Reviews & Analysis

Quality of care for patients with epilepsy can be variable. The American Academy of Neurology has recently published measures to guide physicians during treatment of epilepsy patients. Are these considerations enough to provide optimal care?

A number of established therapies are available for multiple sclerosis (MS), but the advent of numerous novel therapies has meant that treatment decisions for MS are becoming increasingly complex. In this Review, Kieseier and Stüve discuss the challenges that both neurologists and patients face in terms of treatment decision-making, and highlight the risks, benefits and treatment paradigms associated with MS therapy.

Despite the emergence of genetic and molecular approaches, disease categorization on the basis of clinical features remains an appealing approach, especially where the molecular mechanisms are poorly understood. A new study supports distinct clinical subtypes of Parkinson disease that could have implications for understanding the etiology of this condition.

One of the main challenges associated with late-onset genetic neurodegenerative diseases is predicting when the condition begins and how it progresses over time. In a new study, Tabrizi et al. have used a range of imaging, clinical and neuropsychiatric measures to assess the progression of Huntington disease.

Statin use in patients with cerebral hemorrhage may not be without risk. A recent article analyzing existing statin data in a mathematical model suggests that statins might need to be avoided after intracerebral hemorrhage, particularly in patients with a lobar hemorrhage.

Quality improvement in medicine has largely focused on conditions managed in primary care rather than specialist care. The American Academy of Neurology has introduced process-focused quality metrics for neurologists managing patients with Parkinson disease with the goal of informing evaluation of clinical performance. These metrics might eventually inform pay-for-performance decisions.

Acute exacerbations of myasthenia gravis (MG) need effective and urgent treatment because of life-threatening hypoventilation. Plasma exchange and intravenous immunoglobulin (IVIg) are both effective for acute MG. A new study suggests that these treatments produce similar patient outcomes and complications, with IVIg perhaps being superior from an economic perspective.

Focal cortical dysplasia (FCD) is a commonly encountered neuropathology in drug-resistant focal epilepsy; the bizarre pathological appearance of FCD reflects molecular disorder bridging neurodevelopment and neurodegeneration. A new classification stands to resolve discrepancies in FCD categorization and accelerate advances in fundamental understanding and clinical management of drug-resistant epilepsy.

Stroke is an important cause of long-term disability in children. In this Review, Jordan and Hillis examine the etiology of and risk factors associated with pediatric stroke, before exploring the notable diagnostic challenges associated with this condition. The authors also examine the management of stroke in children, highlighting the need for further clinical trials of potential stroke therapies in this patient group.

Psychogenic nonepileptic seizures (PNES) and epileptic seizures share many similar features, as a result PNES are often misdiagnosed and mistreated as epilepsy. In this article, Devinsky et al. provide an overview of the latest findings relating to risk factors and pathogenesis of PNES, and highlight the clinical features that can help clinicians differentiate between this condition and epileptic seizures.

Vigabatrin is an efficacious new-generation antiepileptic drug, but visual field loss (VFL) has strongly limited its use. A systematic review has established that vigabatrin increases the risk of VFL fourfold, with age and exposure as predicting factors. For infantile spasms, the benefits of vigabatrin seem to outweigh the VFL risk.

Many patients with multiple sclerosis relapse or experience continued disease progression despite disease-modifying therapies, such as interferon β. This Review explores responses to interferon β treatment in patients with multiple sclerosis, discusses early identification of nonresponders, and describes a practical approach for incorporating clinical data, biological markers and MRI measures of disease activity into the management of these patients.

Patients with transient ischemic attack (TIA) at high short-term risk of stroke can be identified. Evidence-based treatments can decrease this risk; however, organization of care of TIA patients is suboptimal. The National Stroke Association provides recommendations for improving TIA-related care delivery, but symptom recognition and treatment response remain a challenge.

Multiple system atrophy is characterized by a combination of parkinsonian, cerebellar, autonomic and pyramidal features, but recent data indicate that the clinical spectrum also includes nonmotor symptoms such as urinary disorders and orthostatic hypotension. Colosimo argues that neurologists and other specialists should be made aware that this neurodegenerative disease can manifest with nonmotor symptoms long before patients develop any overt motor disorder.

Age-associated white matter lesions are commonly observed in patients with idiopathic Parkinson disease, and are expected to contribute to the clinical symptoms in this condition. Bohnen and Albin review the literature addressing the occurrence and effects of white matter lesions in Parkinson disease, as well as describing existing and emerging methods for studying white matter pathology.

The occurrence of subarachnoid hemorrhage (SAH) in patients with acute headache is strongly associated with the presence of several clinical variables. Nevertheless, the absence of such variables should not discourage physicians from investigating for SAH in individuals with headache peaking in intensity within a few minutes of onset.

Decisions regarding resumption of anticoagulation are difficult in patients who present with a warfarin-associated intracranial hemorrhage and also have atrial fibrillation or a prosthetic heart valve. Current guidelines suggest waiting 1–2 weeks on average, but new research suggests that the optimal time to restart anticoagulation could be much later.

Alzheimer disease (AD) is the leading cause of dementia, and is set to rise in prevalence with the growth in the global elderly population. Here, Reitz and colleagues provide a comprehensive overview of our current understanding of AD epidemiology. The authors also examine the diagnostic criteria for this disease, and discuss the use of various biomarkers to improve the accuracy of AD detection and risk prediction.

Much is still to be learned regarding how nociceptive stimuli, genes and various other factors influence the generation and maintenance of pain. In this article, Irene Tracey examines possible neuroimaging endophenotypes of pain that could act as measurable markers of this condition. Such markers would assist both the management of and research into acute and chronic pain.

Memory impairment is a major complicating feature of temporal lobe epilepsy (TLE), and our understanding of such cognitive disorders has been enhanced by the study of anterior temporal lobectomy outcomes. In this Review, Bell and colleagues examine the changing view of TLE, and explore the anatomical abnormalities that underlie cognitive impairments that extend beyond memory function.