Reviews & Analysis

Impaired consciousness is a hallmark of epileptic seizures, but the degree of impairment differs depending on the seizure type. Here, Andrea Cavanna and Francesco Monaco review recent insights into the brain mechanisms that underlie alterations of consciousness during epileptic seizures and argue that clinical assessment should take into account both patients' levels of awareness and their subjective contents of consciousness.

MRI provides a very sensitive reflection of the histopathological changes in multiple sclerosis. Many short-term studies fail to appreciate the relationship between MRI and clinical findings, although such shortcomings might be argued to reflect a weakness of clinical measures, rather than of MRI.

The use of repeated microcatheter injections during intra-arterial procedures to treat acute stroke is associated with an increased risk of intracranial hemorrhage. The number of such injections performed should, therefore, be minimized.

Distinguishing between a first episode of multiple sclerosis and acute disseminated encephalomyelitis in children who present with an initial demyelinating event can be a clinical challenge. New brain MRI criteria that aim to differentiate these clinical presentations, and revised McDonald MRI criteria specific for the pediatric population, are both worthy of note.

Differences in the frequencies of physician and emergency-room visits and hospitalizations across socioeconomic and ethnic groups may lead to poor health outcomes in disadvantaged populations. Analyzing the causes and implementing interventions to redress such disparities is a high priority in the US, but neurology lags behind other clinical specialties in this research.

Human prion diseases are sometimes difficult to diagnose because few clinical features distinguish them reliably from other neurological disorders. A new study suggests that analysis of movement disorders might contribute to the clinical differentiation of sporadic Creutzfeldt–Jakob disease from Alzheimer disease and dementia with Lewy bodies.

Malaria is a serious public health problem in the developing world, and is also being seen increasingly in Western countries as a result of travel and immigration. Malaria is associated with a number of neurological complications, including agitation, psychosis, seizures, impaired consciousness and coma. In this article, Mishra and Newton describe these complications, discuss the underlying pathogenesis, and outline current and future management strategies.

Delirium is an acute neuropsychiatric syndrome, the core features of which are inattention and global cognitive dysfunction. Fong and Inouye review current clinical practice in delirium in elderly individuals, including diagnosis, treatment and outcomes. They also consider the profound impact of this syndrome on health-care utilization and costs.

Friedreich ataxia (FRDA) is the most common of the inherited ataxias, with an estimated prevalence of 3–4 cases per 100,000 individuals. There are, as yet, no robust evidence-based standards of care for FRDA. This Review article pools the expertise of FRDA specialists across Western Europe to formulate a set of guidelines for the diagnosis and treatment of this debilitating condition.

The application of neuroimaging to headache has greatly enhanced our understanding of the pathophysiology of this syndrome. Here, Arne May describes neuroimaging as a diagnostic tool for headache and highlights the advances made with functional and structural neuroimaging in the study of primary headache syndromes such as migraine and trigeminal autonomic headaches.

The use of intravenous recombinant tissue plasminogen activator to treat acute ischemic stroke has been limited by the need to administer the treatment within 3 hours of symptom onset, although recent findings indicate that this therapeutic window can be extended to 4.5 hours. In this Viewpoint, Maulaz et al. argue that the safety and efficacy of thrombolysis might be further improved by narrowing the selection criteria for this therapy.

Biebl et al. describe the case of a 12-year-old boy who presented with fever, malaise and fatigue, and was diagnosed with Epstein–Barr virus (EBV) encephalitis when his cerebrospinal fluid tested positive for EBV. Despite intensive care and antiviral treatment, the patient died 1 month after the initial presentation. The authors suggest that EBV encephalitis should be considered in the differential diagnosis when a young patient presents with acute neurological illness of uncertain etiology.

Posterior reversible leukoencephalopathy syndrome (PRES) is a complex disorder with many hypothesized mechanisms. Here, Bhatt and colleagues present a patient who developed PRES subsequent to administration of chemotherapy. The authors discuss in detail the potential causative mechanisms for PRES, emphasizing the need for early recognition of the syndrome and prompt withdrawal of the offending agent in affected patients

Findings from laboratory studies have indicated that long-chain omega-3 fatty acids, which are found in abundance in fish, have neuroprotective properties against cognitive decline and dementia. As Majid et al. report in this article, however, the clinical trials conducted to date have failed to support a role for omega-3 fatty acids in the treatment of Alzheimer disease or other dementias. Ongoing clinical trials are expected to provide more-definitive answers in the next 2–3 years.

In this Review, Leone and colleagues provide comprehensive guidance on the available treatments for cluster headache, the most severe primary headache syndrome. They advise on the use of acute and preventive pharmacological agents and give the latest findings and recommendations regarding use of neurostimulation.

Many issues surround the treatment of patients with idiopathic normal pressure hydrocephalus by use of shunting. In this Viewpoint, Sachin Batra and Daniele Rigamonti advise on how to achieve the best results with this procedure—including use of appropriate patient selection methods, and accurate monitoring after surgery. They believe that many patients can have good outcomes from shunting but urge physicians to actively work to maintain high standards.

Dinakar and Höke report on the case of a woman who presented to a neuromuscular clinic with a history of progressive stiffening and painful spasms of the lower extremities. The patient was diagnosed with paraneoplastic fasciitis–panniculits syndrome associated with recurrence of gastric adenocarcinoma. The symptoms improved on initiation of chemotherapy and worsened on discontinuation of chemotherapy.

Zinc overload is an unusual cause of copper-deficiency myeloneuropathy, in which affected patients have low serum copper and ceruloplasmin levels and high serum zinc levels. This Case Study describes a patient whose copper-deficiency myeloneuropathy was secondary to long-term use of a denture cream that contained high levels of zinc.

Over the past few years, there has been increasing interest in the use of complementary and alternative therapies to treat multiple sclerosis. Dietary supplementation with polyunsaturated fatty acids, which are thought to have anti-inflammatory properties, has been cited as a potential treatment for multiple sclerosis. However, as Mehta et al. discuss in this article, clinical trials have so far provided only limited evidence for the efficacy of this approach.

The cranial movement disorders constitute a diverse group of disorders that can be specific to the facial muscles or part of a generalized movement disorder. A lack of diagnostic tests and biomarkers for the cranial movement disorders means that their differential diagnosis can be difficult. In this Review, Fabbrini et al. summarize the available information pertaining to the clinical features, pathophysiologies and therapies of the main disorders within this group, with a view to aiding their diagnosis and treatment