Spotlight on Treatment of neurologic disorders with marijuana

Cannabis, which for much of the past century was relegated to the status of an oddity (at best) or a drug of abuse (at worst), has in recent years seen a resurgence in its public popularity and use. A number of recent studies show that a majority of Americans believe cannabis should be legalized, and its use has doubled in the last decade. Concordant to this groundswell of public opinion is the increasing public and medical perception of cannabis as a potential treatment for a variety of medical symptoms, including nausea, pain, and anxiety. Recent AAN guidelines as well as stories in the popular media have raised patient perception of its possible utility in a variety of specific neurologic conditions as well. This coincides with increasing legalization of the drug for a variety of health conditions.

Given the increasing availability and patient interest in the potential applications of cannabis, clinician understanding of the history, risks, pathophysiology, and available clinical data, both in animal and human studies, is essential to accurately educate patients and make informed decisions about whether its use could provide benefit for specific neurologic diseases. In this article, Dr. Jonathan Snider of the University of Michigan disucsses treatment of neurologic disorders with marijuana.

To view the complete article, click here and log in.

Spotlight on Rehabilitation of spinal cord injury

Patients with spinal cord injuries present a unique set of challenges for medical management and rehabilitation. Loss of strength in the extremities requires a special focus on rehabilitation techniques to become as functionally independent as possible. Based on the deficits of the individual, there may be an emphasis on family training.

Patients experience many changes in their physiology, including gastrointestinal, genitourinary, cardiovascular, pulmonary, musculoskeletal, neurologic, and psychological changes that require regular monitoring. In this article, Dr. Michael Kryger of the University of Pittsburgh Medical Center and Dr. Amanda Harrington of the University of Pittsburgh Medical Center discuss how understanding these physiologic changes helps a practitioner successfully evaluate and treat patients with spinal cord injury.

To view the complete article, click here and log in.

Spotlight on Paradoxical insomnia

Paradoxical insomnia (previously called sleep state misperception) is characterized by complaints of little or no sleep over long periods of time without the level of impairment expected with such a level of sleep deprivation. Patients often describe heightened awareness of their surroundings when lying down to sleep. Sleep study reveals normal sleep architecture with normal sleep onset latency and sleep efficiency, but with subjective patient reports indicating prolonged sleep onset latency and poor sleep efficiency. Treatment usually involves patient reassurance. Behavioral therapy and sedative-hypnotics have also been tried.

In this article Dr. Deirdre Conroy of the University of Michigan reviews the manifestations, etiology, and diagnosis of paradoxical insomnia.

To view the complete article, click here and log in.

Spotlight on Emery-Dreifuss muscular dystrophy

In this article, Dr. Howard Worman of Columbia University discusses Emery-Dreifuss muscular dystrophy, a syndrome classically characterized by (1) slowly progressive muscle weakness and wasting in a scapulo-humeroperoneal distribution, (2) early contractures of the elbows, ankles, and posterior neck, and (3) dilated cardiomyopathy with conduction defects. Originally described as an X-linked disorder, Emery-Dreifuss muscular dystrophy-like phenotypes can arise from mutations in both autosomal and X chromosome genes including those encoding emerin and A-type lamins as well as in less frequent cases those encoding nesprin1, nesprin2, SUN1, SUN2, four-and-a-half-LIM protein 1, LUMA, and lamina-associated polypeptide 1. Although the skeletal muscle involvement can vary as a result of mutations in these genes, cardiomyopathy is the most prevalent and potentially life-threatening feature.

To view the complete article, click here and log in.

Spotlight on Executive dysfunction

The term “executive function” includes the ability to filter interference, engage in goal-directed behaviors, anticipate the consequences of one’s actions, and exhibit the adaptive concept of mental flexibility. The analysis of executive functions represents one of the most important research areas in contemporary neurosciences. It is partially related to frontal lobe activity.

In this article, Dr. Alfredo Ardila of Florida International University discusses executive disorders, which have been documented in a diversity of conditions. Executive defects early in dementia predict subsequent behavior disturbances, functional decline, and mortality. In elders, intellectual tasks and everyday activity programs may benefit executive function abilities.

To view the complete article, click here and log in.

Spotlight on Acute drug-induced movement disorders

Although it is generally believed that drug-induced movement disorders are much less common in the era of atypical antipsychotic drugs, there are little data to support this contention. Both acute and nonacute extrapyramidal disorders still do occur, so neurologists and psychiatrists should be able to recognize and treat them. Akathisia may be mistaken for other conditions, including restless legs, increased psychosis, or anxiety. These problems are occasionally seen with antiemetics and, more commonly, with antipsychotics (eg, chlorpromazine) used for migraines or depression. Akathisia may also be seen with tetrabenazine, a monoamine-depleting drug approved for the treatment of chorea associated with Huntington disease but also used for other hyperkinetic movement disorders. Although this drug does not cause tardive dyskinesia, it has been associated with acute dystonic reaction. Acute dystonic reactions occur with some, but not all, of the newer antipsychotic medications. Acute akathisia is harder to characterize because of the subjective nature of the symptoms. Neuroleptic malignant syndrome occurs with all antipsychotics, including all the atypicals.

In this article, Dr. Friedman of the Alpert Medical School of Brown University and University of Rhode Island, and Director of the Movement Disorders Program of Butler Hospital discusses acute drug-induced movement disorders.

To view the complete article, click here and log in.

Spotlight on Whipple disease

Whipple disease is a treatable, multisystem disease caused by infection with Tropheryma whipplei. Primarily considered a gastrointestinal disorder, the organism also invades joints, heart, skin, eyes, and the endocrine and nervous system, and, rarely, Whipple disease of the brain may occur as a primary neurologic disorder without multisystem involvement. Cognitive changes, supranuclear gaze palsy, altered consciousness, myoclonus, seizures, and ataxia occur. Oculomasticatory myorhythmia and oculofacioskeletal myorhythmia are pathognomonic signs. Isolated Whipple disease also mimics glioma. PET studies are useful in evaluating atypical MRI; diffusion restriction might also be a useful marker of progression and response to treatment.

In this article, Dr. Peter Panegyres, Director of Neurodegenerative Disorders Research Pty Ltd in Perth Australia, emphasizes the importance of molecular techniques, particularly polymerase chain reaction, to identify and confirm the diagnosis and evaluate therapy. Antibiotic treatment results in improvement with a sustained remission in the majority of patients.

To view the complete article, click here and log in.

Spotlight on Subcortical laminar heterotopia

In this article, Dr. Joseph Siebert of the University of Washington discusses subcortical laminar heterotopia, or double cortex, which is a genetic condition that occurs chiefly in females. Imaging shows a thickened band of subcortical white matter that consists microscopically of 2 layers of gray matter—an outer normal layer and an inner layer of heterotopic neurons—located subcortically in white matter. Developmental delay and seizures are early complications, as is intellectual disability; visual, perceptual, and fine motor deficits; or even spastic quadriparesis. Doublecortin (DCX), a gene involved in the growth of neuronal processes, neuronal migration, and possibly the regulation of cell adhesion, is mutated in a large proportion of patients with subcortical laminar heterotopia. The large number of patients with doublecortin deficiency is female because it is an X-linked dominant trait. However, cases of subcortical laminar heterotopia not associated with doublecortin mutations occur in both sexes.

To view the complete article, click here and log in.

Spotlight on Patent foramen ovale

In this article, Dr. Shadi Yaghi and Dr. Shawna Cutting of the Warren Alpert Medical School of Brown University discuss patent foramen ovale, a highly prevalent anomaly occurring in 25% to 30% of the general population.

Patent foramen ovale represents the postnatal persistence of the normally present foramen ovale, a flap valve structure formed by the septum primum and septum secundum in the fetus. Although it is generally asymptomatic, studies have found associations with ischemic stroke and migraine. The best treatment strategy for patent foramen ovale in the setting of ischemic stroke or migraine remains unclear. Randomized controlled trials on patent foramen ovale closure showed no benefit for secondary stroke prevention or migraine improvement.

To view the complete article, click here and log in.

Spotlight on Impact of sleep on epileptic manifestations

The circadian, homeostatic, ultradian, and microstructural processes that regulate the sleep-wake cycle are endowed with modulatory properties on epileptic events. In particular, sleep is a powerful trigger of both ictal and interictal manifestations. Non-REM sleep and cyclic alternating pattern promote strong activating effects, although REM sleep tends to exert a more inhibitory action. These characteristics are highly expressed in nocturnal frontal lobe epilepsy.

In this article, Dr. Parrino of the University of Parma discusses the impact of sleep on epileptic manifestations.

To view the complete article, click here and log in.