Neurology Times’ Top 11 Clinical Articles of 2018

Pediatric Concussion: Current Trends and New Frontiers: A concussion is a complex condition that has been poorly studied in the pediatric population. The effect and outcome of concussion are far worse in the developing brains of children as compared to that of adults. Studies have shown that concussion in this age group significantly impacts school and sports-related performance, and it often leads to significant academic, social, and financial losses. Concussion may even cause permanent damage and worsening of existing neuropsychological symptoms. Most concerning, repeated head injuries, particularly recurrent and prolonged subconcussive injuries, may lead to a much more severe condition like the chronic traumatic encephalopathy. Here: Experts provide new insights about the challenges of concussion care for pediatric patients, including management, diagnosis, and return to a normal lifestyle.

Top 5 CNS Causes of Dizziness: “Dizziness is a general, umbrella term that encompasses a variety of symptoms that impair spatial perception. It is the second most common complaint in the ambulatory setting, and constitutes 25% of neurology outpatient referrals and 13% of emergency department (ED) neurology consultations. While peripheral causes of dizziness (eg, benign paroxysmal positional vertigo, vestibular neuritis) are more common than those arising from the CNS, neurologists are frequently called on to assess patients who complain of dizziness. As such, it is imperative for neurologists to be aware of common CNS causes of dizziness.”

In Vivo Biomarkers for Chronic Traumatic Encephalopathy: Critical gaps in our knowledge of CTE remain, including its incidence and prevalence, and specific repetitive head impacts exposure and genetic risk factors. In vivo biomarkers that can accurately detect underlying CTE neuropathology are necessary to conduct research to fill these gaps; however, they do not exist. In other neurodegenerative diseases (eg, Alzheimer disease), in vivo biomarkers facilitate disease detection and diagnosis, are used to monitor disease progression, and serve as endpoints for prevention and treatment clinical trials. Identification of in vivo biomarkers for CTE is thus a high priority.

Driving and Epilepsy: Issues to Discuss With Your Patients: Worldwide there are more than 65 million individuals with epilepsy. In the US because driving an automobile is such an important aspect of our culture, driving restriction is an enormous problem for many of these individuals and their families. Indeed, surveys find individuals with epilepsy report driving as a major concern. Physicians and other medical providers play an important role educating and counseling people with seizures and their families regarding driving. Here, we provide some background and guidance regarding this issue.

Neuro-Ophthalmologic Disorders: Issues in Diagnosis and Treatment: Neurologists may be the first or only clinicians to see potentially dangerous neuro-ophthalmologic conditions. They should be able to triage and recognize the key differentiating features of papilledema and idiopathic intracranial hypertension, anterior ischemic optic neuropathy, optic neuritis, ocular motor cranial neuropathy, and Horner syndrome. Early diagnosis and treatment of these conditions may be potentially life or vision saving.

Case Study: True Headache or Drug-Seeking New Mom? A 20-year-old G3P2 with asthma, chronic hypertension, gestational diabetes and morbid obesity had a Caesarian section at 39 weeks. The baby boy was a healthy 10 pounds, but the patient developed headache after epidural anesthesia. She complained of throbbing pain over her whole head with some nausea. The pain increased with activity. She had a history of migraine, but this headache was different. Despite ibuprofen, acetaminophen/butalbital/caffeine and prochlorperazine, the headache continued. The patient requested “something really strong” for the pain. There was concern for drug-seeking behavior. Three days postpartum, anesthesia performed a blood patch with some improvement. She was discharged the next day without opioids.

A Case of PML-IRIS: Diagnostic and Treatment Considerations: A 45-year-old man with a 12-year history of relapsing-remitting multiple sclerosis (RRMS) presented with a loss of balance and weakness on the left side of his body. His symptoms had worsened over the past 2 weeks. He had been stably treated with natalizumab for the past 4 years with no relapses during this period. MRI using the T2 FLAIR sequence was performed to look for white matter hyperintensities associated with demyelinating lesions. The MRI showed evidence of a large area of hyperintense signal within the right superior frontal cortical and subcortical white matter regions, with no enhancement

Case Report: Woman With Headache Pain, Dizziness, and Nausea: A 33-year-old woman has been experiencing recurrent episodes of nausea, headaches, and dizziness for the past 8 months. She has come to the emergency department because she is concerned about her current episode, which is slightly different from her previous ones. Her symptoms began in the early morning, waking her from sleep at around 5 AM. She had head pain, dizziness, and nausea-similar to the previous episodes-yet she has noticed flashing lights in front of her eyes. She also complains of tingling in both arms and hands, which had occurred with a few of her earlier bouts. She has been taking over-the-counter ibuprofen and acetaminophen all day long without improvement. She went to work as usual and has been trying to sleep since returning home from her job. However, she has been unable to sleep due to the pain.

Vertigo With an Effective Treatment But an Unknown Cause?  Vertigo can be caused by a number of neurological problems that affect the vestibular system of the inner ear, which contributes to balance and coordination. Causes of vertigo can range from benign (like migraine and Meniere disease) to serious (like tumors). However, for a fair number of people the cause is never identified. The term benign recurrent vertigo (BRV) refers to people with recurrent vertigo of unknown cause. BRV is largely a diagnosis of exclusion and relies mostly on clinical symptoms.

The Low-Down on Stem Cell Tourism for Neurological Diseases: Some patients have traveled overseas for stem cell treatments that cost up to $80,000 (not including the costs of travel). An estimated 700 stem cell clinics are located in 37 international locations, mostly in Asia, Europe, Central America, and the Caribbean. The top three conditions marketed by such clinics are MS, PD, and stroke. But stem cell tourism is also a domestic problem. At least 570 clinics in the US offer unproven stem cell therapies. The largest number of clinics are found in California, Florida, Texas, Colorado, Arizona and New York. Eighty of these businesses market treatments for neurological diseases, including MS, ALS, PD, AD, spinal cord injury, stroke, and “neuralgia.”

sTMS Device May Prevent Migraine: A study undertaken to evaluate the efficacy and tolerability of single pulse transcranial magnetic stimulation (sTMS) for the preventive treatment of migraine led to an FDA extended indication. The study used a multicenter, prospective, open-label, observational design and took place from December 2014 to March 2016. It included 217 adults with migraine (90% with episodic migraine, 10% with chronic migraine, 33% with aura, and 67% without aura).