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Silberstein, writing for the US Headache Consortium (p. 745) in an AAN-approved report, summarizes five lengthy papers on the diagnosis and treatment of migraine HA. These papers were published in the April 25, 2000 issue of Neurology online (www.neurology.org; AAN Headache Guideline Information) and, like all such AAN papers, are available to the public.
Morbidity and mortality of carotid endarterectomy (CE)
Two papers and an accompanying Editorial consider carotid artery surgery for stenosis. Chauturvedi et al. (p. 769) prospectively followed a series of 44 patients referred for CE (70% symptomatic, 30% asymptomatic). The 30-day mortality rate was 4.5%; the 30-day stroke/death rate was 11.4%. The authors emphasize that the risk/benefit ratios found in large clinical trials need to be reassessed at individual hospitals.
O’Neill et al. (p. 773) used multivariable analysis of a large database from 254 Pennsylvania hospitals to study the characteristics of surgeons operating on carotid stenosis versus the morbidity and mortality of CE. They confirmed previous early observations that those surgeons who did CE very infrequently had worse outcomes. Interestingly, "years since licensure" and "specialty other-than-neurosurgery" were associated with worse outcomes.
The Barnett and Broderick Editorial summarizes the conclusion of papers on carotid artery surgery, notes the continuing debates on the best way to visualize carotid disease, and points out that these two Neurology papers (as well as other literature) make it mandatory that: 1) carotid surgery be performed for proven indications in patients for whom benefit has been established; and 2) independant audits be obtained for the patient outcomes of surgeons at each institution.
Diffusion-weighted imaging (DWI) and MR perfusion imaging (MRPI) in stroke
A major challenge for thrombolytic therapy of acute stroke is to devise a way to determine whether neurologic signs reflect reversible injury as opposed to irreversible infarction of brain tissue. Studying 40 patients with acute stroke, Hillis et al. (p. 782) compared DWI and MRPI and showed that the deficits of patients (aphasia and neglect) correlated better with hyperfused tissue volume (MRPI) than with a DWI lesion volume. Thus, they found evidence that the mismatch between MRPI and MRI indicated regions of potentially salvageable brain tissue.
Hallucinations and dyskinesias in PD: Olanzapine versus clozapine
Two papers and an Editorial consider these vexing issues. The Goetz et al. (p. 789) controlled trial compared the two drugs for hallucinations. The trial was terminated because olanzapine worsened gait and bradykinesia. Moreover, clozapine improved hallucinations and overall behavior whereas olanzapine did not.
The Manson et al. controlled trial (p. 795) studied the effect of olanzapine on dyskinesias. While it reduced dyskinesias, it worsened parkinsonism.
The accompanying Editorial by Richard and Nutt (p. 748) reviews the current treatment of hallucinations and dyskinesias, concluding that clozapine– despite its risks of agranulocytosis–remains the best treatment.
Parkinsonism in SCA-2
Gwinn-Hardy et al. (p. 800) report a large Chinese kindred with an SCA-2 mutation in which those affected had characteristic parkinsonism, including L-dopa responsivity. The disorder could also produce a PSP phenotype.
Acetyl-L-Carnitine (ALCAR) in AD
Thal et al. (p. 805) report that ALCAR had no benefit on the primary outcome variables in a randomized trial: ADAS-Cog and CDR scales. Because patients completing the course of ALCAR showed benefit to a secondary outcome variable (the MMSE), they concluded that ALCAR may deserve further study in combination with a cholinesterase inhibitor.
Oral contraceptives and MS incidence
Hernán et al. (p. 848), using the 121,700 women 18-year and the 116,671 women 8-year follow-up Nurse’s Healthy Study data, found that neither oral contraceptive use nor parity were associated with an increased or decreased risk of MS.
Longitudinal study of estrogen replacement therapy following surgical menopause
Verghese et al. (p. 872) identified 35 women with surgical menopause. Those treated with estrogen had better preserved verbal memory and constructional ability than those who did not.
Information on end-of-life care in neurology texts
Rabow et al. (p. 893) surveyed leading textbooks in a number of specialties. Neurology fared poorly in terms of coverage (however, all do cover end-of-life care in their current or in-press revisions).
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