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Zonneveld H.I.,Alzheimer Center | Goos J.D.C.,Neurology | Wattjes M.P.,Alzheimer Center | Prins N.D.,Neurology | And 5 more authors.
Neurology | Year: 2014

Objective: To determine prevalence, topography, and severity of cortical superficial siderosis (SS), a recently recognized manifestation of cerebral amyloid angiopathy, and its possible association with Alzheimer disease (AD) in a memory clinic patient cohort. Methods: We included 809 patients (56% men, aged 66 6 10 years) from the Amsterdam Dementia Cohort between November 2010 and November 2012 scanned on a 3-tesla MRI system. We analyzed prevalence and topography of cortical SS according to demographic, clinical, and MRI data. Agreement for SS detection between 2 neuroradiologists was calculated by using Cohen k. Results: Agreement for detection of SS was excellent (unweighted k of 0.81). In 17 patients (2.1%), cortical SS was found without a known cause. The prevalence of idiopathic SS differed according to diagnostic groups (p , 0.001): nearly 5% (95% confidence interval [CI] 2.8%- 8.2%) in patients with AD (n 5 168) vs 2% (95%CI 0.7%-6.0%) in patients with mild cognitive impairment (n 5 143) and 2.5% (95% CI 0.7%-8.7%) in other types of dementia (n 5 80). By contrast, SS was not found in patients with subjective complaints (n 5 168) or in those with other disorders (n5157). Presence of SS was associated with APOE e4, microbleeds, and white matter hyperintensities (all p , 0.05) independent of diagnosis. Conclusion: The prevalence of cortical SS in a memory clinic setting is higher than reported in the general population but lower than reported in cerebral amyloid angiopathy. The relatively high prevalence of SS in AD suggests that SS is a relevant radiologic manifestation of amyloid pathology in AD. Presence of SS does not seem to predict severity of AD. Further longitudinal research is needed to investigate clinical relevance.

Furman J.M.,Neurology | Whitney S.L.,University of Pittsburgh
Current Opinion in Otolaryngology and Head and Neck Surgery | Year: 2010

Purpose of Review This review discusses the demographics of dizziness in the older person, the evaluation of the older dizzy patient and how the treatment of dizziness in older patients differs from that in younger individuals. Recent Findings: Seven percent of all visits to primary care physicians for patients older than 65 years of age are for dizziness, and dizziness is the most common complaint for patients older than 75 years. In a German study, the 12-month prevalence of vertigo in the general population was 5% with an incidence of 1.4% in adults overall. For individuals aged 60-69 the 12-month prevalence was found to be 7.2% and in individuals 70 years of age or older 8.9%. Data from the United States National Health and Nutrition Examination Surveys indicated that the prevalence of vestibular dysfunction for individuals in the seventh decade of life, eighth decade of life, and older was 49.4, 68.7, and 84.8 percent, respectively. Only subtle age effects are seen on caloric and rotational testing whereas vestibular evoked myogenic potentials (VEMPs) change somewhat with age. Particle repositioning for benign paroxysmal positional vertigo combined with vestibular rehabilitation is more effective than only performing the repositioning maneuver. Tai Chi appears to be an effective intervention for older adults at risk for falling. Summary: When caring for an older dizzy patient always assess medication use, perform a Dix-Hallpike maneuver, obtain orthostatic vital signs, discuss fall risk precautions, and consider referral for vestibular rehabilitation. © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins.

Weiss S.L.,Neurology | Parker B.,Medical Education | Bullock M.E.,Neurology | Swartz S.,Childrens Memorial Hospital | And 3 more authors.
Pediatric Critical Care Medicine | Year: 2012

OBJECTIVE: Pediatric patients with sepsis are identified using related but distinct criteria for clinical, research, and administrative purposes. The overlap between these criteria will affect the validity of extrapolating data across settings. We sought to quantify the extent of agreement among different criteria for pediatric severe sepsis/septic shock and to detect systematic differences between these cohorts. DESIGN: Observational cohort study. SETTING: Forty-two bed pediatric intensive care unit at an academic medical center. PATIENTS: A total of 1,729 patients ≤18 yrs-old. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: All patients were screened for severe sepsis or septic shock using consensus guidelines (research criteria), diagnosis by healthcare professionals (clinical criteria), and International Classification of Diseases, Ninth Revision, Clinical Modification codes (administrative criteria). Cohen's κ determined the level of agreement among criteria, and patient characteristics were compared between cohorts. Ninety (5.2%) patients were identified by research, 96 (5.6%) by clinical, and 103 (6.0%) by administrative criteria. The κ ± standard error for pair-wise comparisons was 0.67 ± 0.04 for research-clinical, 0.52 ± 0.05 for research-administrative, and 0.55 ± 0.04 for clinical-administrative. Of the patients in the clinical cohort, 67% met research and 58% met administrative criteria. The research cohort exhibited a higher Pediatric Index of Mortality-2 score (median, interquartile range 5.2, 1.6-13.3) than the clinical (3.6, 1.1-6.2) and administrative (3.9, 1.0-6.0) cohorts (p = .005), an increased requirement for vasoactive infusions (74%, 57%, and 45%, p < .001), and a potential bias toward an increased proportion with respiratory dysfunction compared with clinical practice. CONCLUSIONS: Although research, clinical, and administrative criteria yielded a similar incidence (5%-6%) for pediatric severe sepsis/septic shock, there was only a moderate level of agreement in the patients identified by different criteria. One third of patients diagnosed clinically with sepsis would not have been included in studies based on consensus guidelines or International Classification of Diseases, Ninth Revision, Clinical Modification codes. Differences in patient selection need to be considered when extrapolating data across settings. Copyright © 2012 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies.

Krupp L.B.,Stony Brook University Medical Center | Tardieu M.,University Paris - Sud | Amato M.P.,University of Florence | Banwell B.,Children's Hospital of Philadelphia | And 9 more authors.
Multiple Sclerosis Journal | Year: 2013

Background: There has been tremendous growth in research in pediatric multiple sclerosis (MS) and immune mediated central nervous system demyelinating disorders since operational definitions for these conditions were first proposed in 2007. Further, the International Pediatric Multiple Sclerosis Study Group (IPMSSG), which proposed the criteria, has expanded substantially in membership and in its international scope. Objective: The purpose of this review is to revise the 2007 definitions in order to incorporate advances in delineating the clinical and neuroradiologic features of these disorders. Methods: Through a consensus process, in which input was sought from the 150 members of the Study Group, criteria were drafted, revised and finalized. Final approval was sought through a web survey. Results: Revised criteria are proposed for pediatric acute disseminated encephalomyelitis, pediatric clinically isolated syndrome, pediatric neuromyelitis optica and pediatric MS. These criteria were approved by 93% or more of the 56 Study Group members who responded to the final survey. Conclusions: These definitions are proposed for clinical and research purposes. Their utility will depend on the outcomes of their application in prospective research. © The 2013 Author(s).

Chargari C.,Medical and Radiation Oncology | Feuvret L.,Radiation Oncology | Bauduceau O.,Medical and Radiation Oncology | Ricard D.,Neurology | And 3 more authors.
Cancer Treatment Reviews | Year: 2012

Elderly patients with glioblastoma are characterized by a high rate of associated morbidities, and a poor prognosis. Therefore, they have been excluded from most prospective clinical trials. However, the poorer outcome retrospectively reported in these patients might be also related to that those are less likely to receive the appropriate treatment than their younger counterparts. We reviewed the literature with regard to the optimal therapeutic management of this particular population, with focus on molecular perspectives for improving patients' selection. Clinical data have demonstrated that open craniotomy with resection of the tumor was superior to biopsy only in elderly patients with good Karnofsky Performance Status (KPS) score. Then, postoperative radiotherapy (RT) improves survival without impairing functional status or neurocognitive functions, compared with best supportive care only following resection. Despite promising preliminary data, the addition of concomitant temozolomide to RT has not been validated in patients more than 70-years old. In case of additional poor prognostic factors or after biopsy only, there is no definitive demonstration that RT, chemotherapy, or both could improve outcome. Incorporation of more sensitive predictive and/or prognostic molecular factors could help physicians in patients' selection. Further prospective trials should incorporate age-dependent molecular specificities in their design, and better focus on particular subgroup of patients exhibiting specific molecular alterations. © 2012 Elsevier Ltd.

Steinbrecher A.,Neurology
Aktuelle Rheumatologie | Year: 2016

Central nervous system (CNS) vasculitides are defined by inflammatory changes of intracranial and, occasionally, spinal vessel walls. They occur as cerebral manifestations of systemic vasculitides or can be a result of non-vasculitic diseases or present as isolated angiitis of the CNS. Although being rare diseases, they frequently have to be considered in the differential diagnosis due to the etiologically non-specific nature of clinical and radiological findings. A subacute presentation of multifocal neurological symptoms, headache, psychiatric symptoms or systemic inflammation, or the occurrence of stroke in patients of young age lacking a vascular risk profile or with known concomitant rheumatological diseases should raise the suspicion of CNS vasculitis. In addition to the confirmation of vasculitis, its etiology must be clarified, and - most importantly - infections have to be ruled out. In the case of isolated CNS angiitis, even invasive diagnostic measures such as cerebral angiography and CNS biopsy, which is the diagnostic gold standard, often do not lead to a definitive diagnosis. In addition to the treatment of any causative conditions, cerebral vasculitides are typically treated with a combination of corticosteroids and immunosuppressants. Instead of a uniform approach, disease severity and the degree of diagnostic certainty should be considered for the choice of treatment. © Georg Thieme Verlag KG Stuttgart New York.

Karanjia N.,Neurology | Nordquist D.,Westchester Medical Center | Stevens R.,Neurology | Nyquist P.,Neurology
Neurocritical Care | Year: 2011

Background Patients with acute brain injury but normal lung function are often intubated for airway protection, but extubation often fails. Currently, no clinical data exist that describe the events leading to extubation failure in this population. We examined the extubation failure rate, reintubation rate, and clinical characteristics of patients whose reason for intubation was a primary neurological injury. We then identified the clinical characteristics of those patients with primary brain injury who were reintubated. Methods We conducted a retrospective review of patients admitted to the neurocritical care unit of a tertiary care hospital from January 2002 to March 2007. Results Of 1,265 patients who were intubated because of primary neurological injury of brain, spinal cord, or peripheral nerve, 25 (2%) died before extubation and 767 (61%) were successfully extubated. Tracheostomies were placed in 181 (14%) patients, of which, 77 (6.1%) were completed before a trial of extubation and 104 (8.2%) after extubation failure. A total of 129 (10%) patients were reintubated; 77 (6.1%) were reintubated within 72 h, meeting the definition of extubation failure. The other 52 (4.1%) were intubated after 72 h usually in the setting of pneumonia or decreased mental status. Ninety-nine of the patients reintubated had primary brain injury and resulting encephalopathy. All were successfully reintubated. Most patients intubated as a result of a primary brain injury (981) were successfully extubated. The most common clinical scenario leading to reintubation in these encephalopathic patients was respiratory distress associated with altered mental status [59 patients (59%)]. These patients usually had atelectasis and decreased minute ventilation, independent of fever, pneumonia, aspiration, and increased work of breathing [39 patients (39%)]. Conclusion The extubation failure rate in our neurocritical care unit is low. In patients with encephalopathy and primary brain injury who were reintubated, respiratory distress caused by altered mental status was the most common cause of reintubation. These patients demonstrated signs disrupted ventilation usually with periods of prolonged hypoventilation. Increased work of breathing from lung injury due to pneumonia or aspiration was not the most common cause of reintubation in this population. © Springer Science+Business Media, LLC 2011.

Stocchi F.,Institute of Neurology | Zappia M.,University of Catania | Dall'Armi V.,IRCCS San Raffaele Pisana | Kulisevsky J.,Fundacio Of G S Of Lhospital Of La Santa Creu Sant Pau | And 2 more authors.
Movement Disorders | Year: 2010

Melevodopa hydrochloride plus carbidopa in effervescent tablets (M/C) is a readily soluble antiparkinsonian tablet formulation. A total of 221 patients with Parkinson's disease and motor fluctuations entered a randomized, double-blind, double-dummy, controlled parallel group study, which compared the effectiveness of oral M/C effervescent tablets with standard oral formulation levodopa/carbidopa tablets (L/C; Sinemet) in reducing total daily OFF time. The difference of total daily OFF time (intention-to-treat population) between the two groups was not statistically significant (P = 0.07): -39.4 minutes (95%CI: -67.08 to -11.73) in M/C group vs. +3.5 minutes (95%CI: -36.19 to +43.26) in the L/C group. In the intragroup analysis, M/C significantly reduced the baseline daily OFF, which remained unchanged in the L/C group. There were no unexpected adverse events in either treatment arms, and discontinuation rates due to adverse events did not differ between the two groups [M/C: 2 patients (1.3%); L/C: 1 patient (1.4%)]. This study failed to meet the primary endpoint (P = 0.07); however, there was a trend in favour of the M/C preparation, which deserves further attention. © 2010 Movement Disorder Society.

Hubert G.J.,Stadtisches Klinikum Munich GmbH | Muller-Barna P.,Neurology | Audebert H.J.,Charité - Medical University of Berlin
International Journal of Stroke | Year: 2014

TeleStroke has become an increasing means to overcome shortage of stroke expertise in underserved areas. This rapidly growing field has triggered a large amount of publications in recent years. We aimed to analyze recent advances in the field of telemedicine for acute stroke, with main focus on prehospital management, Stroke Unit treatment and network implementations in developing countries. Out of 260 articles, 25 were selected for this systematic review: 9 regarding prehospital management, 14 regarding Stroke Unit treatment and 2 describing a network in developing countries. Prehospital management showed that stroke recognition can start at the dispatch emergency call, important clinical information can be electronically transmitted to hospitals before admission and even acute treatment such as thrombolysis can be initiated in the prehospital field if ambulances are equipped with CT scan and point-of-care laboratory. Articles on remote clinical examination, telemedical imaging interpretation, trial recruitment and cost-effectiveness described various aspects of Stroke Unit treatment within TeleStroke networks, underlining reliability, safety and cost savings of these systems of care. Only one network was described to have been implemented in a developing/emerging nation. TeleStroke is a growing field expanding its focus to a broader spectrum of stroke care. It still seems to be underused, particularly in developing countries. © 2014 World Stroke Organization.

Assal F.,Neurology | Laganaro M.,University of Geneva | Remund C.D.,Geriatric Psychiatry | Paquier C.R.,Geriatric Psychiatry
Behavioural Neurology | Year: 2012

We present the longitudinal neurolinguistic, neuropsychological and neurologic follow-up of a 64 y.o. right-handed woman, who developed progressive apraxia of speech (PAOS), followed by peripheral agraphia then a left corticobasal syndrome (CBS). Neuroimaging (CT, MRI and FDG-PET) unequivocally showed progressive right hemispheric atrophy and hypometabolism. This particular evolution first confirms that PAOS is a phenotype of probable corticobasal degeneration (CBD). More importantly, this case underpins the neural organisation of motor planning processing in relation with speech, as well as graphic and limb praxis impairments, and constitutes a rare example of crossed-PAOS. ©2012-IOS Press and the authors. All rights reserved.

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