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Stead et al. found that patients with ischemic stroke and low blood pressure (diastolic BP < 70, systolic BP < 155, or MAP < 100 mm Hg) were significantly more likely to die within 90 days than those in the normotensive range (dBP 70 to 105, sPB 155 to 220, MAP 100 to 140 mm Hg), even after accounting for age, sex, and NIHSS.
see page 1179
Loss of hypocretin (orexin) and NARP in human narcolepsy
Blouin et al. report that neuronal activity-regulated pentraxin (NARP) colocalizes with hypocretin in the human hypothalamus and is reduced by 89% in narcolepsy, suggesting that narcolepsy results from the loss of hypocretin neurons and that the loss of NARP may contribute to its symptoms.
see page 1189
Orexin/hypocretin deficiency is associated with narcolepsy with cataplexy. Crocker et al. show that hypocretin-producing neurons contain dynorphin and NARP, and all three proteins are markedly reduced in the hypothalamus of patients with narcolepsy.
see page 1184
The editorial by Claudio Bassetti notes that over the last 5 years CSF hypocretin deficiency has been shown to be an accurate biologic marker of narcolepsy with a sensitivity and specificity 90%. Whether the loss of hypocretin is due to a loss of synthesis of hypocretin or from neuronal death has been unclear until these two articles appeared. They show that narcolepsy is characterized by a selective loss of hypothalamic hypocretin signaling, which is accompanied by a selective and parallel decrease in NARP and dynorphin transmission.
see page 1152
Increasing risk of MS in Catania
Nicoletti et al. updated the prevalence and incidence rates of MS in Catania, Italy, during 1990–1999. Prevalence rate was 90.2/100,000, while the mean annual incidence for 5-year intervals was 3.9/100,000 during 1990–1994 and 5.5/100,000 during 1995–1999, showing a further and significant increase during the last decade.
see page 1259
Sensory and autonomic symptoms in acquired neuromyotonia
Clinical descriptions of acquired neuromyotonia (Isaacs’ syndrome) emphasize motor phenomena. Herskovitz et al. describe three patients with prominent symptoms of sensory nerve hyperexcitability, creating diagnostic confusion with polyneuropathy or myelopathy. Gabapentin controlled symptoms in one patient.
see page 1330
Hyperhidrosis is common in neuromyotonia. Gómez-Choco describe a patient with neuromyotonia in whom episodes of hyperhidrosis occurred without concomitant motor symptoms.
see page 1331
Botulinum toxin A for trigeminal neuralgia
Piovesan et al. prospectively studied botulinum A neurotoxin in 13 patients with uncontrolled trigeminal neuralgia. Botulinum A neurotoxin reduced the intensity, frequency, and duration of trigeminal neuralgia paroxysms.
see page 1306
Patient safety data from malpractice claims
Glick et al. found that most harm to patients could have been prevented by improved communication among providers, better consultative follow-up and supervision, and critical review of initial diagnosis.
see page 1284
The editorial by Nora and Studwell notes that instances of medical malpractice commonly implicate faulty systems of care rather than individual physicians. Substantial gains in patient safety often result from making systems modifications. The Glick et al. analysis of legitimate claims reinforces that idea: medication errors and errors related to imaging studies were prominent and both categories can be influenced by systems change. Findings from cases of medical error have implications for medical education as well. In Glick et al., 17 of 24 claims involving preventable adverse outcomes were in part attributable to lapses in communication between practitioners. Glick et al. demonstrate that many malpractice claims are legitimate and prove the need for continued efforts to improve patient safety. Their recommendation that neurologists once involved should stay involved, despite the obvious tension created by time demands and reimbursement schemes, should be applauded and embraced.
see page 1154
Treatment delay and prolonged status epilepticus
Eriksson et al. analyzed factors contributing to the duration of a single convulsive seizure in children. A treatment delay of over 30 minutes was associated with status epilepticus.
see page 1316
Fruit and vegetable consumption and stroke
A meta-analysis of prospective studies, including 230,000 subjects, by Dauchet et al. examined the association between fruit and vegetable intake and stroke. The results showed that the risk of stroke decreased by 11% for each additional portion per day of fruit, suggesting that fruit consumption may prevent stroke.
see page 1193
There is a "Patient Page" on this topic: www.neurology.org.
Self-treatment for benign paroxysmal positional vertigo
The clinical trial by Tanimoto et al. showed that the Epley plus home treatment group had better results than the Epley alone group for benign paroxysmal positional vertigo of the posterior semicircular canal.
see page 1299
Rotational vertebral artery occlusion: Bow hunter’s syndrome
In a study of four patients with rotational vertebral artery syndrome (RVAS), Choi et al. showed that nystagmus was mostly downbeat, with the horizontal and torsional components beating toward the compressed vertebral artery side in three or directed away in one. Three patients showed spontaneous reversal of the nystagmus, and two exhibited no or markedly diminished responses on immediate retrial of head rotation (habituation).
see page 1287
The editorial by Brandt and Baloh notes that rotational vertebral artery occlusion (RVAO) carries a risk of stroke and can be treated by surgical depression. Precipitating horizontal head rotation compresses the dominant vertebral artery (opposite to the head rotation) and interrupts the major blood supply to the vertebrobasilar artery territory. The Choi et al. study of head-rotation-induced attacks of nystagmus/rotational vertigo documents a mixed clockwise torsional downbeat nystagmus with a horizontal component toward the compressed artery.
see page 1156
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