News & Views in 2009

Despite growing interest in both the clinical and scientific aspects of sudden unexpected death in epilepsy (SUDEP), knowledge about the disease mechanisms remains limited. The epileptic baboon—the first natural nonhuman primate model of SUDEP—offers a potential model to evaluate the genetic factors and pathophysiology underlying this mysterious condition.

Prospective research participants, patients and consumers are faced with a cacophony of information about the risks and benefits of brain scans. In light of new data on incidental findings, the professional community has a duty to explicitly and systematically encourage questions that promote rational decision-making and informed choice.

Radiotherapy is administered to most patients with low-grade glioma. A well-designed, retrospective study assessed neurocognitive function in patients who had received radiotherapy for low-grade gliomas versus those who had not. Cognitive function did not differ markedly between groups after 6 years, but by 12 years this feature was worse in the group that received radiotherapy.

The International Classification of Headache Disorders II has undergone several revisions in attempts to meet the challenges of accurately diagnosing medication overuse headache and chronic migraine. Newly proposed revisions to the classification are likely to make diagnoses of all secondary headaches more straightforward than before.

Neurons that seem to be specifically involved in relaying pruritogenic sensory information to the brain have been identified in lamina I of the spinal cord. Are these neurons part of the long sought-after neural pathway for itch? The answer to this question could be important for the development of antipruritogenic drugs.

Collateral circulation is a potent predictor of revascularization and clinical outcomes after acute ischemic stroke, and various features of collateral flow may be seen with a variety of neuroimaging techniques. Maas et al. investigated assessment of collaterals on CT angiography source images as a predictive tool in ischemic stroke.

Continuous EEG monitoring in intensive care units seems to affect physicians' decisions regarding prescription of anticonvulsant drugs. We are just beginning to understand what the EEG patterns mean and to learn whether and when these prescribing changes matter.

Biomarkers are generally used as diagnostic and prognostic tools in clinical practice, but are not yet available for neuropathies. Studies now suggest that neural protein levels in serum and cerebrospinal fluid reflect axonal damage and predict poor outcome in patients with immune-mediated neuropathy, although validation studies are needed to define their clinical relevance.

A new device, comprising a catheter and wire combination that aspirates clot from an occluded vessel, has received FDA approval for the treatment of stroke. Although the device accomplishes the removal of clot at a higher rate than usual, improvement in patient outcomes remains elusive.

The incidence of cerebral microbleeds, which are acknowledged to be markers of hypertensive vasculopathy and cerebral amyloid angiopathy, increases with age. Cerebral microbleeds are particularly prevalent in patients with intracerebral hemorrhage, and a population-based, cross-sectional study indicates that they are also positively associated with antiplatelet drug use.

Generic drug substitution can markedly decrease the cost of health care. For conditions where agents have a relatively narrow therapeutic index, notably epilepsy, financial savings through generic substitution might be offset by increases in patient complications and related costs. Results from a study with topiramate support this view, particularly when a patient receives a drug from multiple manufacturers.

Data from a large multicenter study demonstrate that donepezil can delay the rate of progression from mild cognitive impairment to Alzheimer disease in patients with depressive symptoms, but not in individuals without notable depression. How important are these findings for clinical practice in neurology and psychiatry?

A survey conducted in Canada examined the prevalence of perceived genetic discrimination against patients with Huntington disease. The respondents reported discrimination not only by insurance or mortgage companies, but also in family and social contexts. Discrimination was more frequently attributed to family history than to genetic test results.

The management of acute migraine in the emergency department presents a therapeutic challenge for physicians, who need to provide adequate pain relief while minimizing adverse events and relapses. New research suggests that phenothiazines are effective drug therapies for acute migraine, highlighting their potential use as first-line treatments for acute migraine in the hospital setting.

Clinical trials aimed at preventing hematoma expansion in patients with intraparenchymal hemorrhage have failed to show benefit from experimental intervention. Novel methods for identifying those patients at the highest risk of hemorrhage growth might enable better patient selection and, hence, increase the chance of demonstrating an improvement in clinical outcome.

A genome-wide association study has identified the R92Q variant of the TNFRSF1A gene as a new susceptibility locus for multiple sclerosis. This locus is of special interest because the R92Q substitution was previously detected in a group of multiple sclerosis patients who had additional symptoms compatible with the autoinflammatory syndrome TRAPS.

Nonmotor symptoms are assuming an increasingly important place in the constellation of clinical traits that characterize Parkinson disease. A multicenter survey of patients with Parkinson disease highlights the prevalence of these symptoms. The findings indicate that further research into the pathophysiology and treatment of nonmotor symptoms is warranted.

Thrombolytic therapy is often used to treat arterial ischemic stroke in children, despite lack of FDA approval in this age group. The International Pediatric Stroke Study investigators have assessed the extent and nature of recombinant tissue plasminogen activator use in children in their registry, and have compared their findings with previously published case reports.

The ABCD system uses clinical features identifiable in primary or emergency care to reliably predict the risk of stroke in the acute phase following a transient ischemic attack. Further study is required to establish both the effectiveness of a refined system that includes carotid and brain imaging, and how such a refined system should be implemented in clinical practice.

Estimates of the incidence of cognitive dysfunction following ischemic stroke vary considerably in the medical literature. New research suggests that cognitive dysfunction might occur more frequently than was previously thought, emphasizing the importance of assessing such dysfunction beyond the standard deficits measured on most stroke severity scales.