Correspondence
for suspected patients with CAA
presenting without intracerebral
haemorrhage, such as those with
transient focal neurological episodes
and dementia, are derived from the
largest sample of these presentations
to date. There was nonetheless only
a relatively small number of patients
with CAA–transient focal neurological
episodes in our cohort (n=25),
precluding stable diagnostic accuracy
estimates (sensitivity approaching
100% and specificity of approximately
50%) in just this subgroup.
One important misinterpretation to
avoid in applying the Boston criteria
to patient populations without
intracerebral haemorrhage is assuming
that fulfilment of the probable CAA
criteria necessarily means that CAA is
the primary cause of the presenting
non-intracerebral haemorrhage
syndrome. This consideration is
particularly salient for presentations
of cognitive impairment, which are
typically the result of overlapping
neurodegenerative pathologies of
which CAA might be either a minor
or major contributor. There is also a
separate set of proposed criteria with
additional stipulations for assigning
the probability that presentation with
transient focal neurological episodes is
due to CAA.3
The Boston criteria version 2.0 added
a limited set of non-haemorrhagic
white matter markers, severe enlarged
perivascular spaces in the centrum
semiovale, and multispot white
matter hyperintensity patterns, with
the goal of improving diagnostic
sensitivity without excessively
compromising specificity. In scoring
these markers, it is essential to note
that perivascular spaces in the criteria
refer to the centrum semiovale
(where multiple lines of evidence
point to a strong association with
underlying CAA pathology)4–6 rather
than to perivascular spaces in the
basal ganglia (more characteristic
of other small vessel processes such
as arteriolosclerosis). Even with
this clarification in mind, we agree
www.thelancet.com/neurology Vol 22 June 2023 467
that these white matter lesions are
neither perfectly specific nor perfectly
sensitive for CAA, just as lobar
cerebral microbleeds are not perfectly
sensitive or specific. We emphasise
that all imaging markers should be
interpreted in the intended clinical
context to be useful diagnostically, and
that their diagnostic value for CAA in
asymptomatic people or as incidental
findings has not been established.
We agree with Moura and Maia that
there is somewhat limited experience
with assessing white matter
markers, particularly with multispot
white matter hyperintensities. We
note, however, that the markers
incorporated in the Boston criteria
version 2.0 showed excellent inter-
rater reproducibility under the existing
definitions,1 supporting their feasibility
for widespread use.
The points raised highlight the
need for further research to refine
the specificity and generalisability of
the Boston criteria version 2.0 as we
move towards improved diagnosis and
testing of candidate therapies for this
ever challenging disorder.
AC reports receiving funding from the Bodossaki
Foundation and the Frechette Family Foundation
and consulting fees from Imperative Care. SMG
reports receiving funding from the US National
Institutes of Health, royalties from Up-To-Date,
consulting fees from Eli Lily, and serving on data
safety monitoring committees for Washington
University, Bayer, Biogen, and Roche.
*Andreas Charidimou,
Steven M Greenberg
andreas.charidimou.09@ucl.ac.uk
Department of Neurology, Boston University
Medical Center and Boston University School of
Medicine, Boston, MA 02118, USA (AC);
Department of Neurology, Massachusetts General
Hospital and Harvard Medical School, Boston, MA,
USA (SMG)
1 Charidimou A, Boulouis G, Frosch MP, et al.
The Boston criteria version 2.0 for cerebral
amyloid angiopathy: a multicentre,
retrospective, MRI-neuropathology diagnostic
accuracy study. Lancet Neurol 2022; 21: 714–25.
2 Charidimou A, Boulouis G. Clinical diagnosis of
probable cerebral amyloid angiopathy:
diagnostic accuracy meta-analysis of the
boston criteria. Stroke 2022; 53: 3679–87.
3 Smith EE, Charidimou A, Ayata C, Werring DJ,
Greenberg SM. Cerebral amyloid angiopathy-
related transient focal neurologic episodes.
Neurology 2021; 97: 231–38.
4 Charidimou A, Boulouis G, Pasi M, et al.
MRI-visible perivascular spaces in cerebral
amyloid angiopathy and hypertensive
arteriopathy. Neurology 2017; 88: 1157–64.
5 Perosa V, Oltmer J, Munting LP, et al.
Perivascular space dilation is associated with
vascular amyloid-β accumulation in the
overlying cortex. Acta Neuropathol 2022;
143: 331–48.
6 Charidimou A, Hong YT, Jäger HR, et al. White
matter perivascular spaces on magnetic
resonance imaging: marker of cerebrovascular
amyloid burden? Stroke 2015; 46: 1707–09.
The Brain Research
Africa Initiative (BRAIN)
The burden of neurological disease
is high in Africa, where despite
the efforts made, there is still a
considerable shortage of human,
infrastructural, and financial resources
to provide the continent’s populations
with state-of-the-art brain health
care. 1,2 The Brain Research Africa
Initiative (BRAIN) is working to bridge For BRAIN see
this gap. https://brainafrica.org/
BRAIN is an international research
and development organisation
focused on the production and
translation of brain health evidence
for policy and development in
Africa. Our global headquarters are
located in Geneva, Switzerland, and
our continental headquarters are in
Yaoundé, Cameroon. BRAIN is also a
development partner of the African
Union Commission. For the past
25 years, via a bottom-up approach,
BRAIN has gained the reputation and
Figure: Participants at the BRAIN-SCAN Congress 1.5
The Congress was an activity of BRAIN Week in Cameroon and held at the Faculty of
Medicine and Biomedical Sciences of The University of Yaoundé I, Yaoundé, Cameroon
(Oct 24–29, 2022), under the distinguished patronage of the Prime Minister of
Cameroon. Image provided courtesy of ELFA Media. BRAIN=Brain Research Africa
Initiative. SCAN=Society of Cameroonian Neurologists.
 Correspondence
trust of the Cameroon Government
and other national public and private
stakeholders, for the promotion of
brain health in the country. With
its sister organisation, the Society
of Cameroonian Neurologists
(SCAN), along with The University
of Yaoundé I (UYI), the Cameroon
Government, and the World Federation
of Neurology (WFN) past president
Prof Johan Aarli, BRAIN organised a
historic congress in Yaounde. Primary
and secondary school students were
invited and encouraged to take up
careers in the neurosciences during the
Pan African Association of Neurological
Sciences congress of 2008 in Yaoundé,
under the distinguished patronage
of the President of Cameroon. 3
Dr Nene Ahidjo was one of those
secondary school students, who was
subsequently mentored and directed by
our team at BRAIN through the Faculty
of Medicine and Biomedical Sciences at
UYI (FMBS-UYI), and is now an assistant
lecturer in neuropharmacology in
that Faculty. Dr Ahidjo is a rising
role model for young women in
neuroscience in Africa. In 2019, BRAIN
created the BRAIN Week in Cameroon,
scaling up the World Brain Day. This
event is celebrated annually under
the patronage of the Prime Minister
of Cameroon, and involves medical
students, physicians, and other
stakeholders.4
On Oct 24–29, 2022, the joint
BRAIN-SCAN Congress 1.5 was held
at the FMBS-UYI, with the theme of
“vascular neurology in sub-Saharan
Africa: experiences, challenges, and
perspectives” (figure). This congress
was live-streamed to thousands of
delegates and attended physically
by more than 600 delegates from
15 countries, including WFN past
president Prof Vladimir Hachinski
as keynote speaker. During this
congress BRAIN launched the BRAIN
Trust Tournament, to demystify
neuroscience and encourage medical
students into neuroscience and brain
health careers. 5 This precongress
activity attracted the participation
468 www.thelancet.com/neurology Vol 22 June 2023
of 12 schools of medicine from
four countries in the Economic and
Monetary Community of Central
Africa—Economic Community of
Central African States (CEMAC-CEEAC).
Additionally, the congress programme
included neurology, neurosurgery,
psychiatry, neuroscience (basic and
translational) sessions that were
live-streamed, as well as a cadaverless
simulation neuroanatomy workshop
(with the surgical simulation and
training company UpSurgeOn), a
stereology workshop (with the Turkish
Society of Stereology), and a scientific
writing workshop (with experts
from the University of Fribourg and
University of Geneva, Switzerland).
In barely 4 years, the BRAIN Week in
Cameroon has grown into BRAIN Week
in Cameroon–CEMAC-CEEAC. The
next Brain Week will take place at the
University of Dschang, in West Region,
Cameroon, in October, 2023.
BRAIN thanks its partners and
welcomes new partnerships to
continue the uphill task of promoting
brain health in Africa.
AKN reports honorary participation as chair on an
advisory board for the Epilepsy Pathway Innovation
in Africa project, and is President of the Society of
Cameroonian Neurologists. All other authors declare
no competing interests. Other members of the
BRAIN-SCAN Congress 1.5 Scientific Committee and
Organising Secretariat are Stephen Perrig,
Roman Sztajzel, and Jean Marie Annoni.
*Alfred K Njamnshi, Leonard Ngarka,
Wepnyu Y Njamnshi, Nene Ahidjo,
Joelle N Chabwine, Vladimir Hachinski,
on behalf of the BRAIN-SCAN Congress
1.5 Scientific Committee and
Organising Secretariat
alfred.njamnshi@brainafrica.org
Brain Research Africa Initiative, Geneva, Switzerland
and Yaoundé, PO Box 25625, Cameroon (AKN, LN,
WYN, NA, JNC); Neuroscience Laboratory, Faculty of
Medicine and Biomedical Sciences, The University of
Yaoundé I, Yaoundé, Cameroon (AKN, LN, WYN, NA);
Neurology Department, Yaoundé Central Hospital,
Yaoundé, Cameroon (AKN, LN); Department of
Health Operations Research, Ministry of Public
Health, Yaoundé, Cameroon (WYN); Neurology
Division, Fribourg Hospital, Fribourg, Switzerland
(JNC); Faculty of Medicine and Science, University of
Fribourg, Fribourg, Switzerland (JNC); Robarts
Research Institute (VH) and Department of Clinical
Neurological Sciences (VH), University of Western
Ontario, London, ON, Canada
1 WHO. ATLAS country resources for neurological
disorders, 2nd edn. Sept 15, 2017. https://www.
who.int/publications/i/item/atlas-country-
resources-for-neurological-disorders. (accessed
March 2, 2023).
2 Craven R. Building neurological services in
Africa. Lancet Neurol 2009; 8: 32–33.
3 Schneider ME. PAANS: reaching out to future
neurologists. Feb 13, 2009. https://
wfneurology.org/publications/world-
neurology/world-neurology-archive/
document_19 (accessed March 2, 2023).
4 Njamnshi AK. Migraine in Cameroon: from the
painful truth to the powerful tribute.
Sept 16, 2019. https://worldneurologyonline.
com/wp-content/uploads/2019/09/WFN_July_
Aug_newsletter-1.pdf (accessed March 2, 2023).
5 Njamnshi AK. Looking back into the future of
the neurosciences in Cameroon and
sub-Saharan Africa. Health Sci Dis 2022;
23 (suppl 1): 3–4.
Monomania of political
strife by Géricault
In the winter of 1822–23, the
Romantic master Théodore Géricault
painted a series of ten portraits
called Les Monomanes that were
commissioned by the psychiatrist
Étienne-Jean Georget. The portraits
depict ten patients with so-called
monomanias, now an obsolete
nosology of psychiatric diseases.
Five of these portraits were found in
1863 and are now exhibited in well
known art galleries. They correspond
to the monomanias of kleptomania,
envy, gambling, obsessive fixation
(delusions of military rank), and
kidnapping. The other five portraits
remained missing, and it was therefore
not known which other types of
monomania Géricault had painted.
I began to uncover this mystery in
2021, when I identified the portrait
of a patient with the monomania of
melancholy in a private collection in
Italy.1 In 2022, I discovered a second
lost portrait from the series: a patient
with the monomania of drunkenness.2
The portraits of the series can
be identified by their similar
compositional features, their
attribution to Théodore Géricault,
and the inclusion of the clinical
description of the represented
patient in the medical treatises of