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ORIGINAL CONTRIBUTION: Exclusive Breastfeeding and the Risk of Postpartum Relapses in Women With Multiple Sclerosis

Objective To determine if exclusive breastfeeding protects against postpartum relapses of multiple sclerosis (MS) and, if so, whether this protection is related to prolonged lactational amenorrhea.Design We conducted structured interviews to assess clinical, menstrual, and breastfeeding history during each trimester and 2, 4, 6, 9, and 12 months postpartum and collected neurological examination findings from the treating physicians of women with MS. Hazards ratios (HRs) were adjusted for measures of disease severity and age.Setting Kaiser Permanente Northern California and Stanford University.Participants We prospectively enrolled 32 pregnant women with MS and 29 age-matched, pregnant controls.Main Outcome Measure Postpartum relapse.Results Of the 52% of women with MS who did not breastfeed or began regular supplemental feedings within 2 months postpartum, 87% had a postpartum relapse, compared with 36% of the women with MS who breastfed exclusively for at least 2 months postpartum (unadjusted HR, 5.0; 95% confidence interval, 1.7-14.2; P = .003; adjusted HR, 7.1; 95% confidence interval, 2.1-24.3; P = .002). Sixty percent reported that the primary reason for foregoing exclusive breastfeeding was to resume MS therapies. Women who breastfed exclusively had a later return of menses (P = .001) than women who did not, and lactational amenorrhea was associated with a reduced risk of postpartum relapses (P = .01).Conclusions Our findings suggest that exclusive breastfeeding and concomitant suppression of menses significantly reduce the risk of postpartum relapses in MS. Our findings call into question the benefit of foregoing breastfeeding to start MS therapies and should be confirmed in a larger study.Published online June 8, 2009 (doi:10.1001/archneurol.2009.132).

ORIGINAL CONTRIBUTION: Validity of Self-reported Stroke in Elderly African Americans, Caribbean Hispanics, and Whites

Background The validity of a self-reported stroke remains inconclusive.Objective To validate the diagnosis of self-reported stroke using stroke identified by magnetic resonance imaging (MRI) as the standard.Design, Setting, and Participants Community-based cohort study of nondemented, ethnically diverse elderly persons in northern Manhattan.Methods High-resolution quantitative MRIs were acquired for 717 participants without dementia. Sensitivity and specificity of stroke by self-report were examined using cross-sectional analyses and the 2 test. Putative relationships between factors potentially influencing the reporting of stroke, including memory performance, cognitive function, and vascular risk factors, were assessed using logistic regression models. Subsequently, all analyses were repeated, stratified by age, sex, ethnic group, and level of education.Results In analyses of the whole sample, sensitivity of stroke self-report for a diagnosis of stroke on MRI was 32.4%, and specificity was 78.9%. In analyses stratified by median age (80.1 years), the validity between reported stroke and detection of stroke on MRI was significantly better in the younger than the older age group (for all vascular territories: sensitivity and specificity, 36.7% and 81.3% vs 27.6% and 26.2%; P = .02). Impaired memory, cognitive skills, or language ability and the presence of hypertension or myocardial infarction were associated with higher rates of false-negative results.Conclusions Using brain MRI as the standard, specificity and sensitivity of stroke self-report are low. Accuracy of self-report is influenced by age, presence of vascular disease, and cognitive function. In stroke research, sensitive neuroimaging techniques rather than stroke self-report should be used to determine stroke history.Published online May 11, 2009 (doi:10.1001/archneurol.2009.83).

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EDITORIAL: Cerebral Microbleeds: Evidence of Heightened Risk Associated With Aspirin Use

NEUROLOGICAL REVIEW: Deep Brain Stimulation, Neuroethics, and the Minimally Conscious State: Moving Beyond Proof of Principle

NEUROLOGICAL REVIEW: Primary Angiitis of the Central Nervous System

Primary angiitis of the central nervous system (PACNS) is a rare form of vasculitis of unknown cause. The mean age of onset is 50 years, and men are affected twice as often as women. Headache and encephalopathy are the most frequent initial symptoms. Stroke or focal symptoms develop in less than 20% of patients at the onset of disease and are uncommon in the absence of headache or encephalopathy. Symptoms or signs of vasculitis outside of the central nervous system are rare; serologic markers of inflammation are typically normal. Magnetic resonance imaging of the brain is abnormal in more than 90% of patients, but the pattern of abnormal findings is not specific. Cerebrospinal fluid analysis is also usually abnormal because of modest, nonspecific elevations in total protein level or white blood cell count. Angiography has a low sensitivity and low specificity. Most patients suspected of having PACNS have another disease. The diagnosis of PACNS is established by brain biopsy. The differential diagnosis of PACNS is broad and includes reversal cerebral vasoconstriction. In contrast to patients with PACNS, patients with reversal cerebral vasoconstriction are more often young women who experience a thunderclap headache and have a normal cerebrospinal fluid analysis. Patients with biopsy-proven PACNS are treated with cyclophosphamide and prednisone.

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ORIGINAL CONTRIBUTION: Use of Antithrombotic Drugs and the Presence of Cerebral Microbleeds: The Rotterdam Scan Study

Background Cerebral microbleeds are hemosiderin deposits in the brain that are indicative of microangiopathy. Microbleeds in strictly lobar brain locations have been related to cerebral amyloid angiopathy, a bleeding-prone disease state. Objective To investigate the relation between antithrombotic drug use and the presence of cerebral microbleeds, especially those in strictly lobar locations. Design A population-based, cross-sectional analysis that used magnetic resonance imaging (MRI) to assess the presence and location of microbleeds. Complete information on outpatient use of platelet aggregation inhibitors and anticoagulant drugs before MRI was obtained from automated pharmacy records. Setting The Rotterdam Scan Study, a population-based imaging study in a general elderly community in the Netherlands. Participants A population-based sample of 1062 persons from a longitudinal cohort, 60 years and older, free of dementia, who underwent MRI examinations between August 15, 2005, and November 22, 2006. Main Outcome Measures Presence of cerebral microbleeds on MRI. Results Compared with nonusers of antithrombotic drugs, cerebral microbleeds were more prevalent among users of platelet aggregation inhibitors (adjusted odds ratio [OR], 1.71; 95% confidence interval [CI], 1.21-2.41). We did not find a significant association for anticoagulant drugs and microbleed presence (OR, 1.49; 95% CI, 0.82-2.71). Strictly lobar microbleeds were more prevalent among aspirin users (adjusted OR compared with nonusers, 2.70; 95% CI, 1.45-5.04) than among persons using carbasalate calcium (adjusted OR, 1.16; 95% CI, 0.66-2.02). This difference was even more pronounced when comparing persons who had used similar dosages of both drugs. Conclusions This cross-sectional study shows that use of platelet aggregation inhibitors is related to the presence of cerebral microbleeds. Furthermore, aspirin and carbasalate calcium use may differently relate to the presence of strictly lobar microbleeds. Published online April 13, 2009 (doi:10.1001/archneurol.2009.42).

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ORIGINAL CONTRIBUTION: How Seizure Detection by Continuous Electroencephalographic Monitoring Affects the Prescribing of Antiepileptic Medications

Objectives To assess the effect of continuous electroencephalographic monitoring on the decision to treat seizures in the inpatient setting, particularly in the intensive care unit. Design Retrospective cohort study. Setting Medical and neuroscience intensive care units and neurological wards. Patients Three hundred consecutive nonelective continuous electroencephalographic monitoring studies, performed on 287 individual inpatients over a 27-month period. Main Outcome Measures Epileptiform electroencephalographic abnormalities and changes in antiepileptic drug (AED) therapy based on the electroencephalographic findings. Results The findings from the continuous electroencephalographic monitoring led to a change in AED prescribing in 52% of all studies with initiation of an AED therapy in 14%, modification of AED therapy in 33%, and discontinuation of AED therapy in 5% of all studies. Specifically, the detection of electrographic seizures led to a change in AED therapy in 28% of all studies. Conclusions The findings of continuous electroencephalographic monitoring resulted in a change in AED prescribing during or after half of the studies performed. Most AED changes were made as a result of the detection of electrographic seizures.

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ORIGINAL CONTRIBUTION: Automatisms in Absence Seizures in Children With Idiopathic Generalized Epilepsy

Background Automatisms are well recognized to occur in complex partial seizures; however, their occurrence in generalized epilepsies is not always appreciated. There has been considerable debate regarding the nature, triggers, and timing of automatisms in absence seizures. Objectives To examine the frequency and nature of automatisms in new-onset absence seizures and assess the influence of the state of arousal, provocation, age, and epilepsy syndrome on the presence and type of automatisms. Design Analysis of absence seizures through video electroencephalogram (EEG) recordings. Setting British Columbia's Children's Hospital, Vancouver, British Columbia, Canada. Patients Seventy consecutive children with new-onset untreated absence seizures in idiopathic generalized epilepsy recruited between January 1, 1992, and June 30, 1997. Main Outcome Measures Each seizure was analyzed for the presence and characteristics of automatisms. The influence of the following variables on the presence of automatisms was statistically analyzed: state of arousal (awake, drowsy, asleep), provocation (hyperventilation, photic stimulation), age, and epilepsy syndrome. Results Automatisms occurred in 163 of 405 seizures (40%) in 53 of 70 children (76%). Automatisms were more likely in longer seizures and hyperventilation. Only 23% of spontaneous awake seizures had automatisms. Automatisms were similar for an individual child; however, automatisms were not present in all their seizures. Age, epilepsy syndrome, or state of alertness had no effect on the presence of automatisms. Conclusions Automatisms are frequently seen during childhood absence seizures. The high frequency of automatisms during EEG recordings is predominantly due to the effect of hyperventilation. Their preponderance during longer seizures may relate to opportunity for automatisms to occur. The characteristic pattern of automatisms suggests a reactive phenomenon to internal and external stimuli.

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ORIGINAL CONTRIBUTION: Ganglionic Acetylcholine Receptor Autoantibody: Oncological, Neurological, and Serological Accompaniments

Objective To describe the clinical utility of the nicotinic ganglionic acetylcholine receptor (3-AChR) autoantibody as a marker of neurological autoimmunity and cancer. Design Case-control study. Setting Mayo Clinic, Rochester, Minnesota. Patients A total of 15 000 patients seen at Mayo Clinic (2005-2007) and evaluated on a service basis for paraneoplastic neurological autoimmunity for whom clinical information was obtained retrospectively by medical record review as well as 457 neurologically asymptomatic patients or control subjects of whom 173 were healthy, 245 had lung cancer, and 39 had systemic lupus erythematosus or Sjögren syndrome. Outcome Measures Neurological, oncological, and serological associations of 3-AChR autoantibody seropositivity. Results Of 15 000 patients tested on a service basis, 1% were seropositive (median, 0.12 nmol/L; range, 0.03-18.8 nmol/L; normal, ≤0.02 nmol/L), 55% were male, and the median age was 65 years. Cancer was found (new or by history) in 24 of 78 patients evaluated for cancer while at Mayo Clinic (30%); 43% had adenocarcinoma (more patients had breast cancer than prostate, lung, and gastrointestinal cancers; each of the latter groups had about the same number of patients). Of 12 patients with high antibody values (≥1.00 nmol/L), 83% had pandysautonomia. Of 85 patients with medium antibody values (0.10-0.99 nmol/L), neurological presentations were more diverse and included peripheral neuropathies (36%), dysautonomia (20%, usually limited), and encephalopathy (13%). Of 58 patients with low antibody values (0.03-0.09 nmol/L), 54% had a nonautoimmune neurological disorder or no neurological disorder. Of 245 control patients with lung cancer, 7.8% were seropositive. Only 1 of 212 control patients without cancer (0.5%) was seropositive (P < .001). Conclusion The detection of 3-AChR autoantibody aids the diagnosis of neurological autoimmunity and cancer.

ORIGINAL CONTRIBUTION: Prospective Differentiation of Multiple System Atrophy From Parkinson Disease, With and Without Autonomic Failure

Objective To report preliminary results of a prospective ongoing study of multiple system atrophy (MSA) and Parkinson disease (PD), with a large subset of patients with PD with autonomic failure (25%), to evaluate autonomic indices that distinguish MSA from PD. Methods We used consensus criteria, detailed autonomic studies (Composite Autonomic Symptom Scale, Composite Autonomic Scoring Scale, thermoregulatory sweat test, and plasma catecholamines), and functional scales (Unified MSA Rating Scale [UMSARS] I-IV and Hoehn-Yahr grading) on a prospective, repeated, and ongoing basis. Results We report the results of a study on 52 patients with MSA (mean [SD], age, 61.1 [7.8] years; body mass index (calculated as weight in kilograms divided by height in meters squared), 27.2 [4.6]; Hoehn-Yahr grade, 3.2 [0.9]; UMSARS I score, 21.5 [7.4]; and UMSARS II score, 22.7 [9.0]) and 29 patients with PD, including PD with autonomic failure (mean [SD], age, 66.0 [8.1] years; body mass index, 26.6 [5.5]; Hoehn-Yahr grade, 2.2 [0.8]; UMSARS I score, 10.4 [6.1]; and UMSARS II score, 13.0 [5.9]). Autonomic indices were highly significantly more abnormal in MSA than PD (P < .001) for the Composite Autonomic Scoring Scale (5.9 [1.9] vs 3.3 [2.3], respectively), Composite Autonomic Symptom Scale (54.4 [21.8] vs 24.7 [20.5], respectively), and thermoregulatory sweat test (percentage anhidrosis, 57.4% [35.2%] vs 9.9% [17.7%], respectively). These differences were sustained and greater at 1-year follow-up, indicating a greater rate of progression of dysautonomia in MSA than PD. Conclusions The severity, distribution, and pattern of autonomic deficits at study entry will distinguish MSA from PD, and MSA from PD with autonomic failure. These differences continue and are increased at follow-up. Our ongoing conclusion is that autonomic function tests can separate MSA from PD. Autonomic indices support the notion that the primary lesion in PD is ganglionic and postganglionic, while MSA is preganglionic.

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ORIGINAL CONTRIBUTION: A Long-term Prospective Study of the Natural Course of Sporadic Adult-Onset Lower Motor Neuron Syndromes

Objective To determine the natural course of sporadic adult-onset lower motor neuron syndrome in a long-term prospective study of patients with the syndrome. Design Inception cohort with a follow-up of 72 months. Setting Three university hospitals in the Netherlands (referral centers for neuromuscular diseases). Patients Thirty-two patients were classified as having the following phenotypes according to previously defined criteria: progressive muscular atrophy (PMA; 10 patients), segmental distal muscular atrophy (8 patients), and segmental proximal muscular atrophy (14 patients). A disease duration of at least 4 years was chosen to exclude most patients with amyotrophic lateral sclerosis (ALS). Main Outcome Measures Muscle strength, functional impairment, and respiratory function were assessed at 0, 6, 12, 18, and approximately 72 months. Results The diagnosis had to be changed to ALS in 3 patients (classified at inclusion as PMA in 2 patients and segmental proximal muscular atrophy in 1) owing to the development of upper motor neuron signs in 2 patients and familial ALS in 1. The remaining 8 patients with PMA showed further deterioration, and the other 24 patients remained more or less stable during long-term follow-up. Respiratory insufficiency developed in 6 of the 11 patients with ALS or PMA, 5 of whom died. Conclusions Patients with lower motor neuron syndromes and a disease duration of at least 4 years usually have a favorable prognosis if muscle involvement has a segmental distribution. In patients with a generalized phenotype, progression is relentlessly progressive and eventually leads to death due to respiratory insufficiency.

ORIGINAL CONTRIBUTION: Defining Survival as an Outcome Measure in Amyotrophic Lateral Sclerosis

Objectives To examine how respiratory interventions affect survival as an outcome measure and to define survival rate for trials in amyotrophic lateral sclerosis. Design and Setting We reviewed the data of 3 phase 3 clinical trials and examined differences in times to death, tracheostomy, and permanent assisted ventilation. We assessed the outcomes with 2 and Fisher exact tests for categorical variables and unpaired, 2-tailed t tests for continuous variables. We used Kaplan-Meier methods to estimate the differences in survival times between interventions. A power analysis generated sample size estimates for different end points. Patients In all, 2077 patients in 2 phase 3 trials of xaliproden and 400 patients in a phase 3 trial of pentoxifylline. Main Outcome Measures Death or combined death, tracheostomy, or permanent assisted ventilation. Results Of 745 deaths, 611 (82.0%) were owing to respiratory failure and 134 (18.0%) to other causes. The use of respiratory interventions across centers ranged from 0% to 6.6% (P = .001) of patients for tracheostomy and 11.1% to 23.1% (P = .05) of patients for noninvasive ventilation. Twelve of 55 patients (21.8%) undergoing tracheostomy had a vital capacity of 50% or more. Mean (SD) survival time was 457.9 (3.1) days using a combined end point and 467.2 (2.9) days with death alone as the outcome (P = .02). An estimated sample size to detect a 10% difference at 18 months between groups was 490 patients per arm for the combined end point and 410 patients for death alone. Conclusions Tracheostomy and permanent assisted ventilation are not equivalent to death in amyotrophic lateral sclerosis. The use of respiratory interventions differs between centers, leading to variability in combined outcome assessments. The time to the end point can differ significantly depending on its definition, and combining outcomes does not reduce the estimated sample size of a trial. The death rate alone is the least variable and most easily identifiable measure of survival rate in amyotrophic lateral sclerosis.

ORIGINAL CONTRIBUTION: Effect of Changes in Fat Availability on Exercise Capacity in McArdle Disease

Background The major fuel for exercising muscle at low exercise intensities is fat. Objective To investigate the role of fat metabolism in McArdle disease (also known as glycogen storage disease type V), an inborn error of muscle glycogenolysis, by manipulating free fatty acid availability for oxidation during exercise. Design Randomized, placebo-controlled, crossover trial. Setting Hospitalized care. Patients Ten patients (8 men and 2 women) with McArdle disease. Interventions Patients cycled at a constant workload corresponding to 70% of their maximum oxygen consumption. In random order and on separate days, patients received nicotinic acid (a known blocker of lipolysis) to decrease the availability of free fatty acids or 20% Intralipid infusion to increase free fatty acid availability during exercise. Results were compared with placebo (isotonic sodium chloride solution infusion) and glucose infusion trials. Main Outcome Measures Exercise tolerance was assessed by heart rate response to exercise during different infusions. Results Free fatty acid levels more than tripled by Intralipid infusion and were halved by nicotinic acid administration. Heart rate was significantly higher during exercise in the Intralipid infusion and nicotinic acid trials compared with the placebo and glucose infusion trials, an effect that was observed before and after the patients had experienced the second wind phenomenon. Conclusions Lipids are an important source of fuel for exercising muscle in McArdle disease, but maximal rates of fat oxidation seem limited and cannot be increased above physiologically normal rates during exercise. This limitation is probably caused by a metabolic bottleneck in the tricarboxylic acid cycle due to impaired glycolytic flux in McArdle disease. Therapies aimed at enhancing fat use in McArdle disease should be combined with interventions targeting expansion of the tricarboxylic acid cycle.

ORIGINAL CONTRIBUTION: Biracial Population Study of Mortality in Mild Cognitive Impairment and Alzheimer Disease

Objective To assess mortality associated with mild cognitive impairment (MCI) and Alzheimer disease (AD) among older African Americans and whites from an urban community. Design Longitudinal population-based observational study. Setting Four adjacent neighborhoods in Chicago, Illinois. Participants Persons deemed free of dementia in a previous wave of data collection (n = 1715) underwent detailed clinical evaluation: 802 had no cognitive impairment (46.8%), 597 had MCI (34.8%), 296 had AD (17.3%), and 20 had other forms of dementia (1.2%). Main Outcome Measure All-cause mortality. Results During as many as 10 years of observation (mean [SD], 4.7 [3.0] years), 634 individuals died (37.0%). Compared with people without cognitive impairment, risk of death was increased by about 50% among those with MCI (hazard ratio [95% confidence interval], 1.48 [1.22-1.80]) and was nearly 3-fold greater among those with AD (2.84 [2.29-3.52]). These effects were seen among African Americans and whites and did not differ by race. Among participants with MCI, risk of death increased with more severe cognitive impairment, and this effect did not vary by race. A similar effect was seen among participants with AD, but it was slightly stronger for African Americans vs whites. In the MCI and AD groups, the association of cognitive impairment with survival was stronger for perceptual speed than for other cognitive functions. Conclusion The presence and severity of MCI and AD are associated with reduced survival among African Americans, and these effects are comparable to those seen among whites.

CORRECTION: Error in Correction to Figure Legend in: Episodic Ataxia Associated With EAAT1 Mutation C186S Affecting Glutamate Reuptake

ORIGINAL CONTRIBUTION: Stability of the Clinical Dementia Rating, 1979-2007

Objective To examine dementia severity as determined by the Clinical Dementia Rating (CDR) over time. Design Secondary analysis of data from longitudinal studies of aging and dementia. Setting Alzheimer’s Disease Research Center, where a variety of clinicians contributed CDR ratings during the study. Participants Adults aged 63 to 83 years with no (CDR 0), very mild (CDR 0.5), or mild (CDR 1) dementia enrolled in the Alzheimer’s Disease Research Center at any time from August 13, 1979, through May 30, 2007. Main Outcome Measures Within each CDR group, changes in scores on standardized psychometric tests with time were examined using multiple linear regression analyses. These tests included the Mini-Mental State Examination, Short Blessed Test, Logical Memory IA-Immediate from the Wechsler Memory Scale–Revised, and Blessed Dementia Scale, and a psychometric composite score. Results A total of 1768 participants met the inclusion criteria. With time, participants were older, more educated, and more likely to be nonwhite and less likely to be men. Statistically significant change in psychometric test performance with time occurred only within the CDR 1 group for Logical Memory and the psychometric composite, but the degree of change was minimal. Conclusion Despite changes in participant characteristics, the CDR demonstrates general stability for assessment of dementia for almost 3 decades.

FROM JAMA: Enough Is Enough: Moving on to Deep Brain Stimulation in Patients With Fluctuating Parkinson Disease

OBSERVATION: Cognitive Functions in a Patient With Parkinson-Dementia Syndrome Undergoing Deep Brain Stimulation

Background Dementia represents one of the most challenging health problems. Despite intense research, available therapies have thus far only achieved modest results. Deep brain stimulation (DBS) is an effective treatment option for some movement disorders and is under study for psychiatric applications. Recently, diencephalic DBS revealed selective effects on memory functions, another facet of subcortical DBS. Objective To report a new DBS strategy for the modification of cognitive functions in a patient with severe Parkinson-dementia syndrome. Design Prospective study with double-blinded sham stimulation period. Setting Departments of Stereotaxy and Functional Neurosurgery and Psychiatry and Psychotherapy, University of Cologne, Cologne, Germany. Patient A 71-year-old man with slowly progressive Parkinson-dementia syndrome. Intervention We inserted 2 electrodes into the nucleus basalis of Meynert in addition to electrodes in the subthalamic nucleus. Main Outcome Measure Improvement of cognitive functions. Results Turning on the subthalamic nucleus electrodes improved motor symptoms but left cognitive performance almost unchanged. Turning on electrical stimulation of the nucleus basalis of Meynert resulted in markedly improved cognitive functions. The improvement in attention, concentration, alertness, drive, and spontaneity resulted in the patient's renewed enjoyment of former interests and enhanced social communication. Conclusions Such a broad effect on cognition is consistent with ample experimental evidence revealing that the nucleus basalis of Meynert provides cholinergic innervation to the cortical mantle, complemented by glutaminergic and -aminobutyric acid–transmitting projections from the basal forebrain. These projections provide background tuning facilitating cortical operations. Furthermore, nucleus basalis of Meynert stimulation paired with sensory stimuli can accomplish persistent reorganization of specific processing modules. The improvements in cognitive and behavioral performance in our patient are likely to be related to the effects of stimulating residual cholinergic projections and cell bodies in the nucleus basalis of Meynert.

OBSERVATION: Minimally Conscious State After Ruptured Giant Basilar Aneurysm

Objective To report the clinical and radiologic findings in a case of transient minimally conscious state after rupture and coiling of a giant basilar aneurysm. Design Case report. Setting Neuroscience intensive care unit. Patient A 44-year-old man who developed a transient minimally conscious state in association with perianeurysmal edema in the rostral brainstem and thalamus after rupture and coiling of a giant basilar artery aneurysm. Main Outcome Measure Correlation of clinical and magnetic resonance imaging findings. Results A minimally conscious state and bilaterally symmetric vasogenic edema of the rostral brainstem and thalamus developed 2 days after endovascular aneurysm coiling. The clinical and radiologic abnormalities improved significantly and in parallel during the following 4 weeks. Conclusions Perianeurysmal vasogenic edema in the brainstem and thalamus can develop after rupture and coiling of a giant basilar artery aneurysm. This process can be transient and can produce dramatic alterations in consciousness that later resolve.

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OBSERVATION: Occurrence of Basal Ganglia Germ Cell Tumors Without a Mass

Objective To report a case series in which basal ganglia calcifications without mass effect proved to be germ cell tumors. Design Case series. Setting Tertiary care hospital. Patients Four patients. Interventions Computed tomography, magnetic resonance imaging, positron emission tomography, biopsy, chemotherapy, and radiation therapy. Main Outcome Measures Recognition of clinical syndrome and radiological features. Results All patients had progressive hemiparesis, and 1 patient also had frontal lobe dementia. Imaging demonstrated progressive asymmetric signal abnormality with basal ganglia calcification and associated brainstem atrophy. Fludeoxyglucose F 18–positron emission tomography showed hypometabolism in contrast to malignant glioma. Conclusion Germ cell tumor should be considered in patients with an indolently progressive neurological course, particularly if basal ganglia calcification is present with or without enhancement, asymmetric brain atrophy, or a mass.

OBSERVATION: Propionibacterium acnes Brain Abscess Appearing 10 Years After Neurosurgery

Objective To describe a case of Propionibacterium acnes infection arising 10 years after neurosurgery and to review the literature regarding similar cases and their treatment. Design Case report. Setting Hospital of the University of Pennsylvania. Patient A 70-year-old man with an intracerebral abscess and 2 biopsies culture positive for P acnes 10 years after subdural hematoma evacuation. Intervention Surgical biopsy followed by 6 weeks of intravenous vancomycin. Main Outcome Measures Magnetic resonance imaging, neurologic examination, and microbiology culture results. Results Biopsies obtained from abscesses grew only P acnes. Magnetic resonance imaging and serial neurological examinations showed marked improvement after 6 weeks of intravenous vancomycin. Conclusions Infection by P acnes can complicate neurosurgical procedures as late as 10 years after surgery and therefore should be considered in the evaluation of patients presenting with neurologic signs and symptoms with a history of neurosurgery.

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IMAGES IN NEUROLOGY: Scattered Cerebral Microbleeds Due to Cardiac Myxoma

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IMAGES IN NEUROLOGY: Neurodegeneration With Pantothenate Kinase Syndrome: Retinal and Magnetic Resonance Imaging Findings

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CORRESPONDENCE: Olfactory Disturbance in Parkinson Disease

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