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Fila M, Przyslo L, Derwich M, Pawlowska E, Blasiak J. Potential of focal cortical dysplasia in migraine pathogenesis. Cereb Cortex 2024; 34:bhae158. [PMID: 38615241 DOI: 10.1093/cercor/bhae158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Revised: 03/21/2024] [Accepted: 03/23/2024] [Indexed: 04/15/2024] Open
Abstract
Focal cortical dysplasias are abnormalities of the cerebral cortex associated with an elevated risk of neurological disturbances. Cortical spreading depolarization/depression is a correlate of migraine aura/headache and a trigger of migraine pain mechanisms. However, cortical spreading depolarization/depression is associated with cortical structural changes, which can be classified as transient focal cortical dysplasias. Migraine is reported to be associated with changes in various brain structures, including malformations and lesions in the cortex. Such malformations may be related to focal cortical dysplasias, which may play a role in migraine pathogenesis. Results obtained so far suggest that focal cortical dysplasias may belong to the causes and consequences of migraine. Certain focal cortical dysplasias may lower the threshold of cortical excitability and facilitate the action of migraine triggers. Migraine prevalence in epileptic patients is higher than in the general population, and focal cortical dysplasias are an established element of epilepsy pathogenesis. In this narrative/hypothesis review, we present mainly information on cortical structural changes in migraine, but studies on structural alterations in deep white matter and other brain regions are also presented. We develop the hypothesis that focal cortical dysplasias may be causally associated with migraine and link pathogeneses of migraine and epilepsy.
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Affiliation(s)
- Michal Fila
- Department of Developmental Neurology and Epileptology, Polish Mother's Memorial Hospital Research Institute, Rzgowska 281/289, 93-338 Lodz, Łódzkie, Poland
| | - Lukasz Przyslo
- Department of Developmental Neurology and Epileptology, Polish Mother's Memorial Hospital Research Institute, Rzgowska 281/289, 93-338 Lodz, Łódzkie, Poland
| | - Marcin Derwich
- Department of Developmental Dentistry, Medical University of Lodz, Pomorska 251, 90-647 Lodz, Łódzkie, Poland
| | - Ezbieta Pawlowska
- Department of Developmental Dentistry, Medical University of Lodz, Pomorska 251, 90-647 Lodz, Łódzkie, Poland
| | - Janusz Blasiak
- Faculty of Medicine, Collegium Medicum, Mazovian Academy in Plock, Plac Generała Dabrowskiego 2, 09-420 Plock, Mazowieckie, Poland
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Zheng S, Yuan R, Ni J, Liu H, Yang Y, Zhang S, Li J. Long-term Recurrence-free Survival and Complications of Percutaneous Balloon Compression and Radiofrequency Thermocoagulation of Gasserian Ganglion for Trigeminal Neuralgia:A Retrospective Study of 1313 Cases. Pain Pract 2022; 22:532-540. [PMID: 35460524 DOI: 10.1111/papr.13114] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2021] [Revised: 03/01/2022] [Accepted: 04/12/2022] [Indexed: 12/01/2022]
Abstract
OBJECTIVE To estimate long-term recurrence, complications after percutaneous balloon compression (PBC) and radiofrequency thermocoagulation (RFT) of gasserian ganglion among a large sample of patients with trigeminal neuralgia (TN) during a long-term follow-up. METHODS A retrospective analysis of 1313 patients undergoing PBC or RFT for the treatment of TN was conducted from 2006 to 2020. Recurrence-free survival (RFS) was assessed by Kaplan-Meier method. Complications including facial numbness, corneal reflex decrease and masseter weakness were also estimated. RESULTS For patients who received first initial PBC and RFT, the median RFS was 130.1 months (95%CI: 124.4, 135.9) and 123.3 months (95%CI: 117.6, 128.9) in PBC and RFT group with log-rank p=0.108. The RFS rate was respectively 90.6% (95%CI: 88.1%-93.3%) and 91.4% (95%CI: 89.1%-93.7%) at 1 year, 84.6% (95%CI: 81.4%-87.8%) and 83.3% (95%CI: 80.3%-86.3%) at 3 years, 81.5% (95%CI: 78.1%-85.0%) and 78.6 % (95%CI: 75.2%-81.9%) at 5 years, 71.5% (95%CI: 67.5%-75.5%) and 64.8% (95%CI: 61.0%-68.7%) at 10 years in two groups. No significant difference was observed in facial numbness degree between two groups after procedure. Compared with PBC group, ophthalmic complication prevalence was higher in RFT group (9.6%) (p=0.001). However, masseter weakness incidence was lower (10.7%) than that in PBC group (24.0%) with p<0.001. CONCLUSIONS Patients with TN seemed to attain similar long-term benefit from PBC and RFT, especially in elderly. However, in order to reduce postoperative complications, PBC provided a safer and alternative for treating TN involving ophthalmic division, whereas RFT could be employed as a preferred regimen for maxillary and mandibular TN.
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Affiliation(s)
- Shuyue Zheng
- Department of Pain, Beijing Shijitan Hospital, Capital Medical University, No. 10 Yangfangdian Street, 100038, Haidian District, Beijing, China
| | - Rong Yuan
- Department of Ultrasound Diagnosis, North District of Peking University Third Hospital, No. 10 Chedaogou, 100080, Haidian District, Beijing, China
| | - Jiaxiang Ni
- Department of Pain Management, Beijing Xuanwu Hospital, Capital Medical University, No. 45 Changchun Street, 100053, Xicheng District, Beijing, China
| | - Hongfu Liu
- Department of Pain, Beijing Shijitan Hospital, Capital Medical University, No. 10 Yangfangdian Street, 100038, Haidian District, Beijing, China
| | - Yucheng Yang
- Department of Pain, Beijing Shijitan Hospital, Capital Medical University, No. 10 Yangfangdian Street, 100038, Haidian District, Beijing, China
| | - Shusheng Zhang
- Department of Neurosurgery and Pain, Tsinghua University Affiliated Yuquan Hospital, No. 5 Shijingshan Street, 100049, Shijingshan District, Beijing, China
| | - Juanhong Li
- Department of Pain, Beijing Shijitan Hospital, Capital Medical University, No. 10 Yangfangdian Street, 100038, Haidian District, Beijing, China
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Pediatric Headache in Primary Care and Emergency Departments: Consensus with RAND/UCLA Method. Life (Basel) 2022; 12:life12020142. [PMID: 35207430 PMCID: PMC8877535 DOI: 10.3390/life12020142] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 01/06/2022] [Accepted: 01/12/2022] [Indexed: 01/09/2023] Open
Abstract
Headache is the most frequent neurological symptom in childhood and the main reason for admission to pediatric emergency departments. The aim of this consensus document is to define a shared clinical pathway between primary care pediatricians (PCP) and hospitals for the management of children presenting with headache. For the purposes of the study, a group of hospital pediatricians and a group of PCP from the Emilia Romagna’s health districts were selected to achieve consensus using the RAND/UCLA appropriateness method. Thirty-nine clinical scenarios were developed: for each scenario, participants were asked to rank the appropriateness of each option from 1 to 9. Agreement was reached if ≥75% of participants ranked within the same range of appropriateness. The answers, results, and discussion helped to define the appropriateness of procedures with a low level of evidence regarding different steps of the diagnostic-therapeutic process: primary care evaluation, emergency department evaluation, hospital admission, acute therapy, prophylaxis, and follow-up. The RAND proved to be a valid method to value appropriateness of procedures and define a diagnostic-therapeutic pathway suitable to the local reality in the management of pediatric headache. From our results, some useful recommendations were developed for optimizing the healthcare professionals’ network among primary care services and hospitals.
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Bauer PR, Tolner EA, Keezer MR, Ferrari MD, Sander JW. Headache in people with epilepsy. Nat Rev Neurol 2021; 17:529-544. [PMID: 34312533 DOI: 10.1038/s41582-021-00516-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/18/2021] [Indexed: 02/06/2023]
Abstract
Epidemiological estimates indicate that individuals with epilepsy are more likely to experience headaches, including migraine, than individuals without epilepsy. Headaches can be temporally unrelated to seizures, or can occur before, during or after an episode; seizures and migraine attacks are mostly not temporally linked. The pathophysiological links between headaches (including migraine) and epilepsy are complex and have not yet been fully elucidated. Correct diagnoses and appropriate treatment of headaches in individuals with epilepsy is essential, as headaches can contribute substantially to disease burden. Here, we review the insights that have been made into the associations between headache and epilepsy over the past 5 years, including information on the pathophysiological mechanisms and genetic variants that link the two disorders. We also discuss the current best practice for the management of headaches co-occurring with epilepsy and highlight future challenges for this area of research.
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Affiliation(s)
- Prisca R Bauer
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Freiburg, Freiburg, Germany.
| | - Else A Tolner
- Department of Neurology, Leiden University Medical Centre, Leiden, The Netherlands.,Department of Human Genetics, Leiden University Medical Centre, Leiden, The Netherlands
| | - Mark R Keezer
- Research Centre of the Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada.,School of Public Health, Université de Montréal, Montreal, Quebec, Canada.,Stichting Epilepsie Instellingen Nederland, Heemstede, The Netherlands
| | - Michel D Ferrari
- Department of Neurology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Josemir W Sander
- Stichting Epilepsie Instellingen Nederland, Heemstede, The Netherlands.,NIHR University College London Hospitals Biomedical Research Centre, UCL Queen Square Institute of Neurology, London, UK.,Chalfont Centre for Epilepsy, Chalfont St Peter, UK
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Thu PW, Chen YM, Liu WM. Recurrent Tolosa-Hunt syndrome. Tzu Chi Med J 2021; 33:314-316. [PMID: 34386372 PMCID: PMC8323652 DOI: 10.4103/tcmj.tcmj_137_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 06/29/2020] [Accepted: 07/15/2020] [Indexed: 11/06/2022] Open
Abstract
The Tolosa–Hunt syndrome (THS) is caused by granulomatous inflammation in the cavernous sinus, superior orbital fissure, or orbit characterized by painful ophthalmoplegia. Here, we report a case of recurrent THS in a 48-year-old female, who initially showed a poor response to low-dose steroids. Each episode involved different cranial nerves and painful ophthalmoplegia. Neuroimaging showed enhancement in the right cavernous sinus. The patient was treated with glucocorticoid pulse therapy and azathioprine. THS was previously considered to be responsive to glucocorticoids. This report demonstrates a case of THS with poor response to steroids and unique presentation of frequent recurrence with different cranial nerve involvement.
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Affiliation(s)
- Phyo-Wai Thu
- Department of Neurology, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan
| | - Yu-Ming Chen
- Department of Neurology, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan
| | - Weng-Ming Liu
- Department of Neurology, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan.,Doctoral Degree Program in Translational Medicine, Tzu Chi University and Academia Sinica, Hualien, Taiwan
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Ozturk-Hismi B, Teber S, Ozkan M, Unal O, Deda G. Diagnostic Yield of Neuroimaging and Electroencephalography in Children with Recurrent Headaches. JOURNAL OF PEDIATRIC NEUROLOGY 2021. [DOI: 10.1055/s-0040-1714106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
AbstractNeuroimaging and electroencephalography (EEG) are commonly used for pediatric recurrent headache evaluation, although not routinely recommended. In this study, data of 517 children with recurrent headaches were analyzed to evaluate the diagnostic yield of neuroimaging and EEG. Neuroimaging was performed in 55% (n = 283) of children, 61% with magnetic resonance imaging and 39% with computed tomography. Abnormal findings were reported in 17% (n = 48), and 5% (n = 13) were significant abnormalities altering headache management. Among children with significant imaging abnormalities, 85% had alarming signs on history, physical, or neurological examination. The diagnostic yield of imaging was 0.7% (n = 2), picking a cavernous hemangioma and a giant arachnoid cyst. EEG was performed in 69% (n = 356) of children, significant findings were reported in 8% (n = 29), with sharp waves/spikes in 4.1% (n = 15), and intermittent focal slow waves in 3.9% (n = 14). EEG was diagnostic for epilepsy in 1.6% (n = 6) of children with recurrent headaches. When there are no red flags on history or physical examination, diagnostic yield of neuroimaging is low for pediatric recurrent headaches. EEG can be helpful in selective cases, and when performed during and at headache-free periods.
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Affiliation(s)
- Burcu Ozturk-Hismi
- Department of Pediatric Neurology, School of Medicine, Ankara University, Ankara, Turkey
- Department of Pediatric Metabolic Diseases, School of Medicine, Marmara University, Istanbul, Turkey
| | - Serap Teber
- Department of Pediatric Neurology, School of Medicine, Ankara University, Ankara, Turkey
| | - Mehpare Ozkan
- Department of Pediatric Neurology, School of Medicine, Ankara University, Ankara, Turkey
| | - Ozlem Unal
- Department of Pediatric Neurology, School of Medicine, Ankara University, Ankara, Turkey
| | - Gulhis Deda
- Department of Pediatric Neurology, School of Medicine, Ankara University, Ankara, Turkey
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Raucci U, Della Vecchia N, Ossella C, Paolino MC, Villa MP, Reale A, Parisi P. Management of Childhood Headache in the Emergency Department. Review of the Literature. Front Neurol 2019; 10:886. [PMID: 31507509 PMCID: PMC6716213 DOI: 10.3389/fneur.2019.00886] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Accepted: 07/30/2019] [Indexed: 12/16/2022] Open
Abstract
Headache is the third cause of visits to pediatric emergency departments (ED). According to a systematic review, headaches in children evaluated in the ED are primarily due to benign conditions that tend to be self-limiting or resolve with appropriate pharmacological treatment. The more frequent causes of non-traumatic headache in the ED include primitive headaches (21.8–66.3%) and benign secondary headaches (35.4–63.2%), whereas potentially life-threatening (LT) secondary headaches are less frequent (2–15.3%). Worrying conditions include brain tumors, central nervous system infections, dysfunction of ventriculo-peritoneal shunts, hydrocephalus, idiopathic intracranial hypertension, and intracranial hemorrhage. In the emergency setting, the main goal is to intercept potentially LT conditions that require immediate medical attention. The initial assessment begins with an in-depth, appropriate history followed by a complete, oriented physical and neurological examination. The literature describes the following red flags requiring further investigation (for example neuroimaging) for recognition of LT conditions: abnormal neurological examination; atypical presentation of headaches: subjective vertigo, intractable vomiting or headaches that wake the child from sleep; recent and progressive severe headache (<6 months); age of the child <6 years; no family history for migraine or primary headache; occipital headache; change of headache; new headache in an immunocompromised child; first or worst headache; symptoms and signs of systemic disease; headaches associated with changes in mental status or focal neurological disorders. In evaluating a child or adolescent who is being treated for headache, physicians should consider using appropriate diagnostic tests. Diagnostic tests are varied, and include routine laboratory analysis, cerebral spinal fluid examination, electroencephalography, and computerized tomography or magnetic resonance neuroimaging. The management of headache in the ED depends on the patient's general conditions and the presumable cause of the headache. There are few randomized, controlled trials on pharmacological treatment of headache in the pediatric population. Only ibuprofen and sumatriptan are significantly more effective than placebo in determining headache relief.
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Affiliation(s)
- Umberto Raucci
- Pediatric Emergency Department, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Nicoletta Della Vecchia
- Department of Pediatrics, University of "Studi della Campania Luigi Vanvitelli", Naples, Italy
| | - Chiara Ossella
- Pediatric Emergency Department, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Maria Chiara Paolino
- Chair of Pediatrics, NESMOS Department, Faculty of Medicine and Psychology, Sapienza University, Sant' Andrea Hospital, Rome, Italy
| | - Maria Pia Villa
- Chair of Pediatrics, NESMOS Department, Faculty of Medicine and Psychology, Sapienza University, Sant' Andrea Hospital, Rome, Italy
| | - Antonino Reale
- Pediatric Emergency Department, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Pasquale Parisi
- Chair of Pediatrics, NESMOS Department, Faculty of Medicine and Psychology, Sapienza University, Sant' Andrea Hospital, Rome, Italy
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Parisi P, Paolino MC, Raucci U, Della Vecchia N, Belcastro V, Villa MP, Striano P. Ictal Epileptic Headache: When Terminology Is Not a Moot Question. Front Neurol 2019; 10:785. [PMID: 31396147 PMCID: PMC6664028 DOI: 10.3389/fneur.2019.00785] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2018] [Accepted: 07/08/2019] [Indexed: 11/13/2022] Open
Abstract
The relationship between headache and epilepsy is complex and despite the nature of this association is not yet clear. In the last few years, it has been progressively introduced the concept of the “ictal epileptic headache” that was included in the recently revised International Classification of Headaches Disorders 3rd edition (ICHD-3-revised). The diagnostic criteria for ictal epileptic headache (IEH) suggested in 2012 were quite restrictive thus leading to the underestimation of this phenomenon. However, these criteria have not yet been included into the ICHD-3 revision published in 2018, thus creating confusion among both, physicians and experts in this field. Here, we highlight the importance to strictly apply the original IEH criteria explaining the reasons through the analysis of the clinical, historical, epidemiological and pathophysiological characteristics of the IEH itself. In addition, we discuss the issues related to the neurophysiopathological link between headache and epilepsy as well as to the classification of these epileptic events as “autonomic seizure.”
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Affiliation(s)
- Pasquale Parisi
- Chair of Pediatrics, Child Neurology, NESMOS Department, Faculty of Medicine and Psychology, Sapienza University, Sant'Andrea Hospital, Rome, Italy
| | - Maria Chiara Paolino
- Chair of Pediatrics, Child Neurology, NESMOS Department, Faculty of Medicine and Psychology, Sapienza University, Sant'Andrea Hospital, Rome, Italy
| | - Umberto Raucci
- Pediatric Emergency Department, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | | | - Vincenzo Belcastro
- Neurology Unit, Department of Neuroscience, Sant'Anna Hospital, Como, Italy
| | - Maria Pia Villa
- Chair of Pediatrics, Child Neurology, NESMOS Department, Faculty of Medicine and Psychology, Sapienza University, Sant'Andrea Hospital, Rome, Italy
| | - Pasquale Striano
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, Genova, Italy.,Paediatric Neurology and Muscular Diseases Unit, G. Gaslini' Institute, Genova, Italy
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Salma Z, Hanen HK, Salma S, Olfa H, Nouha F, Mariem D, Chokri M. Headaches and their relationships to epileptic seizures. Epilepsy Behav 2019; 90:233-237. [PMID: 30583857 DOI: 10.1016/j.yebeh.2018.11.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2018] [Revised: 11/03/2018] [Accepted: 11/15/2018] [Indexed: 01/03/2023]
Abstract
PURPOSE The frequent association between headache and epilepsy has been increasingly studied in recent years. Through this study, we attempted to study possible temporal associations between epileptic seizures and headaches. We also tried to describe clinical aspects of headache in our patients with epilepsy. PATIENTS AND METHODS We included patients with epilepsy and patients without epilepsy who presented for a first neurologic episode suggestive of epileptic seizure or unusual headache. These patients were invited to answer a standardized questionnaire screening for headache characteristics. Patients with epilepsy were asked for further data about their epilepsy. Electroencephalogram (EEG) was performed in all patients. Brain Magnetic resonance imaging MRI was reserved for patients in whom we suspected a structural lesion. RESULTS Overall, we included 47 patients with a mean age of about 39 ± 15 years (19 to 68 years old) and a female predominance (Sex Ratio: SR = 1.47). Most frequently, our patients documented periictal headache (Peri-IH) (85.1%) including respectively ictal headache (IH: 31.9%); postictal headache (Post-IH: 21.3%), and preictal headache (Pre-IH: 4.3%). Less frequently, our patients noted interictal headache (Inter-IH: 31.9%). Interestingly, these subgroups exhibited different headache patterns with predominantly unclassified-type headache (U-TH) in patients with IH (72.7%), tension-type headache (T-TH) in patients with Post-IH (73.3%), and migraine-type headache (M-TH) in patients with Inter-IH (60%). CONCLUSIONS Our results suggest that patients with epilepsy could exhibit different headache types. The clinical pattern of headache seemed to be linked to the time of seizure onset.
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Affiliation(s)
- Zouari Salma
- Department of Neurology, Habib Bourguiba University Hospital, 3029 Sfax, Tunisia; Neuroscience Laboratory "LR-12-SP-19", Habib Bourguiba University Hospital, 3029 Sfax, Tunisia.
| | - Haj Kacem Hanen
- Department of Neurology, Habib Bourguiba University Hospital, 3029 Sfax, Tunisia; Neuroscience Laboratory "LR-12-SP-19", Habib Bourguiba University Hospital, 3029 Sfax, Tunisia
| | - Sakka Salma
- Department of Neurology, Habib Bourguiba University Hospital, 3029 Sfax, Tunisia; Neuroscience Laboratory "LR-12-SP-19", Habib Bourguiba University Hospital, 3029 Sfax, Tunisia
| | - Hdiji Olfa
- Department of Neurology, Habib Bourguiba University Hospital, 3029 Sfax, Tunisia; Neuroscience Laboratory "LR-12-SP-19", Habib Bourguiba University Hospital, 3029 Sfax, Tunisia
| | - Farhat Nouha
- Department of Neurology, Habib Bourguiba University Hospital, 3029 Sfax, Tunisia; Neuroscience Laboratory "LR-12-SP-19", Habib Bourguiba University Hospital, 3029 Sfax, Tunisia
| | - Damak Mariem
- Department of Neurology, Habib Bourguiba University Hospital, 3029 Sfax, Tunisia; Neuroscience Laboratory "LR-12-SP-19", Habib Bourguiba University Hospital, 3029 Sfax, Tunisia; Clinical Investigation Center "CIC", Habib Bourguiba University Hospital, 3029 Sfax, Tunisia
| | - Mhiri Chokri
- Department of Neurology, Habib Bourguiba University Hospital, 3029 Sfax, Tunisia; Neuroscience Laboratory "LR-12-SP-19", Habib Bourguiba University Hospital, 3029 Sfax, Tunisia; Clinical Investigation Center "CIC", Habib Bourguiba University Hospital, 3029 Sfax, Tunisia
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