Disease-modifying therapies promise to become available as understanding of the pathophysiological basis of Alzheimer’s disease (AD) improves. The emergence of disease-modifying therapies requires reconsideration of the role of symptomatic agents in the management of AD. Combination therapy with disease-modifying and symptomatic agents will be optimal therapy for patients who have progressed to diagnosable AD. Symptomatic agents also may have a role in delaying the progression to AD in patients with mild cognitive impairment. In addition to current symptomatic treatment with cholinesterase inhibitors and memantine, other symptomatic approaches to the treatment of AD are under study. Therapeutic regimens for the treatment of AD will include both disease-modifying and symptomatic agents. [Rev Neurol Dis. 2007;4(2):57-62]

[Rev Neurol Dis. 2007;4(2):63]

Insomnia is one of the most common symptoms of disordered sleep. The etiology of insomnia is multifaceted, and the correct diagnosis will lead to effective treatment. One cause of insomnia that is often overlooked results from a conflict in schedules and desynchronization between the intrinsic sleep-wake propensity of a person and his or her 24-hour physical and social environment. Sleep propensity is governed by the complex interactions of an oscillating circadian rhythm and a monotonous homeostatic process. This review describes the basic physiology of the circadian system and, based on these understandings, discusses the various clinical manifestations of and treatments for circadian rhythm sleep disorders. [Rev Neurol Dis. 2007;4(2):64-74]

The advocates of evidence-based medicine have established a clear, unambiguous requirement for what they consider credible evidence: the randomized, controlled trial and systematic reviews of several or many randomized, controlled trials. However, evidence from therapeutic trials cannot always be applied to the care of individual patients. These studies yield information only on the likely benefit of a particular treatment strategy among a large group of often heterogeneous patients with a given condition. Some trials may show statistically significant positive results for a certain therapy, but these results may be of little or no practical benefit for most patients with the condition studied. Other studies may show that a certain treatment is beneficial to most patients, although it may have serious risks and cause harm in others with the same condition. To be therapeutically useful, a trial must study specific, well-defined, and quantifiable conditions with important and readily recognized and defined endpoints. More importantly, physicians should spend more time finding out what is wrong with each patient and getting to know his or her circumstances, family situations, psychosocial and economic stresses, thoughts, fears, biases, and wishes. [Rev Neurol Dis. 2007;4(2):75-84]

The stroke patient who deteriorates presents a common and rewarding diagnostic challenge. Up to one third of ischemic stroke patients worsen after admission, though the frequency of deterioration is declining with modern supportive care. The causes of clinical worsening are diverse; common etiologies include collateral failure, brain edema, seizures, reocclusion after successful initial therapeutic recanalization, and systemic medical complications. Clot propagation and recurrent embolization are only infrequent mechanisms of worsening. The advent of multimodal computed tomography and magnetic resonance imaging has transformed the evaluation of the deteriorating stroke patient. History, physical examination, screening blood work, and emergent reassessment of the cervical and cerebral vasculatures, regional hypoperfusion, and infarct core will yield a firm diagnosis of the cause of clinical worsening in the majority of patients. The therapeutic armamentarium for the worsening stroke patient has expanded greatly. Treatment options now include rescue late endovascular recanalization therapy, pressor collateral enhancement therapy, hemicraniectomy, and additional novel interventions in addition to enhanced supportive care. Because most causes of worsening can be treated effectively, the deteriorating stroke patient merits a swift and incisive diagnostic and therapeutic response. [Rev Neurol Dis. 2007;4(2):85-91]

Highlights from the 33rd Annual Meeting of the North American Neuro-Ophthalmology Society Snowbird, UT, February 10-15, 2007 [Rev Neurol Dis. 2007;4(2):92-96]

Highlights from the 30th Annual Meeting of the American Society of Neuroimaging January 17-21, 2007, Miami, FL [Rev Neurol Dis. 2007;4(2):97-99]

The incidence of mumps cases has declined dramatically since the introduction of the measles, mumps, rubella vaccine. A recent outbreak, however, brings to attention the importance of recognizing the clinical symptoms and signs of mumps, because early isolation of patients may prevent spread of the disease. The authors present the case of a 50-year-old man with severe encephalitis found to be caused by the mumps virus. [Rev Neurol Dis. 2007;4(2):100-102]

Although more data are needed, animal studies and clinical experience suggest that marijuana or its active constituents may have a place in the treatment of partial epilepsy. Here we present the case of a 45-year-old man with cerebral palsy and epilepsy who showed marked improvement with the use of marijuana. This case supports other anecdotal data suggesting that marijuana use may be a beneficial adjunctive treatment in some patients with epilepsy. Although challenging because of current federal regulations, further studies are needed to examine the role of marijuana in the treatment of this disorder. [Rev Neurol Dis. 2007;4(2):103-106]