Neurology News
Carotid Atherosclerosis Does Not Predict Coronary, Vertebral, or Aortic Atherosclerosis in Patients With Acute Stroke Symptoms
The purpose of this study was to determine whether significant atherosclerotic disease in the carotid arteries predicts significant atherosclerotic disease in the coronary arteries, vertebral arteries, or aorta in patients with symptoms of acute ischemic stroke. Significant atherosclerotic disease was defined as >50% stenosis in the carotid, coronary, and vertebral arteries, or 4 mm thickness and encroaching in the aorta. Presence of any and significant atherosclerotic disease was compared in the different types of arteries assessed. Overall it was found that significant atherosclerotic disease in the carotid arteries does not predict significant atherosclerotic disease in the coronary arteries, vertebral arteries, or aorta in patients with symptoms of acute ischemic stroke. Significant atherosclerotic disease is most often isolated to 1 type of artery in these patients, whereas nonsignificant atherosclerotic disease tends to be more systemic.
Pregabalin in the treatment of post-traumatic peripheral neuropathic pain
Pregabalin is effective in the treatment of peripheral and central neuropathic pain. This study evaluated pregabalin in the treatment of post-traumatic peripheral neuropathic pain (including post-surgical). Overall it was found that a flexible-dose pregabalin 150–600 mg/day was effective in relieving neuropathic pain, improving disturbed sleep, improving overall patient status, and was generally well tolerated in patients with post-traumatic peripheral neuropathic pain.
Dietary Antioxidants and Long-term Risk of Dementia
The Rotterdam Study previously found that higher dietary intakes of vitamins E and C related to lower risk of dementia and Alzheimer disease (AD) over 6 years of follow-up.This article studied the consumption of major dietary antioxidants relative to long-term risk of dementia. Compared with participants in the lowest tertile of vitamin E intake, those in the highest tertile were 25% less likely to develop dementia (hazard ratio, 0.75; 95% confidence interval, 0.59-0.95 with adjustment for potential confounders). Dietary intake levels of vitamin C, beta carotene, and flavonoids were not associated with dementia risk after multivariate adjustment concluding that higher intake of foods rich in vitamin E may modestly reduce long-term risk of dementia and AD.
Combined antiplatelet prophylaxis fails to impact stroke severity
Adding clopidogrel to aspirin treatment in patients at high vascular risk has no effect on the severity of later stroke, say the CHARISMA investigators. The primary finding of the CHARISMA (Clopidogrel for High Atherothrombotic Risk and Ischemic Stabilization, Management and Avoidance) trial was that the addition of clopidogrel to aspirin therapy did not reduce the rate of stroke, myocardial infarction, or vascular death in high-risk patients, relative to aspirin alone.
Depressive Symptoms Increases Risk of Dementia
Depression may be associated with an increased risk for dementia, although results from population-based samples have been inconsistent. This article examined the association between depressive symptoms and incident dementia over a 17-year follow-up period. During the 17-year follow-up period, 164 participants developed dementia; 136 of these cases were AD. A total of 21.6% of participants who were depressed at baseline developed dementia compared with 16.6% of those who were not depressed. Overall depressed participants had more than a 50% increased risk for dementia and AD.
FDA Panel Endorses 1st Oral Drug for Multiple Sclerosis
An expert advisory panel of the U.S. Food and Drug Administration on Thursday recommended that the agency approve an oral drug, Gilenia, as a first-line treatment for multiple sclerosis (MS).Gilenia appears to be both safe and effective, the panel confirmed in two separate votes.Approval would mark a major shift in MS therapy since other drugs for the neurodegenerative illness require frequent injections or intravenous infusions.
Clinical Findings Distinguishing Hemorrhagic Stroke From Ischemic Stroke
The 2 fundamental subtypes of stroke are hemorrhagic stroke and ischemic stroke. Although neuroimaging is required to distinguish these subtypes, the diagnostic accuracy of bedside findings has not been systematically reviewed. This article out of this weeks JAMA sought to determine the accuracy of clinical examination in distinguishing hemorrhagic stroke from ischemic stroke. Several findings significantly increase the probability of hemorrhagic stroke: coma, neck stiffness, seizures accompanying the neurologic deficit, diastolic blood pressure greater than 110 mm Hg, vomiting, and headache. While other findings decrease the probability of hemorrhage such as cervical bruit and prior transient ischemic attack. In patients with acute stroke, certain findings accurately increase or decrease the probability of intracranial hemorrhage, but no finding or combination of findings is definitively diagnostic in all patients, and diagnostic certainty requires neuroimaging.
Treatment of restless legs syndrome with pregabalin
An article out of Neurology assessed the therapeutic efficacy, required dose, and tolerability of pregabalin in patients with idiopathic restless legs syndrome (RLS). This was a double-blind, placebo-controlled trial with polysomnographic control, providing Class II evidence. Ninety-eight patients underwent a 2-week single-blind period with placebo; 58 were randomized to receive pregabalin or placebo for 12 weeks under a flexible-dose schedule.Patients under treatment with pregabalin had a greater improvement in IRLS score than under placebo (63% vs 38.2%; p < 0.05). The mean effective dose of pregabalin at the end of treatment was 322.50 mg/day (±98.77), although therapeutic effects were already seen at a mean dose of 139 mg/day.
Prophylactic intravenous magnesium sulfate for treatment of aneurysmal subarachnoid hemorrhage: A randomized, placebo-controlled, clinical study
An article in Critical Care Medicine examined whether the maintenance of elevated magnesium serum concentrations by intravenous administration of magnesium sulfate can reduce the occurrence of cerebral ischemic events after aneurysmal subarachnoid hemorrhage. The incidence of delayed ischemic infarction was significantly lower in magnesium-treated patients (22% vs. 51%; p = .002); 34 of 54 magnesium patients and 27 of 53 control patients reached good outcome. Delayed ischemic neurologic deficit was nonsignificantly reduced (9 of 54 vs. 15 of 53 patients; p = .149) and transcranial Doppler-detected/angiographic vasospasm was significantly reduced in the magnesium group (36 of 54 vs. 45 of 53 patients; p = .028). Fewer patients with signs of vasospasm had delayed cerebral infarction indicating that high-dose intravenous magnesium can reduce cerebral ischemic events after aneurysmal subarachnoid hemorrhage by attenuating vasospasm and increasing the ischemic tolerance during critical hypoperfusion.
High-resolution ultrasound in the evaluation and prognosis of Bell's palsy
Bell's palsy is a commonly encountered paralysis of the facial nerve occurring worldwide. Prognosis for Bell's palsy is good, but the proportion of patients with poor outcomes may reach 30%. Ultrasound (US) may provide a novel approach for evaluating and prognosticating Bell's palsy, in comparison with known electrophysiological techniques. A study out of the European Journal of Neurology measured the diameter of the distal facial (VII) nerve using US in patients with Bell's palsy treated with prednisolone, in comparison with healthy controls. Overall it was found that the diameter of the distal VII nerve is a good predictor of favorable (positive predictive value: 100%) and bad outcomes (negative predictive value: 77%) in Bell's palsy at 3 months after clinical presentation. US was also found to be superior to VII nerve conduction and blink reflex studies in outcome prediction.
Time trends in outcome of subarachnoid hemorrhage
Treatment of aneurysmal subarachnoid hemorrhage (SAH) has changed substantially over the last 25 years but there is a lack of reliable population-based data on whether case-fatality or functional outcomes have improved. This article in the Journal of Neurology showed that overall mortality due to subarachnoid hemorrhage fell by about 50% in our study population over the last 2 decades, due mainly to improved outcomes in cases surviving to reach hospital. This improvement is consistent with a significant decrease in case-fatality over the last 25 years in our pooled analysis of other similar population-based studies.
Increased incidence of intracranial aneurysms in patients with bicuspid aortic valve
Bicuspid aortic valve (BAV) is a common congenital heart defect affecting half to 2% of the population. A generalized connective tissue disorder also involving the intracranial arteries has been suspected in this patient population. An article published in the Amercian Acadamy of Neurology screened a group of patients with BAV for the presence of intracranial aneurysms. Intracranial aneurysms were detected in 6 of 61 patients with BAV (9.8%; 95% confidence interval [CI] 2.4%–17.3%). This was significantly higher than in the control population (3/291 [1.1%; 95% CI 0%–2.2%]) (p = 0.0012). Female sex (p = 0.02) and advanced age (p = 0.003), risk factors for intracranial aneurysm development, were more common in the control population than among the patients with a BAV. In this case-control study, the frequency of intracranial aneurysms among our bicuspid aortic valve patient population was significantly higher than in the control population.
Almost 20% of stroke drug trials never published in full
A systematic review of trials of pharmacological interventions for acute ischemic stroke concludes that 19.6% of completed trials were never published in full [1]. The researchers, led by Lorna M Gibson (University of Edinburgh, Scotland), charge that these unpublished studies constitute "a substantial body of evidence that was of relevance both to clinical practice in acute stroke and future research in the field." However, some stroke experts are not so sure. The findings were published online April 22, 2010 in Trials.
Safety of tPA in stroke mimics and neuroimaging-negative cerebral ischemia
Patients with acute neurologic symptoms may have other causes simulating ischemic stroke, called stroke mimics (SM), but they may also have averted strokes that do not appear as infarcts on neuroimaging, which we call neuroimaging-negative cerebral ischemia (NNCI). A study out of the Journal Neurology determined the safety and outcome of IV thrombolysis within 3 hours of symptom onset in patients with SM and NNCI. The data support the safety of administering IV tissue plasminogen activator to patients with suspected acute cerebral ischemia within 3 hours of symptom onset, even when the diagnosis ultimately is found not to be stroke or imaging does not show an infarct.
ALS disease onset may occur later in patients with pre-morbid diabetes mellitus
Several metabolic derangements associated with diabetes mellitus type 2 (DM) have been associated with a better outcome in amyotrophic lateral sclerosis (ALS), including hyperlipidemia and obesity. An article in this weeks European Journal of Neurology tested the hypothesis that DM would have a positive effect on the motor and cognitive findings of ALS. The age of onset was later for women, Caucasians and patients with bulbar-onset ALS. However, we also found that after adjusting for gender, ethnicity and site of onset, DM was associated with a 4-year later onset of ALS. Overall it was found that diabetes mellitus type 2 may delay the onset of motor symptoms in ALS. These findings support other studies suggesting a relationship between the pathophysiology of ALS and metabolic derangements. Further investigations are needed to ascertain whether manipulating metabolic parameters would improve outcomes in ALS.
Anti-inflammatory drugs seem to decrease the risk of Parkinson's disease
Anti-inflammatory drugs may prevent Parkinson disease (PD) by inhibiting a putative underlying neuroinflammatory process. An article published in the Journal Neurology tested the hypothesis that anti-inflammatory drugs reduce PD incidence and that there are differential effects by type of anti-inflammatory, duration of use, or intensity of use. Overall, a 15% reduction in PD incidence was observed among users of nonaspirin NSAIDS (relative risk [RR] 0.85, 95% confidence interval [CI] 0.77–0.94), with a similar effect observed for ibuprofen use. The protective effect of nonaspirin NSAIDs was more pronounced among regular users (RR 0.71, 95% CI 0.58–0.89) and long-term users (RR 0.79, 95% CI 0.59–1.07).
Herpes zoster ophthalmicus increases the risk of stroke
An article from this months Neurology investigated the risk of stroke development following a diagnosis of herpes zoster ophthalmicus (HZO). Stroke developed in 8.1% of patients with HZO and 1.7% of patients in the comparison cohort during the 1-year follow-up period. HZO patients had significantly lower 1-year stroke-free survival rates than patients in the comparison cohort. After adjusting for patients' demographic characteristics, selected comorbidities, and medication habits, HZO patients were found to have a 4.52-fold.
Lower Dose Alteplase Shows Similar Clinical Outcomes in Middle Cerebral Artery Occlusion than Higher Dose
A study out the Journal Stroke evaluated the efficacy of 0.6 mg/kg intravenous alteplase on vascular and clinical outcomes in patients with middle cerebral artery occlusion in a postmarketing Phase IV trial of prospective cohort study design. Recanalization was noted in 51.7% on 6-hour MR angiography and 69.0% on 24-hour MR angiography. A favorable clinical outcome was achieved in 46.6% concluding the rates of recanalization and favorable outcome are comparable to that previously reported with the 0.9-mg/kg dose.
Increased tissue damage and lesion volumes in African Americans with multiple sclerosis
African American (AA) patients with multiple sclerosis (MS) have more rapid disease progression and poorer responses to disease-modifying therapies than white American (WA) patients with MS. A study out of the Journal of Neurology investigated brain MRI characteristics in AA compared to WA in a cohort of consecutive patients with MS. The study showed that African American patients showed increased tissue damage, as measured by magnetization transfer ratio, and presented higher lesion volumes compared to white Americans. The greater tissue damage and faster lesion volume accumulation may explain the rapid clinical progression in African American patients.
Antiplatelet pre-treatment increases the risk of intracranial haemorrhage in acute ischaemic stroke after intravenous thrombolysis
Pre-treatment with antiplatelet agents (AP) is present amongst 30% of acute stroke patients. Previous studies have shown conflicting results on the effect of these drugs regarding haemorrhagic transformation after thrombolytic therapy. This retrospective study of consecutive prospectively registered patients with acute ischaemic stroke treated with iv tPA in the last 5 years. Parietal Hemorrhage was observed prior in 54.5% of patients with prior Anti-Platlet (AP) therapy vs 26.9% of patients not on any therapy, concluding pre-treatment with AP is associated with an increased risk of PH after intravenous thrombolysis in patients with acute ischaemic stroke.
A score to predict early risk of recurrence after ischemic stroke
There is currently no instrument to stratify patients presenting with ischemic stroke according to early risk of recurrent stroke. We sought to develop a comprehensive prognostic score to predict 90-day risk of recurrent stroke. The 90-day risk of recurrent stroke was calculated by summing up the number of independent predictors weighted by their corresponding β-coefficients. The resultant score was called recurrence risk estimator at 90 days or RRE-90 score ( Link Here ). The RRE-90 score demonstrated adequate calibration and good discrimination, which was maintained when applied to a separate cohort of 433 patients. The model's performance was also maintained for predicting early (14-day) risk of recurrence.
Imaging Recomendations for new-onset afebrile seizures in infants
To investigate the presenting characteristics of new-onset afebrile seizures in infants (age 1–24 months) a prospective trial was conducted. It was found half of the infants had partial features to their seizures, yet evidence for primary generalized seizures was rare. The majority had more than 1 seizure upon presentation. Seizures in this age group tended to be brief, with 44% lasting less than 1 minute. EEG abnormalities were found in half. One-third of CTs were abnormal, with 9% of all CTs requiring acute medical management. Over half of MRIs were abnormal, with cerebral dysgenesis being the most common abnormality (p < 0.05). One-third of normal CTs had a subsequent abnormal MRI—only 1 resulted in altered medical management. Infantile seizures are usually brief, but commonly recurrent, and strong consideration should be made for inpatient observation. Acute imaging with CT can alter management in a small but important number of infants. Due to the superior yield, strong consideration for MRI should be given for all infants, as primary generalized seizures are rare, and there is a high rate of cerebral dysgenesis.
Strong Independent Correlation of Proteinuria With Cerebral Microbleeds in Patients With Stroke and Transient Ischemic Attack
To assess the association of proteinuria with the frequency and number of cerebral microbleeds (CMB), a harbinger of future hemorrhagic stroke, a cross sectional analysis was conducted.Of 236 patients, 72 (31%) had CMB present on gradient-echo imaging and 89 (38%) had evidence of proteinuria. In multivariable analyses with presence of CMB as the outcome, higher urinary protein, being female, history of atrial fibrillation , elevated serum homocysteine, and small-vessel disease subtype were all significantly associated with presence of CMB.
Cancer linked to Alzheimer disease but not vascular dementia
To investigate whether cancer is associated with Alzheimer disease (AD) and vascular dementia (VaD). A Cox proportional hazards models were used to test associations between prevalent dementia and risk of future cancer hospitalization, and associations between prevalent cancer and risk of subsequent dementia. It showed that in white older adults, prevalent Alzheimer disease (AD) was longitudinally associated with a reduced risk of cancer, and a history of cancer was associated with a reduced risk of AD. Together with other work showing associations between cancer and Parkinson disease, these findings suggest the possibility that cancer is linked to neurodegeneration.
