News & Views in 2011

Despite probable higher rates of recanalization with endovascular therapies, limited evidence exists to support the clinical benefits in patients with stroke who are unresponsive to standard intravenous reperfusion. A new study supports combined intravenous-intra-arterial treatment in a subset of acute stroke patients, and recognizes the need for definitive randomized trials.

A recently published case report describes the use of epidural spinal cord stimulation to treat a patient with a complete cervical spinal cord injury. Clear improvements in facilitated standing and stepping were demonstrated, as well as some conscious control of movement.

Cladribine, an oral immunomodulatory drug, has been denied FDA and European Medicines Agency approval for the treatment of relapsing–remitting multiple sclerosis. However, a new post-hoc analysis of CLARITY study data shows that cladribine treatment is associated with a significantly increased likelihood of sustained freedom from disease activity.

Disease-modifying therapies can positively influence the progression of multiple sclerosis, but how many patients continue to take their medications? A new study shows that the majority of patients with multiple sclerosis stop treatment. Research should focus on ways to improve adherence to disease-modifying therapies.

The clinical presentation of Guillain–Barré syndrome (GBS) is heterogeneous and, despite effective treatments, some patients die or sustain severe disabilities. An improved clinical prognostic score for GBS facilitates early identification of patients expected to have poor outcomes. These individuals might benefit from modified treatment or participation in therapeutic trials.

Accumulating evidence suggests that prestroke statin therapy could improve functional recovery following acute ischemic stroke. A recent meta-analysis of previous findings and a new study support this suggestion. These findings should, however, be interpreted with caution owing to possible publication bias favoring small studies with positive results.

John W. Griffin, internationally renowned expert on peripheral nerve disorders, founding Director of the Johns Hopkins Brain Science Institute and launch Editor-in-Chief of Nature Reviews Neurology, died on 16^th April 2011. He will be remembered for his leadership in academic medicine, strong advocacy for young neurologists, and many original research contributions.

Increased blood pressure is associated with poor outcomes in acute stroke, but studies assessing the use of antihypertensive agents have been inconclusive. The recent SCAST trial has found that the angiotensin receptor blocker candesartan does not benefit patients with acute stroke and elevated blood pressure, and might even be harmful.

Consistent with previous findings, two recent studies of temporal lobectomy from Kerala, India demonstrate that early seizure recurrence bodes poorly for long-term seizure control, and that relapse following drug discontinuation affects one-third of patients. Key questions in the field now concern advanced preoperative and intraoperative techniques for improving surgical outcomes.

Human leukocyte antigen (HLA) screening could identify patients at risk of adverse reactions to carbamazepine, one of the most commonly used anticonvulsants. A European genome-wide association study revealed strong correlations between HLA-A^*3101 and carbamazepine hypersensitivity. In Taiwan, HLA-B^*1502 screening led to significant reductions in the incidence of carbamazepine-induced adverse events.

Advances in the clinical and genetic understanding of Rett syndrome have meant that existing diagnostic guidelines for this neurodevelopmental disorder need to be revisited. New clinical criteria for the diagnosis of Rett syndrome by Neul and colleagues are welcome, but should more prominence be given to molecular diagnosis?

Charcot–Marie–Tooth disease (CMT) is a hereditary neuropathy attributed to mutations in more than 30 different genes. A recent study identified the causative mutation in 67% of 787 screened patients with CMT, and the findings raise important issues concerning genetic testing for CMT.

A new survey of British neurologists shows that no commonly accepted model exists for the diagnosis of conversion disorder. Instead, the results indicate that the neurologist's diagnosis is influenced largely by their communication with the patients.

Biomarker development is important to the therapeutic imperative for neurodegenerative diseases, as biomarkers hold transformative promise for the design and conduct of clinical trials and, ultimately, for medical management of these diseases. Some of this promise is now being realized in Alzheimer disease, and progress in Parkinson disease is accelerating.

The American Academy of Neurology has updated its 1996 assessment of the value of plasma exchange in neurology. The report confirms the efficacy of plasma exchange in inflammatory neuropathy and possibly acute CNS demyelinating disease, but not in pediatric autoimmune neuropsychiatric disorders. Its conclusions, however, are limited by inadequate evidence.

New research shows that a substantial proportion of patients with acute disseminated encephalomyelitis have serum antibodies against myelin oligodendrocyte glycoprotein. The relationship between these antibodies and other demyelinating disorders such as multiple sclerosis, however, remains unclear.

A recent study has combined clinical, laboratory and imaging parameters, all acquired within 48 h of clinical onset of middle cerebral artery territory stroke, in the same logistic regression model to predict 1-month functional outcome. A composite set of five independent items was found to be associated with good outcome.

Recent revisions to the diagnostic criteria for multiple sclerosis have simplified MRI definitions for dissemination of CNS lesions in space and time, and may enable an earlier and easier diagnosis of the disease. The validity of this approach needs to be assessed in real-world clinical practice.

Various clinical scores are available to assess the outcome of chronic inflammatory demyelinating polyneuropathy (CIDP), but these existing scales have some major limitations. A novel, simple scoring system—the CIDP disease activity status—incorporates the concept of disease activity as a feature that informs the long-term outcome in CIDP patients.

Quality of care for patients with epilepsy can be variable. The American Academy of Neurology has recently published measures to guide physicians during treatment of epilepsy patients. Are these considerations enough to provide optimal care?