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May 25 Highlights

Organizing their review around a scene from the 1939 movie "The Wizard of Oz," Shaner et al. offer a model procedure for communicating the diagnosis of death by neurologic criteria. An unequivocal, straightforward approach provides a message better understood by family and staff. Confusion and inconsistent decision-making is reduced with adherence to policy.

see page 1683

Daily opioid therapy for intractable headache: Long-term observations

Saper et al. studied treatment response, compliance, and other variables in 160 patients placed on daily opioid therapy for intractable head pain. They found that only a quarter of the patients showed sustained improvement over 3 to 5 years; many of these failed to improve in functional activity or non-opioid medication reduction. Medication noncompliance/misuse was identified in up to 50% of patients, despite intense supervision of treatment.

see page 1687

Narcotic overuse for acute migraine headache treatment

Narcotics are not considered first line therapy for migraine headache. The Colman et al. study of five linked Emergency Departments in one Canadian region suggests that initial treatment with narcotics remains common (60%); however, practice variation is considerable (site ranges: 35 to 78%). Factors associated with narcotic use are predictable and suggest that a concerted effort to replace their use is indicated.

see page 1695

Opioid therapy and headache: A cause and a cure

The editorial accompanying these two articles by Richard B. Lipton and Marcelo E. Bigal notes that the role of opioids in headache treatment is complex because of the closely related issues of medication overuse headache and transformed migraine—opioids are a risk factor for medication overuse headache and transformed migraine. Taken together, the Colman et al. and Saper et al. studies support a diminished role for opioids as an acute treatment of migraine and cautious expansion of their use in the long-term preventive treatment of otherwise intractable headache. Given the availability of better treatment options (triptans, dihydroergotamine, neuroleptics, or nonsteroidal anti-inflammatory agents) it is surprising that nearly 60% of migraine sufferers presenting to the Emergency Departments of five Canadian hospitals received narcotics as their first treatment.

see page 1662

Improved developmental outcomes after hemispherectomy

(A) Enlarged right vs left cerebral hemisphere. (B) Cortical dysplasia consisting of polymicrogyria (arrow). (C) Signal change in the motor-sensory region on the right (arrows) and Rasmussen’s encephalitis by pathology. (D) Early onset left hemiparesis after a large infarct.

Jonas et al. evaluated outcomes on 115 cerebral hemispherectomy patients. Better postsurgery Vineland developmental quotients were associated with <2-year seizure durations. In addition, children with cortical dysplasia (but not hemimegalencephaly) had similar outcomes as Rasmussen encephalitis and infarct cases. Therefore, seizure and developmental outcomes post-hemispherectomy depend on early surgery, seizure control, and pathologic substrate.

see page 1712

The accompanying editorial by Michael Duchowny traces the history of hemispherectomy from its first introduction by Dandy in 1928 through the successive refinements of technique which have made it an important treatment modality for uncontrolled epilepsy. He notes that the Jonas et al. experience is the largest reported and that they make major strides in defining the criteria that may soon make hemispherectomy an early as opposed to a last resort treatment for medication-refractory epilepsy.

see page 1664

Cognition in temporal lobe epilepsy

A cross-sectional study by Oyegbile et al. reports that chronic temporal lobe epilepsy is associated with widespread cognitive dysfunction, cognitive morbidity being worse in those with more years of epilepsy. Individuals with less educational attainment exhibit especially poor cognitive function associated with chronicity of epilepsy.

see page 1736

Elevated alpha-synuclein marks Parkinson disease in rare family

In this expedited Brief Communication, Miller et al. report a doubling in -synuclein protein in the blood of patients with an -synuclein gene triplication and accumulation of insoluble, aggregated -synuclein in brain. This suggests that -synuclein aggregation and deposition are important in the cause of PD.

see page 1835

Intravenous r-TPA in vertebrobasilar ischemia

The observational study by Montavont et al. reports 18 patients with vertebrobasilar ischemia who were treated by IV r-TPA after a mean delay 5 ± 3.6 hours (baseline NIHSS score 17 ± 4). At 3 months, 10 patients were independent.

see page 1854

L-2 hydroxyglutaric aciduria (L-2-OPHGA) and brain tumors

A large tumor right temporal region.

Moroni et al. reported the occurrence of brain malignancy in four patients with L-2-OHGA. Their observation suggests the need for close clinical and imaging follow-up in patients with this disease.

see page 1882

This Article Full Text (PDF) Correspondence: Submit a response Alert me when this article is cited Alert me when Correspondence are posted Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via Google Scholar Google Scholar Search for Related Content