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New frontiers in epilepsy surgery

20 Oct, 14 | by Arun Krishnan, Web Editor

Epilepsy remains one of the most common and disabling neurological conditions. Even though there has been some progress in educating the public about epilepsy, patients with this condition suffer significantly, not just from seizures, but also from the social and psychological consequences of an illness that continues to remain a stigma in many parts of the world. There have been lots of new treatments for epilepsy, in the form of new drugs that target different brain pathways. Nevertheless, there has been little change in the outcomes for patients who do not benefit from drug treatments. This remains a fairly high proportion of patients, in the order of 20-40%. Surgery for epilepsy is an option for these patients and it can be a life-changing decision for some.

In the present issue of JNNP, Nowell and colleagues from London have presented a very well written state-of-the-art review that outlines the surgical options for patients with intractable epilepsy http://jnnp.bmj.com/content/85/11/1273.abstract . In addition to resection procedures, they also discuss the role of stereotactic radiosurgery and laser ablation as methods of removing the seizure focus. They also outline the importance of early referral to centres of excellence as an important step in the management of patients who fail to respond to drug treatment.

Expanding the antibody spectrum of limbic encephalitis!

17 Oct, 14 | by Steve Vucic, Web Editor

Limbic encephalitis (LE) mat have an underlying autoimmune etiologiy.  over the last decade numerous antibodies have emerged as potenital causative agents, and the antibodies have been directed against external epitopes of specific receptors.  In an upcoming issue of JNNP, Onugoren and colleagues reaffirm the association between GABAB and AMPR receptor antibodies and LE.  Importantly neoplastic causes need to be considered.

 

Read more at :  http://jnnp.bmj.com/content/early/2014/10/09/jnnp-2014-308814.full

 

Typical MRI changes in LE

Figure 2

Cholinesterase inhibitors in Parkinsons disease?

8 Oct, 14 | by Steve Vucic, Web Editor

Cholinesterase inhibitors (ChIs) improve cholinergic transmission and thereby may lead to improved cognitive function in PD, although the risk of side-effects such as falls may be potentially increased.  In an upcoming issue of JNNP (On line first)  Pagano and colleagues conducted a meta-analysis to further assess these issues.  The results show a clear improvement of cognitive function in PD, without an increase in risk of falls, although the risk of tremor and adverse drug reactions was increased.

 

 

Read more at:  http://jnnp.bmj.com/content/early/2014/09/15/jnnp-2014-308764.abstract

 

J Neurol Neurosurg Psychiatry doi:10.1136/jnnp-2014-308764
  • Movement disorders
  • Research paper

Cholinesterase inhibitors for Parkinson’s disease: a systematic review and meta-analysis

IVIg versus methylprednisone in CIDP: The treatment dilemmas!

8 Oct, 14 | by Steve Vucic, Web Editor

The long-term treatment of CIDP is a vexing one often mired in lack of data from randomized controlled trials.  The ICE study suggested that a maintenance IVIg dose of 1g/kg every 3 weeks is associated with good therapeutic outcome.  Subsequent studies have suggested that steroids may lead to remission in a greater proportion of patients, although the side-effects may be limiting.  The question remains about the longevity of therapy and at what point therapies in CIDP can be stopped.  In an upcoming issue of JNNP, Nobile-Orazio report on outcomes in CIDP patients in whom IVIg and steroid therapy were stopped.  Interestingly, while a similar proportion of patients tended to relapse in both treatment groups (IVIg vs steroids) the time to relapse was longer in the steroid group, supporting previous studies.  The question of harmful effects of steroids, however, remains!

 

Read more http://jnnp.bmj.com/content/early/2014/09/22/jnnp-2013-307515.abstract

 

J Neurol Neurosurg Psychiatry doi:10.1136/jnnp-2013-307515
  • Neuromuscular
  • Research paper

Frequency and time to relapse after discontinuing 6-month therapy with IVIg or pulsed methylprednisolone in CIDP

Tinnitus: don’t just “live with it”, let’s do something about it

7 Oct, 14 | by Arun Krishnan, Web Editor

Of the many conditions in medicine that are thrown into the ‘too hard basket’, tinnitus, that perception that there is constant noise in your ear even when there is no clear source, would have to be one of the most prevalent. I see a lot of GP referral letters that provide an electronically generated list of medical conditions that the patient has experienced since the day they first took breath on this earth, and on those occasions when I have enough left in the tank to sit down and read this long and all too frequently inaccurate list, I will often see a mention of tinnitus at some stage in the past. This is not entirely unexpected as it affects a significant proportion of the population. In my experience as a neurologist, I have never actually seen anyone receive any treatment for tinnitus and it is tempting to assume that there is simply nothing you can do about it.

In this issue of the journal, Minen and colleagues from Harvard have provided an outstanding review that explores management of tinnitus http://jnnp.bmj.com/content/85/10/1138.abstract . They have approached this condition from a neuropsychiatric perspective, highlighting the psychiatric disorders that often develop in patients who are forced to live with this condition. In addition to providing a through overview of the clinical features that may occur in this patient group, they provide sound advice on the various treatment possibilities, both pharmacological and non-pharmacological, that are available for patients with tinnitus.

Neurological disorders: bad to the bone.

1 Oct, 14 | by Arun Krishnan, Web Editor

It can be tempting to think of the brain, nervous system and the practice of neurology in general as existing in their own discrete compartment, separate from the rest of the body and from other facets of medicine. After all, there is a blood-brain barrier and a blood-nerve barrier and I can’t think of any other organ system that has such a well-developed system of insulation. Neurologists also like to separate themselves from the masses and this is readily achieved by throwing around names of anatomical structures that no one has ever heard about. The clinical reality however is quite different. We know that systemic diseases, such as diabetes, kidney failure and vascular disease all have the propensity to affect the nervous system but there is now increasing evidence that neurological illness can have significant impact on other organs, especially bone. Neurologists therefore need to now, more than ever, look at the patient as a whole.

There is significant evidence that epilepsy and multiple sclerosis are associated with osteoporosis and the current issue of JNNP has an interesting meta-analysis that explores the association of Parkinson’s Disease (PD) and osteoporosis http://jnnp.bmj.com/content/85/10/1159.abstract . The authors put forward a number of potential explanations, including vitamin D deficiency and also address the possible deleterious effects of levodopa, the most effective treatment for PD. Could it be that patients who are taking levodopa are more mobile and therefore at a greater risk of falls?

This review is timely, given that bone health is critical in elderly patients, particularly given the potentially fatal consequence of fractures in that group. These days we routinely assess patients taking anti-epileptic medications for changes in bone health. Should we be doing the same for our PD patients?

NMO versus MS: The debate of discriminators continues!

28 Sep, 14 | by Steve Vucic, Web Editor

Differentiating NMO from MS may be a difficult task.  Yet the distinction is crucial as treatment and prognosis vary.  In an upcoming issue of JNNP (On line first) an elegant review discusses potential clinical, CSF and radiological discriminators between NMO, NMO spectrum disorder and MS.
Read more at:
J Neurol Neurosurg Psychiatry doi:10.1136/jnnp-2014-308984
  • Multiple sclerosis
  • Review

Overlapping CNS inflammatory diseases: differentiating features of NMO and MS

Attention junior doctors: assessing delirium in hospital, it’s time to pay attention.

20 Sep, 14 | by Arun Krishnan, Web Editor

If you take a wander through your local hospital emergency department, you will generally not find any similarity to what you see on TV. It will not look like an episode of ‘ER’, with ambulances pulling up at breakneck speed and doctors yelling instructions in an attempt to save a life. Generally, the atmosphere is more sedate and if you look around there is one thing that becomes very clear-the general atmosphere of confusion. No, I am not talking about the medical staff but rather about the patients. Confused, delirious patients are very common in hospital and while diagnosing and treating delirium may not sound sexy, it is unbelievably important. There are lots of causes for delirium including medication side effects, infection and stroke but one of the most difficult things to do is to actually be able diagnose delirium effectively. Sounds easy, but it is far from it.

In this issue of JNNP, O’Regan and colleagues have undertaken an interesting study looking at simple ways of assessing delirium http://jnnp.bmj.com/content/85/10/1122.abstract . Their study shows that a simple test, naming the months of the year backwards, was a reliable way of diagnosing delirium. The screening tests were undertaken by junior medical doctors, who are the people that are generally faced with the initial assessment of delirious patients.

This is an interesting paper that has very clear and immediate clinical application.

Cortical atrophy progresses in MS

17 Sep, 14 | by Steve Vucic, Web Editor

Progression in MS has been associated with cortical atrophy.  Consequently, the holy grail of trying to prevent diability development in MS is to slow or even prevent the rate of cortical atrophy.  In this issue of JNNP, Zivadinovs groups elegantly demonstrate that cortical atrophy evolves over a 10 year period, being more pronounced in those patients developing disability.  This is an important study, especially when drug therapies are considered.

 

Read more at:  http://jnnp.bmj.com/content/85/10/1109.abstract

 

J Neurol Neurosurg Psychiatry 2014;85:1109-1115 doi:10.1136/jnnp-2013-306906
  • Multiple sclerosis
  • Research paper

Brain atrophy and disability progression in multiple sclerosis patients: a 10-year follow-up study

Editor's Choice

Interferons: The safety continues!

15 Sep, 14 | by Steve Vucic, Web Editor

In the new ear of MS drugs, safety has been an important consideration.  The risk of cancer in patients treated with IFNs has been raised, although never proven.  In this issue of JNNP, a large study from British Columbia categoricaly excludes the association of any cancers with MS.  Interestingly, there was a non-signifcant increase in the risk of breast cancer, most likely a chance occurence.

 

Must read more at:  http://jnnp.bmj.com/content/85/10/1096.abstract

 

J Neurol Neurosurg Psychiatry 2014;85:1096-1102 doi:10.1136/jnnp-2013-307238
  • Multiple sclerosis
  • Research paper

Assessment of cancer risk with β-interferon treatment for multiple sclerosis

Latest from JNNP

Latest from JNNP