February 14 Highlights

No secondary stroke prevention age bias in the very elderly

Ovbiagele et al. evaluated patterns of drug prescription for cardiovascular prevention in the very elderly (≥80 years) vs their younger counterparts after hospitalization for an ischemic cerebrovascular event, and found no differences between both age groups in overall optimal combination treatment rates.

See page 313

Antiplatelet use before stroke may improve outcome

Sanossian et al. found that patients without a history of stroke or TIA who were taking antiplatelet agents at the time of ischemic stroke presented with less severe strokes. All antiplatelet users were twice as likely to be discharged without disability.

see page 319

DCA causes toxic neuropathy in MELAS: A randomized, controlled clinical trial

Kaufmann et al. found that dichloroacetate (DCA), a lactate-lowering drug, causes peripheral neuropathy in mitochondrial encephalomyopathy, lactic acidosis and stroke-like episodes (MELAS). DCA has been used as a treatment for MELAS, but this randomized trial shows that any possible benefit is overshadowed by peripheral neurotoxicity.

see page 324

The editorial by Andrew M. Schaefer notes that the Kaufmann et al. study demonstrates that it is possible to approach this uncommon and clinically heterogenous disorder in a scientific and statistically sound manner. While their study clearly highlights the pitfalls of DCA usage in patients with MELAS, it also has an impact in the broader setting of evidence-based medicine. Citing a recent Cochrane review that assesses the current evidence base for treatments in mtDNA disease, there is currently no evidence to support or refute any of the available therapies for mtDNA disease. Moreover, only six studies met inclusion criteria for Cochrane review. The Global Assessment of Treatment Efficacy (GATE) used in the study usefully considers not only clinical manifestations (Columbian score) but also the functional consequences of disability (Karnofsky score), neuropsychological domains, and health-related events inquiry. The GATE score requires formal validation.

see page 302

Posterior cortical atrophy (PCA) and the dorsal stream

McMonagle et al. report the clinical characteristics of 19 patients with PCA using a novel psychometric assessment (OFCAS) and compare them with typical Alzheimer disease (AD). Alexia and agraphia predominated. Compound letters and complex picture descriptions reliably detected simultanagnosia defining PCA as mainly a dorsal stream syndrome distinct from typical AD.

see page 331

The editorial by Tang-Wai and Mapstone notes that this study reveals a remarkable consistency of clinical signs and symptoms reflecting disruption of posterior cortical areas. Although Balint syndrome was found in only five cases and Gerstmann syndrome in three, one or more individual elements of these syndromes were found in all but one patient. The long-term data of this cohort indicate that PCA is a clinical syndrome with more than one pathology including dementia with Lewy bodies, corticobasal degeneration, and prion disease.

see page 300

CSF in West Nile virus meningitis and encephalitis

Tyler et al. studied CSF from 250 patients with WNV meningitis and encephalitis. Over 95% of patients had a pleocytosis (mean 225 cells/mm³) and >40% had neutrophilia. Over 90% had elevated protein but only one patient had a glucose <40 mg/dL. Pleocytosis and protein concentration were negative prognostic factors, but less important than patient age in predicting outcome.

see page 361

Myelination of language areas in the developing brain

Pujol et al. analyzed the course of myelination in the lateral part of the verbal left hemisphere from birth to 3 years using MRI. A movie sequence displayed the anatomic details of myelination progression and a performance analysis illustrated its relationship to children’s vocabulary acquisition.

see page 339

The editorial by Aslin and Schlaggar notes that myelination is suspiciously coincident with the timing of early language/cognitive development and this study provides a novel, detailed quantitative assessment of the time course of myelination in the lateral-perisylvian region of each hemisphere between birth and 39 months postnatally. Their findings show a clear difference between the rates of myelination for language regions compared to the control region. The 50th percentile of myelination was achieved by 6 months of age for the control region, but not until 18 months of age for both the anterior and posterior language regions.

see page 304

Oral contraceptives and increased headache prevalence

In a cross-sectional study among 13,944 menstruating women using estrogen-containing oral contraceptives, Aegidius et al. found a significant association between both migraines and non-migrainous headaches. There was no association to oral contraceptives only containing gestagens.

see page 349

Seizure control and treatment in pregnancy

Out of 1,736 prospective pregnancies of women with epilepsy analyzed by The EURAP Study Group, 58% remained seizure free throughout their pregnancy. Status epilepticus occurred in 36 pregnancies resulting in stillbirth in only one case.

see page 354

Migraine in families

Little is known about the characteristics of migraine probands that predict family aggregation of migraine. Stewart et al. directly interviewed 532 first-degree relatives of migraine sufferers identified from the general population. Migraine probands with early age at onset and severe pain have higher levels of migraine family aggregation.

Figure. Prevalence of migraine in first-degree relatives vs status of the proband.

see page 344

Silent microbleeds and volume of intracerebral hemorrhage

The Lee et al. radiologic study of the correlation between microbleeds and volume of intracerebral hemorrhage found that lobar or putaminal hemorrhage volumes were larger in the patients with microbleeds.

see page 430

Two albendazole doses compared in cysticercosis

Góngora-Rivera et al. evaluated albendazole at 15 vs 30 mg/kg/day in patients with subarachnoid and intraventricular cysticercosis. Results favored high dose treatment, but a single treatment was inadequate for giant and intraventricular cysts.

see page 436