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Volume 4, No 1 - Winter 2007

Volume 4, No 1 - Winter 2007

Table of Contents

Functional Neuroimaging and Repetitive Transcranial Magnetic Stimulation in Parkinson’s Disease Imaging and Management Update
Functional neuroimaging provides insights into the pathogenesis of motor symptoms in Parkinson’s disease (PD) and improves our understanding of both established neuromodulatory therapies such as deep brain stimulation (DBS) and potential ones such as repetitive transcranial magnetic stimulation (rTMS). Functional imaging studies can reveal the consequences of the dopaminergic lesion in PD among a widespread network of subcortical–cortical regions. Characteristic patterns of normal cortical brain activation for motor tasks are systematically altered in PD. Recent work has emphasized the task dependence of these changes and their gradual evolution over the course of the disease. Clinically relevant PD treatment with medications or DBS tends to normalize these patterns. In this context, rTMS is discussed as a potential noninvasive alternative for neuromodulation of cortical function. Although rTMS is not a current treatment, we review recent rTMS studies in PD that suggest its promise, illustrate how functional imaging can guide application of rTMS, and suggest that subcortical dopamine release could be an rTMS mechanism of action. The combination of rTMS and functional neuroimaging broadens our knowledge of functional cortical networks in PD, which can eventually provide physicians with pathophysiologic information about different PD treatment options and rationales for neuromodulatory interventions. [Rev Neurol Dis. 2007;4(1):1-9]
Current Acute Care of Intracerebral Hemorrhage Diagnosis and Management Update
Intracerebral hemorrhage is the stroke subtype with the highest mortality rate (40% to 50%). Until the hypotheses investigating the amelioration of disease severity factors are completely tested and found to be correct, intracerebral hemorrhage will remain the leading cause of stroke morbidity and mortality in the United States. The acute management of intracerebral hemorrhage with particular emphasis on the evolving areas of probable therapeutic benefit, which are early stabilization, management of mass effect by intraventricular clot removal, and intracranial pressure management, are reviewed. [Rev Neurol Dis. 2007;4(1):10-18]
The Neurology of Insomnia: Introduction to the Series The Neurology of Insomnia Series
[Rev Neurol Dis. 2007;4(1):19-20]
Clinical Neurology of Insomnia in Neurodegenerative and Other Disorders of Neurological Function Treatment Update
Complaints of insomnia are prevalent in neurodegenerative and neurological disorders. Neurologists therefore must be aware of the underlying causes, pathophysiologic mechanisms, and potential interventions when encountering a patient with underlying neurological disorders who is also complaining of poor sleep and insomnia. This article describes the underlying pathophysiology, diagnostic approaches, and potential interventions for insomnia in the neurological patient. Clinicians need to recognize that insomnia in older patients with underlying neurological disorders is not only unique, but also complex, demanding comprehensive and careful evaluation and management. Treatment of insomnia should start by addressing nonpharmacologic options, including improvements in sleep hygiene, improving sunlight exposure during the day, and searching for underlying reversible causes, such as sleep apnea, restless legs syndrome, periodic leg movements, and circadian rhythm disturbances, all of which can precipitate insomnia when left untreated. Some patients may benefit from targeted and carefully tailored pharmacologic treatment. Successful amelioration of insomnia can ultimately be a very rewarding experience for the patient, family members, and the practitioner. [Rev Neurol Dis. 2007;4(1):21-34]
Studies in Neuropathy and Myasthenic Disorders Meeting Review
Highlights of the American Association of Neuromuscular and Electrodiagnostic Medicine Annual Meeting October 11-14, 2006 Washington, DC [Rev Neurol Dis. 2007;4(1):35-38]
Anterior Cingulate Epilepsy in an 18-Year-Old Woman Case Review
Anterior cingulate epilepsy is a diagnostic and therapeutic challenge, with a broad range of nonspecific symptoms. Seizures can arise from any region of the anterior cingulate cortex (ACC) and manifest distinctive features based on the area of onset and pattern of spread. These features may provide insight as to the origin of the seizures, but because the ACC integrates information from several networks involving emotional and executive functions and has a diverse cytoarchitecture, functional–structural correlates are complex. Further, the location of the ACC within the interhemispheric fissure limits the capacity of scalp electrodes to record seizure activity from this region. This case review illustrates one part of the spectrum of cingulate epilepsy and discusses clinical features of the disorder. [Rev Neurol Dis. 2007;4(1):39-42]
Should Electroconvulsive Therapy Be Given to Patients With Intracranial Vascular Lesions? Case Review
The risk of rupture and hemorrhage of intracranial vascular lesions during electroconvulsive therapy (ECT) is currently unknown. We describe 2 cases in which ECT was discontinued because of perceptual disturbances, confusion, and the subsequent discovery of intracranial angiomas. ECT has been associated with nonconvulsive status epilepticus and prolonged altered mental status following treatment, but there has been scant documentation of side effects associated with intracranial vascular malformations. We review the literature on ECT in patients with such lesions and present 2 cases in which lesions were found in the context of perceptual disturbances and altered states of consciousness following ECT. [Rev Neurol Dis. 2007;4(1):43-50]