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Volume 4, No 4 - Fall 2007

Volume 4, No 4 - Fall 2007

Table of Contents

Antiplatelet Agents and Randomized Trials Treatment Update
Patients who have transient ischemic attack (TIA) or ischemic stroke are at a high risk of having a first or recurrent stroke. The annual risk is between 5% and 15%; the risk is highest in the first 48 hours following a TIA and highest in the first 7 days following an ischemic stroke. Secondary prevention includes antithrombotic therapy, treatment of risk factors, and interventional treatment of carotid stenosis. Antithrombotic options can include antiplatelet drugs such as aspirin, aspirin plus extended-release dipyridamole (ER-DP), clopidogrel, or clopidogrel plus aspirin. Oral anticoagulation is used in patients with a cardiac source of embolism such as atrial fibrillation. Aspirin monotherapy offers a modest risk reduction for recurrent stroke and for the combined endpoint of nonfatal stroke, myocardial infarction (MI), and vascular death. The combination of ER-DP and aspirin was shown to be superior to aspirin monotherapy in several trials. Clopidogrel is superior to aspirin in high-risk patients suffering from stroke, MI, or peripheral arterial disease. The combination of clopidogrel plus aspirin is not superior to aspirin or clopidogrel monotherapy and carries a significantly higher bleeding risk. The combination might offer benefit in short-term secondary prevention after TIA or stroke. Another ongoing trial is currently investigating the possible benefit and side effects of aspirin plus ER-DP versus clopidogrel in secondary stroke prevention. [Rev Neurol Dis. 2007;4(4):177-183]
Treating Multiple Sclerosis in the Natalizumab Era: Risks, Benefits, Clinical Decision Making, and a Comparison Between North American and European Union Practices Treatment Update
Multiple sclerosis (MS) is the most common cause of nontraumatic severe neurological disability in young adults. If left untreated, most individuals with MS will accumulate significant physical and/or cognitive disability as the consequence of demyelination and axonal injury. Treatment has focused on disease-modifying therapies (DMTs) and questions remain about timing and indications for their use. Natalizumab is a humanized monoclonal antibody directed against 4-integrin that prevents migration of leukocytes into the brain parenchyma. The clinical and radiological efficacy of natalizumab has been shown in several randomized trials; however, adverse events associated with natalizumab have limited its use as a first-line agent. In this review we compare current recommendations for the use of first-line DMTs, adverse events associated with MS therapies, and differences between the practices in North American and the European Union. [Rev Neurol Dis. 2007;4(4):184-193]
Antiepileptic Drug Resistance and Tolerance in Epilepsy Treatment Update
Drug-resistant epilepsy is a prevalent problem despite the multiple antiepileptic drug (AED) options available. Despite variations in the definition of drug resistance, clinicians can identify risk factors for AED resistance. Drug-resistant partial epilepsy should be referred early to an epilepsy surgery center. Mimics of drug-resistant epilepsy abound and cause diagnostic confusion. Rapid advances in epilepsy research and pharmacogenomics are providing new insight into the mechanisms of drug resistance and tolerance. Rational AED strategies and promising interventions to treat or prevent drug resistance will reduce the impact on the patient. [Rev Neurol Dis. 2007;4(4):194-202]
Management of Acute Shingles (Herpes Zoster) Management Update
Practical, evidence-based recommendations for the management of acute shingles (herpes zoster) were published this year in Clinical Infectious Diseases. These guidelines were the result of a consensus meeting of several groups with an interest in neuropathic pain and varicella-zoster virus research. This article summarizes the key findings and recommendations that were generated from this meeting and reviews some of the research on which these guidelines are based. [Rev Neurol Dis. 2007;4(4):203-208]
Progressive Supranuclear Palsy Diagnosis and Management Update
Since progressive supranuclear palsy (PSP) was first reported as a separate clinicopathological entity in 1964, hundreds of other cases have been recorded, and PSP is now one of the most common atypical Parkinson-plus disorders. Diagnostic criteria have been developed by the National Institute of Neurological Disorders and Stroke and the Society for PSP, Inc. Because there is no biological marker for PSP, definitive diagnosis depends on neuropathological examination. Characteristics of PSP include gait disturbances, supranuclear ophthalmoplegia, axial limb rigidity, and frontal lobe dysfunction. Although there are no treatments that alter the natural history of disease in PSP and no drugs that provide significant symptomatic benefits, several supportive measures are available. [Rev Neurol Dis. 2007;4(4):209-216]
Advances in Epilepsy Meeting Review
Highlights from the 60th Annual Meeting of the American Epilepsy Society,December 1-5, 2006, San Diego, CA
Neuro-ophthalmology Meeting Review
Highlights of the 59th Annual Meeting of the American Academy of Neurology, April 28-May 5, 2007, Boston, MA
Tussive Headache with Weakness and Atrophy of the Right Hand Case Review
Although headaches are a very common complaint, those accompanied by paresthesia and muscle wasting indicate an underlying neurological disorder. In this review, we present the case of a 58-year-old man with chronic headaches who developed tingling and numbness in his right limbs along with right-hand muscle atrophy. [Rev Neurol Dis. 2007;4(4):224-228]
Parkinson’s Disease Reviewing the Literature