| In Focus |
spotlight on the may 21 issue.
- Gross, Robert, MD, PhD, Editor-in-Chief, Neurology. Pages: 1913
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| Editorial |
stroke risk after tia: dwi is only part of the answer.
- Coutts, Shelagh, MD, FRCPC, Cucchiara, Brett. Pages: 1914-1915
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economics of neurology 101: the dismal science meets the dismal prognosis.
- Ney, John, MD, MPH, Nuwer, Marc, MD, PhD. Pages: 1916-1917
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| In Memoriam |
robert a. fishman, md (1924-2012).
- Hauser, Stephen, Rowland, Lewis. Pages: 1918-1919
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| Article |
mri findings and stroke risk in tia patients with different symptom durations.
- Al-Khaled, Mohamed, Eggers, Jurgen, MD, PhD. Pages: 1920-1926
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Show/Hide Abstract
Objective: To determine the frequency of acute infarction detected by diffusion-weighted imaging (DWI)-MRI and stroke risk in TIA patients with different symptom duration in a population-based study.Methods: During a 54-month period (starting November 2007), 3,724 admitted patients (mean age, 67 +/- 14 years; 45% women) with transient neurologic symptoms lasting <24 hours from 15 hospitals were included. All patients underwent DWI-MRI during hospitalization.Results: Of 3,724 patients, 1,166 showed an acute infarction (32.2%; 95% confidence interval [CI], 30.8%-33.8%) and 88 (2.4%; 95% CI, 1.9%-2.9%) had a stroke during hospitalization (7 days). Stroke risk was higher in patients with tissue-positive DWI than in those with tissue-negative DWI (4.5% vs 1.5%, respectively; p < 0.001). Logistic regression analysis revealed that stroke risk was correlated with positive DWI (odds ratio [OR], 3.1; 95% CI, 2.0-4.8; p < 0.001), atrial fibrillation (OR, 2.1; 95% CI, 1.3-3.5; p = 0.001), and symptom duration <1 hour (OR, 1.5; 95% CI, 1.0-2.4; p = 0.042). Patients with symptoms lasting <1 hour had a lower rate of acute infarction than those with symptoms lasting >=1 hour (24% vs 36%, respectively; p < 0.001), whereas stroke risk did not differ between the groups (2.8% vs 2.1%, respectively; p = 0.22). Stroke risk was higher after tissue-positive events than tissue-negative ones in patients with symptom duration <1 hour (5.2% vs 2.0%, respectively; p = 0.002) and in those with symptom duration >=1 hour (4.1% vs 1.1%, respectively; p < 0.001).Conclusion: Stroke risk was higher after tissue-positive events than tissue-negative ones in TIA patients with different symptom duration.(C)2013 American Academy of Neurology
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low-dose propranolol and exercise capacity in postural tachycardia syndrome: a randomized study.
- Arnold, Amy, Okamoto, Luis, Diedrich, Andre, MD, PhD, Paranjape, Sachin, Raj, Satish, Biaggioni, Italo, Gamboa, Alfredo. Pages: 1927-1933
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Objective: To determine the effect of low-dose propranolol on maximal exercise capacity in patients with postural tachycardia syndrome (POTS).Methods: We compared the effect of placebo vs a single low dose of propranolol (20 mg) on peak oxygen consumption (VO2max), an established measure of exercise capacity, in 11 patients with POTS and 7 healthy subjects in a randomized, double-blind study. Subjects exercised on a semirecumbent bicycle, with increasing intervals of resistance to maximal effort.Results: Maximal exercise capacity was similar between groups following placebo. Low-dose propranolol improved VO2max in patients with POTS (24.5 +/- 0.7 placebo vs 27.6 +/- 1.0 mL/min/kg propranolol; p = 0.024), but not healthy subjects. The increase in VO2max in POTS was associated with attenuated peak heart rate responses (142 +/- 8 propranolol vs 165 +/- 4 bpm placebo; p = 0.005) and improved stroke volume (81 +/- 4 propranolol vs 67 +/- 3 mL placebo; p = 0.013). In a separate cohort of POTS patients, neither high-dose propranolol (80 mg) nor metoprolol (100 mg) improved VO2max, despite similar lowering of heart rate.Conclusions: These findings suggest that nonselective [beta]-blockade with propranolol, when used at the low doses frequently used for treatment of POTS, may provide a modest beneficial effect to improve heart rate control and exercise capacity.Classification of evidence: This study provides Class II evidence that a single low dose of propranolol (20 mg) as compared with placebo is useful in increasing maximum exercise capacity measured 1 hour after medication.(C)2013 American Academy of Neurology
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8ohdg is not a biomarker for huntington disease state or progression.
- Borowsky, Beth, Warner, John, Leavitt, Blair, Tabrizi, Sarah, FRCP, PhD, Roos, Raymund, Durr, Alexandra, MD, PhD, Becker, Chris, Sampaio, Cristina, MD, PhD, Tobin, Allan, Schulman, Howard. Pages: 1934-1941
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Objective: To evaluate plasma 8-hydroxy-deoxy-guanosine (8OHdG) levels as a potential biomarker of premanifest and early Huntington disease (HD).Methods: Personnel from 2 independent laboratories quantified 8OHdG in blinded longitudinal plasma samples taken 24 months apart from 160 TRACK-HD participants, as well as samples containing control plasma with added ("spiked") 8OHdG. One laboratory used a liquid chromatography-electrochemical array (LCECA) assay, and the other used liquid chromatography-mass spectrometry (LCMS).Results: The LCMS assay was more accurate than the LCECA assay for measurements of "spiked" 8OHdG levels in plasma. Neither assay demonstrated cross-sectional differences in plasma 8OHdG among controls, premanifest HD, and early symptomatic HD. Similarly, neither assay showed longitudinal changes in any disease group over 24 months.Conclusions: Plasma concentration of 8OHdG is not a biomarker of disease state or progression in HD. We recommend that future putative biomarker studies use blinded sample analysis, standard curves, independent analytical methods, and strict quality control of sample collection and storage.(C)2013 American Academy of Neurology
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incidence and prevalence of treated epilepsy among poor health and low-income americans.
- Kaiboriboon, Kitti, Bakaki, Paul, Lhatoo, Samden, Koroukian, Siran. Pages: 1942-1949
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Objectives: To determine the incidence and prevalence of treated epilepsy in an adult Medicaid population.Methods: We performed a retrospective, dynamic cohort analysis using Ohio Medicaid claims data between 1992 and 2006. Individuals aged 18-64 years were identified as prevalent cases if they had >=2 claims of epilepsy (ICD-9-CM: 345.xx) or >=3 claims of convulsion (ICD-9-CM: 780.3 or 780.39) and >=2 claims of antiepileptic drugs. Incident cases were required to have no epilepsy or convulsion claims for >=5 years before epilepsy diagnosis. Subjects were determined as having preexisting disability and/or comorbid conditions, including brain tumor, depression, developmental disorders, migraine, schizophrenia, stroke, and traumatic brain injury, when at least one of these conditions occurred before epilepsy onset.Results: There were 9,056 prevalent cases of treated epilepsy in 1992-2006 and 1,608 incident cases in 1997-2006. The prevalence was 13.2/1,000 (95% confidence interval, 13.0-13.5/1,000). The incidence was 362/100,000 person-years (95% confidence interval, 344-379/100,000 person-years). The incidence and prevalence were significantly higher in men, in older people, in blacks, and in people with preexisting disability and/or comorbid conditions. The most common preexisting conditions in epilepsy subjects were depression, developmental disorders, and stroke, whereas people with brain tumor, traumatic brain injury, and stroke had the higher risk of developing epilepsy.Conclusions: The Medicaid population has a high incidence and prevalence of epilepsy, in an order of magnitude greater than that reported in the US general population. This indigent population carries a disproportionate amount of the epilepsy burden and deserves more attention for its health care needs and support services.(C)2013 American Academy of Neurology
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cervical artery dissection: trauma and other potential mechanical trigger events.
- Engelter, Stefan, Grond-Ginsbach, Caspar, Metso, Tiina, MD, PhD, Metso, Antti, Kloss, Manja, Debette, Stephanie, Leys, Didier, Grau, Armin, Dallongeville, Jean, Bodenant, Marie, Samson, Yves, Caso, Valeria, Pezzini, Alessandro, Bonati, Leo, Thijs, Vincent, MD, PhD, Gensicke, Henrik, Martin, Juan, Bersano, Anna, Touze, Emmanuel, Tatlisumak, Turgut, Lyrer, Philippe, Brandt, Tobias. Pages: 1950-1957
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Objective: To examine the import of prior cervical trauma (PCT) in patients with cervical artery dissection (CeAD).Methods: In this observational study, the presence of and the type of PCT were systematically ascertained in CeAD patients using 2 different populations for comparisons: 1) age- and sex-matched patients with ischemic stroke attributable to a cause other than CeAD (non-CeAD-IS), and 2) healthy subjects participating in the Cervical Artery Dissection and Ischemic Stroke Patients Study. The presence of PCT within 1 month was assessed using a standardized questionnaire. Crude odds ratios (ORs) with 95% confidence intervals (CIs) and ORs adjusted for age, sex, and center were calculated.Results: We analyzed 1,897 participants (n = 966 with CeAD, n = 651 with non-CeAD-IS, n = 280 healthy subjects). CeAD patients had PCT in 40.5% (38.2%-44.5%) of cases, with 88% (344 of 392) classified as mild. PCT was more common in CeAD patients than in non-CeAD-IS patients (ORcrude 5.6 [95% CI 4.20-7.37], p < 0.001; ORadjusted 7.6 [95% CI 5.60-10.20], p < 0.001) or healthy subjects (ORcrude 2.8 [95% CI 2.03-3.68], p < 0.001; ORadjusted 3.7 [95% CI 2.40-5.56], p < 0.001). CeAD patients with PCT were younger and presented more often with neck pain and less often with stroke than CeAD patients without PCT. PCT was not associated with functional 3-month outcome after adjustment for age, sex, and stroke severity.Conclusion: PCT seems to be an important environmental determinant of CeAD, but was not an independent outcome predictor. Because of the characteristics of most PCTs, the term mechanical trigger event rather than trauma may be more appropriate.(C)2013 American Academy of Neurology
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syncope and orthostatic intolerance increase risk of brain lesions in migraineurs and controls.
- Kruit, Mark, MD, PhD, Thijs, Roland, MD, PhD, Ferrari, Michel, MD, PhD, Launer, Lenore, van Buchem, Mark, MD, PhD, van Dijk, J., Gert MD, PhD. Pages: 1958-1965
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Objectives: We and others showed that migraineurs are at increased risk of subclinical and clinical ischemic brain lesions. Migraineurs also have a higher prevalence of frequent syncope and orthostatic intolerance, symptoms that are associated with transient reductions in cerebral blood flow. In this study, we assessed whether these autonomic symptoms may contribute to the increased risk of brain lesions in migraine.Methods: Migraineurs (n = 291) and controls (n = 140) from the population-based, cross-sectional CAMERA (Cerebral Abnormalities in Migraine, an Epidemiologic Risk Analysis) cohort (aged 30-60 years, and free of other neurologic symptoms) underwent 1) brain MRI scan, and 2) structured telephone interview including questions on frequent syncope (>=5/lifetime) and orthostatic intolerance.Results: Frequent syncope (odds ratio [OR] = 2.7; 95% confidence interval: 1.3-5.5) and orthostatic intolerance (OR = 2.0 [1.1-3.6]) were independent risk factors for high load of deep white matter lesions. Effects were strongest in women and similar in migraineurs and controls. Migraine diagnosis did not mediate or moderate these associations. Individuals with orthostatic intolerance had higher prevalence of high periventricular white matter lesion load (OR = 1.9 [1.1-3.5]). Syncope and orthostatic intolerance were not related to subclinical infarcts or infratentorial lesions.Conclusions: Frequent syncope, orthostatic intolerance, and migraine independently increase the risk of white matter lesions, particularly in females.(C)2013 American Academy of Neurology
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nonmelanoma skin cancer is associated with reduced alzheimer disease risk.
- White, Robert, Lipton, Richard, Hall, Charles, Steinerman, Joshua. Pages: 1966-1972
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Objective: To explore the association of nonmelanoma skin cancer (NMSC) and Alzheimer disease (AD) in the Einstein Aging Study, an epidemiologic study of aging in New York City.Methods: Community-residing volunteers aged 70 years or older were assessed annually, followed by multidisciplinary diagnostic consensus. Cancer status and type was obtained by self-report. Cox proportional hazards models were used to test associations between NMSC and subsequent risk of developing a neurocognitive disorder. To deduce a biologically specific association between AD and NMSC, we considered 3 nested outcomes groups: only AD (probable or possible AD as the sole diagnosis), any AD (probable AD or possible AD, as well as mixed AD/vascular dementia), and all-cause dementia.Results: We followed 1,102 adults with a mean age of 79 years at enrollment. Prevalent NMSC was associated with reduced risk of only AD (hazard ratio = 0.21; 95% confidence interval = 0.051-0.87; p = 0.031) among subjects after adjustment for demographics, hypertension, diabetes, and coronary heart disease. APOE [epsilon]4 genotypes were available in 769 individuals. The association was similar in magnitude, but nonsignificant, when the number of APOE [epsilon]4 alleles was included in the model. No significant association was found between NMSC and subsequent development of any AD or all-cause dementia.Conclusions: This population-based longitudinal study shows that individuals older than 70 years with NMSC have a significantly reduced risk of developing AD compared with individuals without NMSC. We deduce Alzheimer-specific neuroprotection, because the effect is attenuated or eliminated when considering less-specific diagnoses such as AD with another diagnosis (any AD) or all-cause dementia.(C)2013 American Academy of Neurology
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interrater reliability of the new criteria for behavioral variant frontotemporal dementia.
- LaMarre, Amanda, Rascovsky, Katya, Bostrom, Alan, Toofanian, Parnian, JD, PsyD, Wilkins, Sarah, Sha, Sharon, Perry, David, Miller, Zachary, Naasan, Georges, Laforce, Robert, Jr MD, PhD, Hagen, Jayne, Takada, Leonel, Tartaglia, Maria, Kang, Gail, Galasko, Douglas, Salmon, David, Farias, Sarah, Kaur, Berneet, Olichney, John, Quitania Park, Lovingly, Mendez, Mario, MD, PhD, Tsai, Po-Heng, Teng, Edmond, MD, PhD, Dickerson, Bradford, Domoto-Reilly, Kimiko, McGinnis, Scott, Miller, Bruce, Kramer, Joel. Pages: 1973-1977
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Objective: To evaluate the interrater reliability of the new International Behavioural Variant FTD Criteria Consortium (FTDC) criteria for behavioral variant frontotemporal dementia (bvFTD).Methods: Twenty standardized clinical case modules were developed for patients with a range of neurodegenerative diagnoses, including bvFTD, primary progressive aphasia (nonfluent, semantic, and logopenic variant), Alzheimer disease, and Lewy body dementia. Eighteen blinded raters reviewed the modules and 1) rated the presence or absence of core diagnostic features for the FTDC criteria, and 2) provided an overall diagnostic rating. Interrater reliability was determined by [kappa] statistics for multiple raters with categorical ratings.Results: The mean [kappa] value for diagnostic agreement was 0.81 for possible bvFTD and 0.82 for probable bvFTD ("almost perfect agreement"). Interrater reliability for 4 of the 6 core features had "substantial" agreement (behavioral disinhibition, perseverative/compulsive, sympathy/empathy, hyperorality; [kappa] = 0.61-0.80), whereas 2 had "moderate" agreement (apathy/inertia, neuropsychological; [kappa] = 0.41-0.6). Clinician years of experience did not significantly influence rater accuracy.Conclusions: The FTDC criteria show promise for improving the diagnostic accuracy and reliability of clinicians and researchers. As disease-altering therapies are developed, accurate differential diagnosis between bvFTD and other neurodegenerative diseases will become increasingly important.(C)2013 American Academy of Neurology
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| Global Perspectives |
background of the sociedad neurologica argentina: current state and concerns about neurologic education.
- Correale, Jorge, Allegri, Ricardo, MD, PhD, Pelli-Noble, Raul, Federico MD, PhD. Pages: 1978-1980
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| Clinical Implications of Neuroscience Research |
synaptic vesicle exocytosis: molecular mechanisms and clinical implications.
- Benarroch, Eduardo. Pages: 1981-1988
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| Contemporary Issues |
the coming crisis: obtaining care for the growing burden of neurodegenerative conditions.
- Dorsey, E., Ray MD, MBA, George, Benjamin, Leff, Bruce, Willis, Allison. Pages: 1989-1996
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Show/Hide Abstract
As the US population ages, the burden of neurodegenerative disorders, including Alzheimer disease and Parkinson disease, will increase substantially. However, many of these patients and their families currently do not receive neurologic care. For example, a recent study found that over 40% of Medicare beneficiaries with an incident Parkinson disease diagnosis did not receive neurologist care early after diagnosis and those who did not were more likely to fracture a hip, be placed in a nursing home, and die. While geography, age, race, and sex likely contribute to these observed disparities in care and outcomes, a large barrier may be Medicare's reimbursement policies, which value procedures over care. With further reductions in Medicare reimbursement constantly on the horizon, the devaluing of clinical care will likely continue. Rather than guaranteeing access to care, Medicare's reimbursement policies may increasingly be an impediment to care.(C)2013 American Academy of Neurology
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| Clinical/Scientific Notes |
administration of isoflurane-controlled dyskinetic movements caused by anti-nmdar encephalitis.
- Gumbinger, Christoph, Hametner, Christian, Wildemann, Brigitte, Veltkamp, Roland, Bosel, Julian. Pages: 1997-1998
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| Reflections: Neurology and the Humanities |
ode upon an open brain.
- Oermann, Eric. Pages: e218-e219
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| NeuroImages |
midbrain neurocysticercal granuloma appearing as "face of panda".
- Konanki, Ramesh, Varma, Dandu, Lingappa, Lokesh, Shenoy, Bhamy. Pages: 1999
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| Resident and Fellow Section |
child neurology: diagnosis of lambert-eaton myasthenic syndrome in children.
- Morgan-Followell, Bethanie, Reyes, Emily. Pages: e220-e222
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Show/Hide Abstract
Objective: To report a case of Lambert-Eaton myasthenic syndrome (LEMS) in a child and review the existing literature of LEMS in children.Methods: We report a pediatric case of LEMS with the classic clinical triad of proximal weakness, autonomic dysfunction, and areflexia; the characteristic increment in compound motor action potential on high-frequency repetitive nerve stimulation; and positive serum P/Q-type voltage-gated calcium channel antibodies. Only 11 pediatric cases of LEMS have been reported in the literature.Results: The patient's presentation with LEMS led to the diagnosis of occult neuroblastoma. Based on review of the existing pediatric literature, no consistent clinical or electrodiagnostic criteria exist to diagnose LEMS in children.Conclusions: There exists a need for consistent clinical criteria and electrodiagnostic testing for prompt diagnosis of LEMS in children. Prompt identification of LEMS will alert the physician to search for malignancy or another immune-mediated process.(C)2013 American Academy of Neurology
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clinical reasoning: a 47-year-old man with progressive gait disturbance and stiffness in his legs.
- Fontes-Villalba, Ariadna, Palma, Jose-Alberto, Fernandez-Seara, Maria, Pastor, Maria, MD, PhD, de Castro, Purificacion, MD, PhD. Pages: e223-e227
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teaching neuroimages: susceptibility-weighted mri: first clue to davf complicating sinovenous thrombosis.
- Kalra, Vivek, Malhotra, Ajay, Matouk, Charles. Pages: e228
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teaching neuroimages: "pancake-like" gadolinium enhancement suggests compressive myelopathy due to spondylosis.
- Flanagan, Eoin, Marsh, Richard, Weinshenker, Brian. Pages: e229
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