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October 10 Highlights

Two papers and an editorial consider new evidence that abnormal regulation of cell death could disturb the function of T cells and play a key role in the immunopathogenesis of MS. Comi et al. (p. 921) studied MS patient T cells to show that Fas—a member of the tumor necrosis factor receptor family—did not induce appropriate cell death in MS patient T cells.

Huang et al. (p. 928) also studied MS patient T cells and showed an upregulation of Fas and TRAIL in patients versus controls.

The accompanying editorial by Segal and Cross (p. 906) reviews how these complementary papers on the regulation of cell death may explain MS disease exacerbations and remissions.

MS: Fatigue and cognitive function

Krupp and Elkins (p. 934) compared 14 controls (normal subjects) with 45 MS patients as to their change in cognitive performance during a lengthy (4-hour) session of neuropsychological testing. Remarkably, MS patients worsened during testing in verbal memory and conceptual planning, whereas normal subjects’ performance improved.

Amyloid angiopathy (AA) and warfarin-induced cerebral hemorrhage?

Rosand et al. (p. 947) used APOE genotype as a surrogate marker for AA to study 42 patients who developed cerebral hemorrhage while on warfarin (76% occurred at a therapeutic international normalized ratio [INR]). They found an overrepresentation of the APOE 2 allele. They also showed that in seven out of 11 patients with tissue available for study, there was histopathologic evidence of AA.

The accompanying editorial by Hart (p. 907) reviews the extent to which amyloid or other risk factors are responsible for cerebral hemorrhage in patients on warfarin whose INR values are in the therapeutic range. He notes that it may soon be possible to develop a strategy to prevent anticoagulation of patients at high risk of bleeding.

NIH Stroke Scale (NIHSS) predictors of prognosis after stroke

Data from the National Institute of Neurological Disorders and Stroke rt-PA Stroke Trial placebo group were analyzed by Frankel et al. (p. 952) to develop predictors of poor prognosis using the NIHSS. An initial NIHSS >17 in patients with atrial fibrillation, or at 24 hours an NIHSS >22, predicted moderate to severe disability or death.

Stroke with arteriovenous malformations (AVMs) in hereditary hemorrhagic telangiectasis (HHT)

Neurologic complications are frequent in HHT, particularly seizures and cerebral hemorrhage. Moussouttas et al. (p. 959) report a remarkably high incidence of cerebral infarction in HHT—32% of HHT patients with single AVMs and 60% with multiple AVMs. They postulate that paradoxical embolization was the cause.

NMDA glutamate receptor antagonists in facial neuralgia

Gilron et al. (p. 964) showed that high-dose dextromethorphan was not of benefit for anesthesia dolorosa or possible trigeminal neuralgia. Dextromethorphan has shown some benefit in other forms of neuropathic pain. The authors reason why the NMDA antagonist might be beneficial, and why its limited entry into the CNS may preclude benefit.

Imagining movement: PET localization in PD vs normal subjects

Thobois et al. (p. 996) found that normal subjects imagining unilateral hand movements bilaterally activate the supplementary motor area, superior parietal lobe, inferior frontal gyrus, and cerebellum, but activate the contralateral primary motor cortex only with the right dominant hand. PD patients had major abnormalities in cortical activation.

AD caregivers: How much risk will they accept for a moderate benefit of treatment?

Karlawish et al. (p. 1008) examined caregivers’ preferences for a medication that slows the progression of AD, with the benefits of increased survival and delay in nursing home placement, versus side effects of varying severity. AD caregivers were very willing to tolerate the risk of side effects if AD could be slowed.

Mesial temporal sclerosis in nonepileptic seizures

Patients with psychogenic nonepileptic seizures (PNES) can have coexisting epilepsy, but most do not. Benbadis et al. (p. 1061) report four patients with only PNES who had MRI evidence of mesial temporal sclerosis, which would have suggested a diagnosis of epilepsy to the unwary.

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