Residents don't just look miserable... they really are
Is the rite of passage of residency and fellowship a process of learning and maturing, or an exhausting and demoralizing experience that sets the stage for burnout? What factors can influence the start of burnout or help to promote wellness? It has become abundantly clear that physicians face a crisis not only of regulatory burdens, but also of a lack of well-being or burnout. This is especially true for neurologists. This does not begin with the graduation certificate from residency or fellowship, but instead the indicators for burnout are very much present early in their training—during residency. More than 50% of ...
Source: Neurology - July 31, 2017 Category: Neurology Authors: Tilton, A., Gutmann, L. Tags: EDITORIALS Source Type: research

Self-reported sleep and Alzheimer disease CSF biomarkers: A wake-up call
Alzheimer disease (AD) is the most prevalent cause of dementia, and numerous studies have described sleep disturbances and circadian abnormalities in persons with symptomatic AD.1 A rapidly accumulating body of research suggests that disturbed sleep is not only a consequence of pathologic brain changes of AD, but may also contribute to AD pathophysiologic mechanisms, even in the preclinical stages of AD.2 Sleep disturbances are associated with amyloid deposition, the first known stage of preclinical AD. Poorer sleep quality, as measured by wrist actigraphy, and more frequent napping were tied to CSF evidence of amyloid dep...
Source: Neurology - July 31, 2017 Category: Neurology Authors: Spira, A. P., Ju, Y.-E. S. Tags: All Sleep Disorders, Alzheimer's disease, Cerebrospinal Fluid, Cohort studies, Risk factors in epidemiology EDITORIALS Source Type: research

Max-ICH score: Can it prevent self-fulfilling prophecy in ICH?
Prediction of outcomes of patients with spontaneous intracerebral hemorrhage (ICH) can be helpful for patients, their families, and physicians when deciding on treatment strategies, including consideration of withdrawal of care. The most recent American Heart Association guideline for the management of spontaneous ICH recommends the routine use of a standardized severity score to "help streamline assessment and communication between providers."1 However, it warns that "severity scales should not be used as a singular indicator of prognosis." (Source: Neurology)
Source: Neurology - July 31, 2017 Category: Neurology Authors: Jacobs, B. S., Poggesi, A., Terry, J. B. Tags: EDITORIALS Source Type: research

On being sick: Musings about kindness, side effects, and slowing down
Editor's Note: Ted Burns is the founding editor of our podcast, an enormously successful venture, bringing Neurology® and AAN content to listeners worldwide. One of the highlights of the podcast to date was Ted's insightful and moving discussion when he was initially diagnosed with cancer. In presenting this update, we continue a series of pieces that present a patient or caregiver's views; these are important and informative, and we hope that our readership (or listeners) will benefit by seeing these perspectives.—Robert A. Gross, MD, PhD, FAAN (Source: Neurology)
Source: Neurology - July 31, 2017 Category: Neurology Authors: Burns, T. M. Tags: SPECIAL EDITORIALS Source Type: research

Spotlight on the August 1 issue
(Source: Neurology)
Source: Neurology - July 31, 2017 Category: Neurology Authors: Gross, R. A. Tags: IN FOCUS Source Type: research

Teaching Video NeuroImages: Running into a "useless" hand
A 68-year-old woman presented with an insidious onset of strictly asymmetric left arm clumsiness (video at Neurology.org) in absence of any brain lesion but mild right hemisphere hypotrophy (figure). The presence of limb apraxia and bradykinesia fostered the clinical diagnosis of possible corticobasal syndrome, in the context of suspected corticobasal degeneration.1 Bradykinesia and apraxia are 2 possible different faces of hypokinesia; their correct discrimination is not a diagnostic problem if a higher-level disturbance of praxis is present. An isolated limb apraxia is a confounder, and its early recognition allows clini...
Source: Neurology - July 31, 2017 Category: Neurology Authors: Marano, M., Salomone, G., di Biase, L., Di Lazzaro, V. Tags: Parkinson's disease/Parkinsonism, Apraxia, All Cognitive Disorders/Dementia, Corticobasal degeneration, Motor Control RESIDENT AND FELLOW SECTION Source Type: research

Teaching NeuroImages: Bilateral intracerebral hemorrhage in expanded dengue syndrome
A 66-year-old Brazilian woman presented with fever, malaise, and myalgia, followed 10 days later by left hemiparesis and altered mental status. Brain MRI revealed bilateral intracerebral hemorrhages (figure, A and B) and CSF showed mild lymphocytic pleocytosis. Serologic testing for dengue fever was positive. Brain biopsy demonstrated nonspecific inflammatory changes and areas of recent hemorrhage and necrosis (figure, C). After 1 month, partial clinical and radiologic improvement occurred (figure, D). Expanded dengue syndrome1 refers to atypical manifestations of dengue such as intracerebral hemorrhage, which is a rare pr...
Source: Neurology - July 31, 2017 Category: Neurology Authors: Palmeira Cavalcante, W. C., Neto, H. R. S., Grativvol, R. S., Spera, R. R., Frassetto, F. P., Lucato, L. T., Nitrini, R. Tags: MRI, Viral infections, Intracerebral hemorrhage RESIDENT AND FELLOW SECTION Source Type: research

Pearls & Oy-sters: Transient neurologic events in a patient with leptomeningeal metastases
Patients with leptomeningeal metastases (LM) may develop transient neurologic events in the setting of temporary elevations of intracranial pressure (ICP). (Source: Neurology)
Source: Neurology - July 31, 2017 Category: Neurology Authors: Stretz, C., Mook, A. R., Zhang, Y. Tags: EEG RESIDENT AND FELLOW SECTION Source Type: research

Clinical Reasoning: A 22-year-old man with diplopia
A 22-year-old previously healthy man presented to an ophthalmology clinic with binocular horizontal diplopia. He had recently traveled to the main island of Hawaii. About 2 weeks after returning home, he developed a severe headache with associated fever, emesis, photophobia, phonophobia, and neck stiffness. He also reported a sensation of pressure in his left eye and both ears but denied any pulsatile tinnitus or transient vision loss. Over the next 2 weeks, his headaches worsened, causing him to wake up frequently in the night. He then developed horizontal diplopia that was worse at a distance and was referred to the neur...
Source: Neurology - July 31, 2017 Category: Neurology Authors: Meyer, C., Wynn, D. P., Pulst, S. M., Chen, R., Digre, K. Tags: Parasitic infections, Optic nerve, Diplopia (double vision) RESIDENT AND FELLOW SECTION Source Type: research

Balo concentric sclerosis evolving from apparent tumefactive demyelination
(Source: Neurology)
Source: Neurology - July 24, 2017 Category: Neurology Tags: CORRECTIONS Source Type: research

Author response: Neonatal vitamin D status and risk of multiple sclerosis: A population-based case-control study
In response to our article,1 Dr. Zarghami suggests that clinical trials are necessary to compare the efficacy and cost–benefit of vitamin D supplementation vs sun exposure in pregnancy. Such trials are not feasible because of the relatively low frequency of multiple sclerosis (MS) and the long interval between any intervention in pregnancy and the observation of its potential effect on MS risk in offspring. We agree, nevertheless, that judicious sun exposure provides an alternative approach for the correction of vitamin D deficiency in regions with levels of ultraviolet B radiation high enough to support year-round v...
Source: Neurology - July 24, 2017 Category: Neurology Authors: Nielsen, N. M., Munger, K. L., Stenager, E., Ascherio, A. Tags: WRITECLICK & amp;reg; EDITOR ' S CHOICE Source Type: research

Letter re: Neonatal vitamin D status and risk of multiple sclerosis: A population-based case-control study
We read with interest the article by Nielsen et al.,1 which described an inverse association between neonatal levels of 25(OH)D and risk of multiple sclerosis (MS), similar to the recent study by Munger et al.2 However, both articles might only reflect a short-time influence of 25(OH)D, which could be affected by environmental factors (e.g., sun exposure and dietary structure). Two recent studies provided new insights into the effects of latitude and vitamin D supplementation on the disease course in MS,3,4 indicating that a long-time cumulative effect of environmental factors might play an important role in the risk of MS...
Source: Neurology - July 24, 2017 Category: Neurology Authors: Xia, Z., Cheng, Q., Li, J. Tags: WRITECLICK & amp;reg; EDITOR ' S CHOICE Source Type: research

Letter re: Neonatal vitamin D status and risk of multiple sclerosis: A population-based case-control study
In the article by Nielsen et al.,1 the authors supported justification of routine vitamin D supplementation during pregnancy. The region type and ethnic-related characteristics of the study population were well-underlined in the editorial.2 The distribution of multiple sclerosis (MS) might vary in different populations with different geographic characteristics, sociodemographic characteristics, and genetic predisposition.3 Both the current study and similar previous studies were conducted among Scandinavian populations with genetic homogeneity.1,4 Conversely, the geographic placement of these neighboring countries and the ...
Source: Neurology - July 24, 2017 Category: Neurology Authors: Zarghami, A. Tags: WRITECLICK & amp;reg; EDITOR ' S CHOICE Source Type: research

Editors' Note
: Comments in WriteClick this week relate to "Neonatal vitamin D status and risk of multiple sclerosis: A population-based case-control study." Dr. Zarghami asks whether sun exposure may be a more cost-effective measure than vitamin D supplementation during pregnancy and suggests randomized clinical trials in the future to compare the 2 interventions. Authors Nielsen et al. respond that a clinical trial of that nature would not be possible due to the relatively low frequency of multiple sclerosis (MS) and the long-time course between intervention and disease onset. (Source: Neurology)
Source: Neurology - July 24, 2017 Category: Neurology Authors: Alcauskas, M., Griggs, R. C. Tags: WRITECLICK & amp;reg; EDITOR ' S CHOICE Source Type: research

Enteroviral T-cell encephalitis related to immunosuppressive therapy including rituximab
Enteroviruses are a common cause of aseptic meningitis and mild infections in childhood. However, in immunocompromised patients they may cause severe neurologic conditions such as encephalitis or polio-like paralysis. (Source: Neurology)
Source: Neurology - July 24, 2017 Category: Neurology Authors: Garzo-Caldas, N., Ruiz-Sainz, E., Vila-Bedmar, S., Llamas-Velasco, S., Hernandez-Lain, A., Ruiz-Morales, J., Folgueira-Lopez, D., Villarejo-Galende, A. Tags: Encephalitis, Viral infections CLINICAL/SCIENTIFIC NOTES Source Type: research

Real-world experience of treatment decision-making in carotid stenosis in a neurovascular board
Conclusions: Interdisciplinary board decisions are a helpful and transparent tool to assure adherence to guideline recommendations, and to provide consensus-based individualized treatment strategies in clinical practice in the absence of unequivocal evidence. (Source: Neurology)
Source: Neurology - July 24, 2017 Category: Neurology Authors: Rimmele, D. L., Larena-Avellaneda, A., Alegiani, A. C., Rosenkranz, M., Schmidt, N. O., Regelsberger, J., Hummel, F. C., Magnus, T., Debus, E. S., Fiehler, J., Gerloff, C., Thomalla, G. Tags: Stroke prevention CONTEMPORARY ISSUES Source Type: research

Disruptive technology disorder: A past, present, and future neurologic syndrome
Based upon an analysis of 6 major historical technological advances over the last 150 years, a new syndrome, disruptive technology disorder (DTD), is introduced. DTD describes the human health ailments that accompany the implementation of disruptive technologies. Elevator sickness, railway spine, and bicycle face are representative examples. Though the underlying causative disruptive technologies may differ, many neurologic symptoms (headache, dizziness, weakness) are common to multiple DTDs. Born of technology-driven societal change, DTDs manifest as a complex interplay between biological and psychological symptoms. (Source: Neurology)
Source: Neurology - July 24, 2017 Category: Neurology Authors: Weaver, D. F. Tags: Clinical neurology history HISTORICAL NEUROLOGY Source Type: research

DNM1 encephalopathy: A new disease of vesicle fission
Conclusions: The phenotypic spectrum of DNM1-related encephalopathy is relatively homogeneous, in contrast to many other genetic epilepsies. Up to one-third of patients carry the recurrent p.Arg237Trp variant, which is now one of the most common recurrent variants in epileptic encephalopathies identified to date. Given the predicted dominant-negative mechanism of this mutation, this variant presents a prime target for therapeutic intervention. (Source: Neurology)
Source: Neurology - July 24, 2017 Category: Neurology Authors: von Spiczak, S., Helbig, K. L., Shinde, D. N., Huether, R., Pendziwiat, M., Lourenco, C., Nunes, M. E., Sarco, D. P., Kaplan, R. A., Dlugos, D. J., Kirsch, H., Slavotinek, A., Cilio, M. R., Cervenka, M. C., Cohen, J. S., McClellan, R., Fatemi, A., Yuen, A Tags: Developmental disorders, Infantile spasms ARTICLE Source Type: research

Emergency response to out-of-hospital status epilepticus: A 10-year observational cohort study
Objective: To determine the implications of first responses of emergency medical services (EMS) to out-of-hospital status epilepticus (SE) on outcome. Methods: From 2005 to 2014, prehospital and in-hospital data were assessed in consecutive adults admitted to an academic medical center with out-of-hospital SE. Logistic regression was performed to identify variables with a robust association between missed epileptic events by the EMS and no recovery to functional baseline in survivors. Results: Among 213 SE patients, 150 were admitted via EMS. While nonconvulsive SE (NCSE) was missed by the EMS in 63.7%, convulsive SE (CS...
Source: Neurology - July 24, 2017 Category: Neurology Authors: Semmlack, S., Yeginsoy, D., Spiegel, R., Tisljar, K., Rüegg, S., Marsch, S., Sutter, R. Tags: Outcome research, Medical care, Critical care, Status epilepticus, Cohort studies ARTICLE Source Type: research

Upgoing thumb sign: A sensitive indicator of brain involvement?
In this study conducted between March 2016 and October 2016 at the Stroke Prevention Clinic at University Hospital, University of Western Ontario, London, Canada, participants were examined independently by stroke faculty and fellows who were blinded to each other's findings. The frequency of the upgoing thumb sign in patients with minor or threatened stroke was compared to that in patients with stroke mimics, and the level of agreement between examiners and clinical findings was assessed with the Cohen test. Results: The upgoing thumb sign was observed more frequently in those with minor stroke/TIA than in those with str...
Source: Neurology - July 24, 2017 Category: Neurology Authors: Hachinski, V., Alsubaie, R., Azarpazhooh, M. R. Tags: ARTICLE Source Type: research

BMI increase through puberty and adolescence is associated with risk of adult stroke
Conclusions: BMI increase through puberty and adolescence is associated with risk of adult IS and ICH in men. We propose that greater BMI increases during puberty contribute to increased risk of adult stroke at least partly via increased blood pressure. (Source: Neurology)
Source: Neurology - July 24, 2017 Category: Neurology Authors: Ohlsson, C., Bygdell, M., Sonden, A., Jern, C., Rosengren, A., Kindblom, J. M. Tags: All Pediatric, Adolescence, Cohort studies, Infarction, Intracerebral hemorrhage ARTICLE Source Type: research

Permanent CSF shunting after intraventricular hemorrhage in the CLEAR III trial
Conclusions: Among patients with spontaneous IVH requiring emergency CSF diversion, those with early elevated intracranial pressure, high CSF output, and placement of more than one EVD are at increased odds of permanent ventricular shunting. Administration of intraventricular alteplase, early radiographic findings, and CSF measures were not useful predictors of permanent CSF diversion. (Source: Neurology)
Source: Neurology - July 24, 2017 Category: Neurology Authors: Murthy, S. B., Awad, I., Harnof, S., Aldrich, F., Harrigan, M., Jallo, J., Caron, J.-L., Huang, J., Camarata, P., Lara, L. R., Dlugash, R., McBee, N., Eslami, V., Hanley, D. F., Ziai, W. C., For the CLEAR III Trial Investigators Tags: Critical care, Intracerebral hemorrhage ARTICLE Source Type: research

Comment: Does patient sex affect decision-making after hemorrhagic stroke?
Women do worse than men after both ischemic and hemorrhagic stroke, with evidence that sex bias in physician decision-making may contribute to this increased morbidity and mortality.1 Intracerebral hemorrhage (ICH) poses additional challenges, as the etiologies—amyloid angiopathy associated with prior cognitive decline, illicit drug use—carry their own assumptions. Guha et al.2 report findings from the Ethnic/Racial Variations of Intracerebral Hemorrhage (ERICH) study, a prospective, multicenter, triethnic, case-control study of ICH risk factors and outcomes. In almost 3,000 people, they examined comorbidities,...
Source: Neurology - July 24, 2017 Category: Neurology Authors: Brodtmann, A. Tags: All Cerebrovascular disease/Stroke, Intracerebral hemorrhage ARTICLE Source Type: research

Aggressiveness of care following intracerebral hemorrhage in women and men
Objective: To compare comorbidities and use of surgery and palliative care between men and women with intracerebral hemorrhage (ICH). Methods: The Ethnic/Racial Variations of Intracerebral Hemorrhage (ERICH) study is a prospective, multicenter, case-control study of ICH risk factors and outcomes. We compared comorbidities, treatments, and use of do-not-resuscitate (DNR) orders in men vs women. Multivariate analysis was used to assess the likelihood of ICH surgery and palliative care after adjustment for variables that were p
Source: Neurology - July 24, 2017 Category: Neurology Authors: Guha, R., Boehme, A., Demel, S. L., Li, J. J., Cai, X., James, M. L., Koch, S., Langefeld, C. D., Moomaw, C. J., Osborne, J., Sekar, P., Sheth, K. N., Woodrich, E., Worrall, B. B., Woo, D., Chaturvedi, S. Tags: All Cerebrovascular disease/Stroke, Intracerebral hemorrhage ARTICLE Source Type: research

Effects of increasing IV tPA-treated stroke mimic rates at CT-based centers on clinical outcomes
Objective: To determine to what degree stroke mimics skew clinical outcomes and the potential effects of incorrect stroke diagnosis. Methods: This retrospective analysis of data from 2005 to 2014 included IV tissue plasminogen activator (tPA)–treated adults with clinical suspicion for acute ischemic stroke who were transferred or admitted directly to our 2 hub hospitals. Primary outcome measures compared CT-based spoke hospitals' and MRI-based hub hospitals' mimic rates, hemorrhagic transformation, follow-up modified Rankin Scale (mRS), and discharge disposition. Secondary outcomes were compared over time. Results:...
Source: Neurology - July 24, 2017 Category: Neurology Authors: Burton, T. M., Luby, M., Nadareishvili, Z., Benson, R. T., Lynch, J. K., Latour, L. L., Hsia, A. W. Tags: Outcome research, CT, MRI, DWI, All Cerebrovascular disease/Stroke ARTICLE Source Type: research

Slowing gait and risk for cognitive impairment: The hippocampus as a shared neural substrate
Conclusions: The association between gait slowing and cognitive impairment is supported by a shared neural substrate that includes a smaller right hippocampus. This finding underscores the value of long-term gait slowing as an early indicator of dementia risk. (Source: Neurology)
Source: Neurology - July 24, 2017 Category: Neurology Authors: Rosso, A. L., Verghese, J., Metti, A. L., Boudreau, R. M., Aizenstein, H. J., Kritchevsky, S., Harris, T., Yaffe, K., Satterfield, S., Studenski, S., Rosano, C. Tags: MRI, All Cognitive Disorders/Dementia, Cognitive aging, Cohort studies, Risk factors in epidemiology ARTICLE Source Type: research

Odor identification as a biomarker of preclinical AD in older adults at risk
Objective: To assess odor identification (OI) as an indicator of presymptomatic Alzheimer disease (AD) pathogenesis in cognitively normal aging individuals at increased risk of AD dementia. Methods: In 274 members of the PREVENT-AD cohort of healthy aging persons with a parental or multiple-sibling history of AD dementia, we assessed the cross-sectional association of OI with potential indicators of presymptomatic AD. Some 101 participants donated CSF, thus enabling assessment of AD pathology with the biomarkers total tau (t-tau), phospho-tau (P181-tau), and their ratios with β-amyloid (Aβ1-42). Adjusted analyse...
Source: Neurology - July 24, 2017 Category: Neurology Authors: Lafaille-Magnan, M.-E., Poirier, J., Etienne, P., Tremblay-Mercier, J., Frenette, J., Rosa-Neto, P., Breitner, J. C. S., For the PREVENT-AD Research Group Tags: All Cognitive Disorders/Dementia, Alzheimer's disease, Cognitive aging, Assessment of cognitive disorders/dementia ARTICLE Source Type: research

A new potential biomarker for dementia with Lewy bodies: Skin nerve {alpha}-synuclein deposits
Conclusions: (1) In autonomic skin nerves, p-syn is a sensitive biomarker for DLB diagnosis, helping to differentiate DLB from other forms of dementia, although this needs to be confirmed in a larger, more representative sample; and (2) skin autonomic neuropathy is part of the DLB pathology and may contribute to autonomic symptoms. Classification of evidence: This study provides Class III evidence that p-syn in skin nerve fibers on skin biopsy accurately distinguishes DLB from other forms of dementia. (Source: Neurology)
Source: Neurology - July 24, 2017 Category: Neurology Authors: Donadio, V., Incensi, A., Rizzo, G., Capellari, S., Pantieri, R., Stanzani Maserati, M., Devigili, G., Eleopra, R., Defazio, G., Montini, F., Baruzzi, A., Liguori, R. Tags: Autonomic diseases, Alzheimer's disease, Dementia with Lewy bodies, Vascular dementia, Class III ARTICLE Source Type: research

Improving practice through neurovascular board
Management of cervical internal carotid artery (ICA) stenosis remains contentious despite numerous randomized trials and observational studies over the decades since the first report of carotid endarterectomy. Rimmele et al.1 in this issue of Neurology® summarize the 53-month experience of deliberations by a Neurovascular Board at the University Medical Center, Hamburg-Eppendorf (UKE), on management of ICA disease. The multidisciplinary board of senior vascular specialists reviewed 614 cases. The board recommended revascularization in 76% of symptomatic cases and in 27% of asymptomatic cases and encouraged trial p...
Source: Neurology - July 24, 2017 Category: Neurology Authors: Meschia, J. F., Brott, T. G. Tags: Stroke prevention EDITORIALS Source Type: research

Missed diagnosis of prehospital status epilepticus: Is it serious, doctor?
Status epilepticus (SE) represents one of the most frequent neurologic emergencies, with potentially severe morbidity and mortality.1 Considerable attention has been directed towards implementation of treatment protocols,2 and recently of anesthetic treatment,3,4 but prognostic studies focused on early recognition of SE by emergency medical services (EMS) are lacking. (Source: Neurology)
Source: Neurology - July 24, 2017 Category: Neurology Authors: Rossetti, A. O., Waterhouse, E. Tags: Outcome research, Medical care, Critical care, Status epilepticus, Cohort studies EDITORIALS Source Type: research

Adolescent weight gain confers long-term increased stroke risk: Weighty matters
Adult obesity has been consistently associated with risk of total, ischemic, and hemorrhagic stroke1–3; however, the degree to which change in weight and body mass index (BMI) during late childhood and adolescence affects adult risk of stroke has remained uncertain. Understanding this relationship is of particular importance given the rising obesity epidemic during childhood and adolescence. (Source: Neurology)
Source: Neurology - July 24, 2017 Category: Neurology Authors: Rexrode, K. M., Kimm, S. Y. S. Tags: All Pediatric, Adolescence, Cohort studies, Infarction, Intracerebral hemorrhage EDITORIALS Source Type: research

Dementia with Lewy bodies: Diagnosis is only skin deep?
Dementia with Lewy bodies (DLB) is currently diagnosed clinically by identifying dementia in combination with a number of hallmark features: REM sleep behavior disorder (RBD), prominent visual hallucinations, parkinsonism, and marked fluctuations of cognition and alertness.1 DLB is often underdiagnosed, suggesting a role for biomarkers. The main differential diagnosis of DLB is Alzheimer disease (AD); whereas both AD and DLB have amyloid deposition, DLB also has additional α-synuclein deposition (Lewy bodies and Lewy neurites). So, one way to establish DLB diagnosis might be to detect the α-synucleinopathy itse...
Source: Neurology - July 24, 2017 Category: Neurology Authors: Postuma, R. B., Walker, Z. Tags: Autonomic diseases, Alzheimer's disease, Dementia with Lewy bodies, Vascular dementia, Class III EDITORIALS Source Type: research

Spotlight on the July 25 issue
(Source: Neurology)
Source: Neurology - July 24, 2017 Category: Neurology Authors: Gross, R. A. Tags: IN FOCUS Source Type: research

Body mass index in early life and stroke in adult life: What is the risk?
The article "BMI increase through puberty and adolescence is associated with risk of adult stroke" by Ohlsson et al.1 explores the relationship between body mass index (BMI) when a person is young (adolescence) and risk of stroke when the person is older (adults). Previous studies2,3 have shown that rate of stroke is decreasing in older adults but increasing in younger adults. This finding coincides with an increasing BMI in children and young adults. The researchers wanted to ask: Does an increased BMI during puberty and adolescence increase the risk for stroke later in life? The authors also explored wheth...
Source: Neurology - July 24, 2017 Category: Neurology Authors: Jones, S. H., Karceski, S. C. Tags: Stroke prevention, Other cerebrovascular disease/ Stroke, All Cerebrovascular disease/Stroke, Infarction, Intracerebral hemorrhage PATIENT PAGES Source Type: research

Teaching NeuroImages: Three complications of small-cell lung cancer involving the brain
A 53-year-old man with small-cell lung cancer (SCLC) with brain metastases presented with acute hyperthermia (up to 39°C) without evidence of infection, aphasia, and 2 generalized epileptic seizures. MRI made 3 brain complications of SCLC visible. First, multiple brain metastases (figure, A and B) were noted. Second, hyperintense areas at the limbic system (figure, C) were present, favoring a diagnosis of paraneoplastic limbic encephalitis, although associated antibodies were negative. Limbic encephalitis can cause both hyperthermia and seizures.1 Third, aphasia was explained by a region of reduced diffusion at the lef...
Source: Neurology - July 24, 2017 Category: Neurology Authors: Neuhaus, O., Käfer, G. Tags: Metastatic tumor, Paraneoplastic syndrome RESIDENT AND FELLOW SECTION Source Type: research

Teaching NeuroImages: The Charcot shoulder: Chiari malformation with syringomyelia associated with arthropathy
A 39-year-old man presented with 1-year history of shoulder pain, swelling, and limitation of movement. There was a 20-year history of left shoulder and arm numbness. Examination showed decreased vibratory sensitivity on left shoulder, glenohumeral instability, and dislocation. Radiography showed humeral head destruction (figure 1); a spine MRI showed tonsillar herniation and cervical syringomyelia (figure 2). Arthropathy related to syringomyelia was diagnosed. (Source: Neurology)
Source: Neurology - July 24, 2017 Category: Neurology Authors: Bocca, L. F., Tonholo Silva, T. Y., Ejnisman, B., Pedroso, J. L., Barsottini, O. G. Tags: MRI, All Clinical Neurology, Peripheral neuropathy RESIDENT AND FELLOW SECTION Source Type: research

Mystery Case: CNS posttransplant lymphoproliferative disorder
A 74-year-old right-handed Hispanic woman with history of renal transplant 19 years prior presented at an away institution with episodic confusion and gait ataxia progressing over 2 weeks. She was alert and oriented on initial presentation but with fluctuation in mental status and without obvious cranial nerve, motor, or sensory deficits. The patient received transplant immunosuppression therapy with mycophenolate mofetil (Cellcept; Roche, Basel, Switzerland) and had a history of hypertension and chronic kidney disease. CT of the head showed a hypodense lesion in the right temporal lobe. MRI of the brain demonstrated multi...
Source: Neurology - July 24, 2017 Category: Neurology Authors: Kesari, N. K., Sivakumar, S., Kapadia, A. M., Chen, W., Blieden, C. R., Venkatasubba Rao, C. P., Suarez, J. I. Tags: All Immunology RESIDENT AND FELLOW SECTION Source Type: research

Clinical Reasoning: A man with rapidly ascending paralysis
A 38-year-old construction worker with no medical history presented with back pain, urinary retention, and flaccid lower extremity paralysis. Three weeks prior to presentation, he fell from a ladder with no immediate injury. Two weeks after the fall, he presented to another hospital for back pain and urinary retention. MRI of the lumbar, cervical, and thoracic spine without contrast were reportedly normal, and his back pain improved with an oral methylprednisolone dose pack (figure). The urinary retention remained, and he was discharged with an indwelling catheter. Within a week of the initial urinary symptoms, he develope...
Source: Neurology - July 24, 2017 Category: Neurology Authors: Rosenberg, J., Aradi, S., Pruitt, A. Tags: Clinical neurology examination, All Spinal Cord, Optic neuritis; see Neuro-ophthalmology/Optic Nerve, Transverse myelitis RESIDENT AND FELLOW SECTION Source Type: research

Discovering the patient within
The gently winding road from Jackson Hole to Yellowstone National Park follows the imposing Grand Teton mountains, which rise abruptly out of the flat plains of northwestern Wyoming. In May, the heavily snow-laden peaks contrasted dramatically with the skies above and lakes below. To the east lay sparse forestland within which I would soon make an unexpected discovery. (Source: Neurology)
Source: Neurology - July 24, 2017 Category: Neurology Authors: Morton, R. Tags: Migraine, Clinical neurology history REFLECTIONS: NEUROLOGY AND THE HUMANITIES Source Type: research

Author response: Munchausen syndrome by genetics: Next-generation challenges for clinicians
We thank Dr. Oliveira for the thoughtful commentary on our Clinical/Scientific Note.1 Dr. Oliveira raises the issue of the differential diagnosis of F68.1 (factitious disorder, Munchausen syndrome) vs Z76.5 (feigning illness with obvious motivation). Such a differentiation would indeed be relevant for further patient management. (Source: Neurology)
Source: Neurology - July 17, 2017 Category: Neurology Authors: Zittel, S., Alvarez-Fischer, D., Schweiger, U., Klein, C., Münchau, A. Tags: WRITECLICK & amp;reg; EDITOR ' S CHOICE Source Type: research

Letter re: Munchausen syndrome by genetics: Next-generation challenges for clinicians
Zittel et al.1 reported a very interesting patient who presented with a faked genetics test, along with faking clinical symptoms and signs, supporting diagnosis of Munchausen syndrome presenting as pseudo-dopa-responsive dystonia. The Clinical/Scientific Note provided an instructive example of how to pay attention to details that we usually take for granted during the busy clinician routine. It would be crucial to check if the patient had a specific motivation, such as pension application or welfare. Based on ICD-10, this differentiates Munchausen (F68.1) from person feigning illness (with obvious motivation) (Z76.5). (Source: Neurology)
Source: Neurology - July 17, 2017 Category: Neurology Authors: Oliveira, J. R. M. Tags: WRITECLICK & amp;reg; EDITOR ' S CHOICE Source Type: research

Author response: Transient smartphone blindness: Relevance to misdiagnosis in neurologic practice
We thank Drs. Tripathy and Sengupta for the interest in our Clinical/Scientific Note.1 We agree that our patient's clinical presentation was not consistent with demyelinating optic neuritis. This was one of several factors that led to misdiagnosis. (Source: Neurology)
Source: Neurology - July 17, 2017 Category: Neurology Authors: Wingerchuk, D. M., Sathiamoorthi, S. Tags: WRITECLICK & amp;reg; EDITOR ' S CHOICE Source Type: research

Letter re: Transient smartphone blindness: Relevance to misdiagnosis in neurologic practice
A few observations regarding transient smartphone blindness (TSB) being misdiagnosed as multiple sclerosis (MS), as noted by Drs. Sathiamoorthi and Wingerchuk,1 require further discussion:While optic neuritis cases may exhibit amaurosis fugax, diagnosis requires visual decline, relative afferent papillary defect, color vision or visual field changes, and pain during ocular movements with or without changes in the optic disc on funduscopy. Therefore, the ocular features of the presented case did not support the diagnosis of optic neuritis.1 We agree that MS diagnosis requires careful consideration of clinical features and c...
Source: Neurology - July 17, 2017 Category: Neurology Authors: Tripathy, K., Sengupta, T. Tags: WRITECLICK & amp;reg; EDITOR ' S CHOICE Source Type: research

Editors' Note
: Commenting on "Transient smartphone blindness: Relevance to misdiagnosis in neurologic practice," Drs. Tripathy and Sengupta discuss additional observations such as monocular viewing in people with binocular vision, the nonspecificity of transient smartphone blindness (TSB) that can occur when viewing any bright object under the right circumstance, and potential conditions that can predispose certain individuals to TSB. (Source: Neurology)
Source: Neurology - July 17, 2017 Category: Neurology Authors: Karam, C., Griggs, R. C. Tags: WRITECLICK & amp;reg; EDITOR ' S CHOICE Source Type: research

Multinodular vacuolating and neuronal tumor of the cerebrum
A 31-year-old woman presented with chronic headache. MRI revealed an atypical right parietal lesion involving the deep cortical ribbon and adjacent superficial subcortical white matter (figures 1 and 2). (Source: Neurology)
Source: Neurology - July 17, 2017 Category: Neurology Authors: Badat, N., Savatovsky, J., Charbonneau, F., Collin, A., Lecler, A. Tags: MRI, Primary brain tumor NEUROIMAGES Source Type: research

Dento-corneal aberrant regeneration as evidence of V2 innervation of the inferior human cornea
Aberrant regeneration (AR) of axons may occur following nerve trauma or compression and causes axonal signals to be misdirected to structures other than their original targets. Ocular–oral synkinesis and gustatory hyperlacrimation (crocodile tears), which can each follow facial nerve palsy, are examples of motor and autonomic AR, respectively. Somatosensory AR is rarely reported, and causes the referral of a sensory stimulus at one location to a distant site; the referred sensation is usually perceived as more noxious than the initiating stimulus.1 (Source: Neurology)
Source: Neurology - July 17, 2017 Category: Neurology Authors: Bery, A., Fraser, J. A. Tags: All Neuro-ophthalmology, Neuropathic pain, Plasticity, Cranial neuropathy CLINICAL/SCIENTIFIC NOTES Source Type: research

Prognostic factors for chronic headache: A systematic review
Conclusions: This review identified several potential predictors of poor prognosis and worse outcome postinterventions in people with chronic headache. The majority of these are modifiable. The findings also highlight the need for more longitudinal high-quality research of prognostic factors in chronic headache. (Source: Neurology)
Source: Neurology - July 17, 2017 Category: Neurology Authors: Probyn, K., Bowers, H., Caldwell, F., Mistry, D., Underwood, M., Matharu, M., Pincus, T., On behalf of the CHESS Team Tags: Migraine, Tension headache VIEWS & amp;amp; REVIEWS Source Type: research

Hospital safety among neurologic patients: A population-based cohort study of adverse events
Conclusions: This study demonstrates that neurologic patients have a high proportion of AEs in hospital. The findings provide information on the quality and safety of care for people with neurologic conditions in hospital, which can help inform future quality improvement initiatives. (Source: Neurology)
Source: Neurology - July 17, 2017 Category: Neurology Authors: Sauro, K. M., Quan, H., Sikdar, K. C., Faris, P., Jette, N. Tags: All Health Services Research, Medical care, All Clinical Neurology, Patient safety ARTICLE Source Type: research

Increased rate of venous thrombosis may be associated with inpatient dihydroergotamine treatment
Conclusions: IV dihydroergotamine treatment may be associated with an increased risk of catheter-associated venous thrombosis. A low threshold for diagnostic ultrasound investigation is appropriate because anticoagulation therapy was frequently required. (Source: Neurology)
Source: Neurology - July 17, 2017 Category: Neurology Authors: Tso, A. R., Patniyot, I. R., Gelfand, A. A., Goadsby, P. J. Tags: Migraine, All Clinical Neurology, Clinical trials Observational study (Cohort, Case control) ARTICLE Source Type: research

Diagnostic algorithm for relapsing acquired demyelinating syndromes in children
Conclusions: Children with MS and AQP4-Ab NMOSD showed features typical of adult cases. Because MOG-Ab–positive children showed notable and distinctive clinical and MRI features, they were grouped into a unified phenotype (MOG-Ab–associated disease), included in a new diagnostic algorithm. (Source: Neurology)
Source: Neurology - July 17, 2017 Category: Neurology Authors: Hacohen, Y., Mankad, K., Chong, W. K., Barkhof, F., Vincent, A., Lim, M., Wassmer, E., Ciccarelli, O., Hemingway, C. Tags: Multiple sclerosis, Devic's syndrome, Acute disseminated encephalomyelitis ARTICLE Source Type: research