Neurology® Clinical Practice

Summary: The relationship between head trauma and parkinsonism has been debated since James Parkinson's first description of the shaking palsy in the late 19th century. We observed in our outpatient clinic a young woman in whom hemiparkinsonism developed within 3 weeks of sustaining closed head trauma with loss of consciousness. The patient had a discrete unilateral midbrain hemorrhage on head MRI which involved the contralateral substantia nigra. The condition responded well to carbidopa/levodopa. This patient is a convincing example of posttraumatic midbrain hemorrhage causing parkinsonism.(C)2013AAN Enterprises, Inc.

Summary: Although restricted diffusion without coincident contrast enhancement is most commonly associated with cerebral ischemia, large or tumefactive multiple sclerosis (MS) lesions may demonstrate this pattern initially, followed by subsequent gadolinium (Gd) enhancement. The clinical and MRI characteristics of 3 patients with MS with this imaging pattern are reviewed. All patients had brain MRI lesions >1 cm in diameter, in locations consistent with new neurologic symptoms, and with prominent restricted diffusion but no Gd enhancement. Demyelinating lesion etiologies were supported by CSF findings, laboratory exclusion of alternative diagnoses, lesion evolution, or additional lesions characteristic of MS on brain MRI. Follow-up imaging within 2-4 weeks showed decreased restricted diffusion with patchy Gd enhancement which resolved on subsequent imaging. This imaging evolution may reflect early demyelination prior to inflammation-associated blood-brain barrier disruption.(C)2013AAN Enterprises, Inc.

Summary: The current Iraq and Afghanistan conflicts have seen the highest survival rates in US service members ever, despite staggering numbers of traumatic brain injury and limb loss cases. The improvement in survival can be attributed at least in part to advances in far-forward, rapid medical treatment, including the administration of hypertonic saline solutions and decompressive craniectomies to manage elevated intracranial pressure. After evacuation to military hospitals in the continental United States, service members who have had limb loss face extensive rehabilitation. The growing amputee population has led to a burgeoning interest in the treatment of phantom limb pain and in the development of advanced prostheses.(C)2013AAN Enterprises, Inc.

Summary: Measuring and reporting health care quality is increasingly becoming part of clinical practice and reimbursement for specialists, including neurologists. The goal is to improve the value of care. Current major programs tie quality measurements to reimbursement, including programs from the Centers for Medicare and Medicaid Services: the Physician Quality Reporting System, the Electronic Health Record Incentive Program (and Meaningful Use), and Accountable Care Organizations. Many specialty boards, including the American Board of Psychiatry and Neurology, now require clinical practice quality measurements for maintenance of certification. Practitioners may find these programs confusing, overlapping, burdensome, and not clearly relevant to promoting better patient care. Yet, integrating quality metrics into practice has entered the mainstream and is increasingly tied to reimbursement. Further, over the next few years, most programs will switch from bonus incentives for participation to penalties for nonparticipation. This article aims to clarify current and rising quality measurement programs relevant to neurologists.(C)2013AAN Enterprises, Inc.

Summary: In March 2010, President Obama signed into law the Patient Protection and Affordable Care Act (the Act or ACA), which is felt to be the most comprehensive reform to health care in the United States since the enactment of Medicare/Medicaid in 1965. Nothing this big happens overnight and without controversy. Numerous concerns were raised from all demographics and from both sides of the political aisle. Some of the concerns were legal questions regarding constitutionality and so legal processes began to address this issue. In June 2012, the Supreme Court decided in a 5-4 vote that the Act is constitutional. This has allowed the legislation to stand and over the next few years the more transforming parts will start to be implemented. It is important to understand the issues surrounding the Supreme Court decision and the impact this may have on health care and specifically the practice of neurology.(C)2013AAN Enterprises, Inc.