Reviews & Analysis

An analysis of 12 different second-generation antidepressants rated sertraline and escitalopram as having the most favorable balance between benefit and harm for the treatment of major depressive disorder in adults. A second look at the methods and results from the study reveals that such a positive conclusion might not be warranted.

The triptan drugs provide effective migraine relief for many people. Nevertheless, a substantial number of migraine-affected individuals are unresponsive to triptans, and such therapy can also lead to an array of adverse effects. A new class of antimigraine drugs, currently undergoing clinical trials, could offer hope to those for whom triptan medication is unsuitable.

Parkinson disease is commonly recognized as a neurodegenerative disorder that leads to disabling motor and cognitive impairment, but less widely appreciated is the association of this condition with a variety of pain syndromes. A recent survey emphasizes the high prevalence and severity of pain in patients with Parkinson disease.

The need for early diagnosis of Alzheimer disease is gathering importance with the prospect of disease-modifying therapy. Medial temporal lobe atrophy on MRI is a characteristic, early and predictive feature of the disease. A new visual rating system has been proposed to facilitate assessment of such atrophy in routine clinical practice.

Sips and colleagues describe the onset of intravascular lymphomatosis (IVL) of the brain in a 77-year-old retired research pharmacologist with a history of anemia, pancytopenia, and a recently confirmed diagnosis of myelodysplastic syndrome (MDS). The authors discuss the mechanisms of IVL and MDS and possible relationships between the conditions, as well as a beneficial effect of treatment of IVL with high-dose combination chemotherapy and rituximab

Multiple sclerosis is traditionally considered to be an inflammatory disease, but it also has a neurodegenerative component, which can manifest early in the disease course. New therapeutic strategies are being developed to elicit CNS neuroprotection and repair in patients with multiple sclerosis, and Barkhof et al. review the available data on imaging outcome measures that could be used to track the efficacy of these approaches.

Agitation and aggression are common symptoms of Alzheimer disease (AD), causing risk and distress to the patient and others. Atypical antipsychotics are the most widely prescribed pharmacological treatments for these symptoms, but they can cause harmful effects. Here, Clive Ballard and colleagues review the risks associated with atypical antipsychotics and present the many alternative treatments and approaches that are available for managing agitation and aggression in AD.

The hereditary optic neuropathies, which include dominant optic atrophy, Leber hereditary optic neuropathy and certain types of glaucoma, result in characteristic changes in the morphology of the optic nerve head and the surrounding retinal nerve fiber layer. In this article, O'Neill et al. review the currently available retinal imaging technologies and describe the typical morphological features of the optic nerve head in various hereditary optic neuropathies.

Impaired consciousness is a hallmark of epileptic seizures, but the degree of impairment differs depending on the seizure type. Here, Andrea Cavanna and Francesco Monaco review recent insights into the brain mechanisms that underlie alterations of consciousness during epileptic seizures and argue that clinical assessment should take into account both patients' levels of awareness and their subjective contents of consciousness.

MRI provides a very sensitive reflection of the histopathological changes in multiple sclerosis. Many short-term studies fail to appreciate the relationship between MRI and clinical findings, although such shortcomings might be argued to reflect a weakness of clinical measures, rather than of MRI.

The use of repeated microcatheter injections during intra-arterial procedures to treat acute stroke is associated with an increased risk of intracranial hemorrhage. The number of such injections performed should, therefore, be minimized.

Distinguishing between a first episode of multiple sclerosis and acute disseminated encephalomyelitis in children who present with an initial demyelinating event can be a clinical challenge. New brain MRI criteria that aim to differentiate these clinical presentations, and revised McDonald MRI criteria specific for the pediatric population, are both worthy of note.

Differences in the frequencies of physician and emergency-room visits and hospitalizations across socioeconomic and ethnic groups may lead to poor health outcomes in disadvantaged populations. Analyzing the causes and implementing interventions to redress such disparities is a high priority in the US, but neurology lags behind other clinical specialties in this research.

Human prion diseases are sometimes difficult to diagnose because few clinical features distinguish them reliably from other neurological disorders. A new study suggests that analysis of movement disorders might contribute to the clinical differentiation of sporadic Creutzfeldt–Jakob disease from Alzheimer disease and dementia with Lewy bodies.

Malaria is a serious public health problem in the developing world, and is also being seen increasingly in Western countries as a result of travel and immigration. Malaria is associated with a number of neurological complications, including agitation, psychosis, seizures, impaired consciousness and coma. In this article, Mishra and Newton describe these complications, discuss the underlying pathogenesis, and outline current and future management strategies.

Delirium is an acute neuropsychiatric syndrome, the core features of which are inattention and global cognitive dysfunction. Fong and Inouye review current clinical practice in delirium in elderly individuals, including diagnosis, treatment and outcomes. They also consider the profound impact of this syndrome on health-care utilization and costs.

Friedreich ataxia (FRDA) is the most common of the inherited ataxias, with an estimated prevalence of 3–4 cases per 100,000 individuals. There are, as yet, no robust evidence-based standards of care for FRDA. This Review article pools the expertise of FRDA specialists across Western Europe to formulate a set of guidelines for the diagnosis and treatment of this debilitating condition.

The application of neuroimaging to headache has greatly enhanced our understanding of the pathophysiology of this syndrome. Here, Arne May describes neuroimaging as a diagnostic tool for headache and highlights the advances made with functional and structural neuroimaging in the study of primary headache syndromes such as migraine and trigeminal autonomic headaches.

The use of intravenous recombinant tissue plasminogen activator to treat acute ischemic stroke has been limited by the need to administer the treatment within 3 hours of symptom onset, although recent findings indicate that this therapeutic window can be extended to 4.5 hours. In this Viewpoint, Maulaz et al. argue that the safety and efficacy of thrombolysis might be further improved by narrowing the selection criteria for this therapy.

Biebl et al. describe the case of a 12-year-old boy who presented with fever, malaise and fatigue, and was diagnosed with Epstein–Barr virus (EBV) encephalitis when his cerebrospinal fluid tested positive for EBV. Despite intensive care and antiviral treatment, the patient died 1 month after the initial presentation. The authors suggest that EBV encephalitis should be considered in the differential diagnosis when a young patient presents with acute neurological illness of uncertain etiology.