill children and provide suitable therapies for different patient groups., Objectives: To examine risk factors and appropriate scoring systems in children suffering from malaria for outcome in terms of morbidity and mortality., Methods: A prospective, consecutive study in children admitted to the Muhimbili Medical Centre in Dar es Salaam was conducted to evaluate risk factors and test appropriate scoring systems. The simplified Multi-Organ Dysfunction Score (sMODS), a severity of disease classification consisting mainly of clinical data, was applied. Chosen outcome parameters were morbidity and mortality. Results were compared to those obtained from the World Health Organisation (WHO) classification of severe malaria, the Blantyre Coma Scale (BCS) and selected single clinical parameters., Results: Seventy-five children were recruited into the study. Mean age was 28 months ranging from 6 months to 8 years. 'Severe Malaria', according to WHO criteria was evident in 57 patients (76%). Mean sMODS on admission was 15.6 +/- 2. Seven patients (9%) died. Among single symptoms, impaired consciousness and respiratory distress predicted both, fatal outcome and morbidity. In terms of scoring systems, the sMODS correlated with both outcome parameters. In comparison, the WHO criteria did not correlate with any of the two parameters, the BCS correlated with mortality only., Conclusion: In our study, sMODS has been shown to represent a useful quantitative approach towards disease severity classification in resource poor settings and can be used for risk estimation in children suffering from malaria in terms of both morbidity and mortality.