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	July Highlights

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Epilepsy In a multicenter trial of left vagus nerve stimulation for the treatment of refractory seizures, Handforth et al. (p. 48) used low frequency stimulation as a control condition for comparison with the effects of therapeutic, high frequency stimulation. High stimulation reduced total seizure frequency and had other benefits. The major adverse effects of high stimulation were dyspnea and voice alterations. Rasmussen's encephalitis, characterized by focal status epilepticus and cognitive deficits, is caused by antibodies to GluR3 (the type 3 glutamate receptor). The Brief Communication by Antozzi et al. (p. 302) reports reduction of antibody levels and striking clinical improvement with IgG immunoadsorption. The Clinical Note by Ifergane et al. (p. 314) describes three patients with slight renal insufficiency in whom vigabatrin, which is cleared by the kidneys, produced an acute encephalopathy. The Brief Communication by Blindauer et al. (p. 292) reports another unusual complication of anticonvulsant therapy: the rapid progression of multiple sclerosis with hyperammonemia and obtundation in a patient taking valproate.

Movement disorders Pallidotomy reduces levodopa-induced dyskinesias and improves nadirs of parkinsonian disability. However, Trepanier et al. (p. 207) sound a cautionary note in their report of persistent cognitive and emotional consequences of pallidotomy. These complications must be balanced against the potential therapeutic benefit. Neurogenic orthostatic hypotension has remained a difficult therapeutic problem. Wright et al. (p. 120) report 25 patients treated with the alpha-adrenergic agonist midodrine who showed significant improvement in standing systolic blood pressure and in global symptomatology.

Alzheimer's disease Efforts to delay the onset and slow the progression of AD require us to know the factors that affect progression in untreated patients. Craft et al.(p. 149) found that patients with the apoE 4 allele had a more rapid course than those with the 2 allele. Drigalenko et al. (p. 131) found that one of the alleles of apoCI, a gene close to apoE on chromosome 19, is associated with an increased risk of AD. Heyman et al. (p. 159) found that patients with strokes, in addition to AD, had a much more rapid and severe course.

Stroke The article by Leibson et al. (p. 163) suggests that stroke prevention may result in fewer nursing home admissions and a smaller proportion of life after stroke being spent in a nursing home; however, the total number of nursing home days (and therefore, costs) may not be reduced. The study implies that quality-adjusted life years increase, an important target for further studies. Prevention of stroke-related morbidity and developing effective treatments may be dependent on identifying patients who are most likely to have fixed deficits. Firlik et al. (p. 177) suggest that xenon-enhanced computed tomography identifies patients who will have spontaneous resolution of ischemic symptoms. Patients who had normal cerebral blood flow by xenon CT went on to spontaneous resolution of ischemic symptoms. Earley et al. (p. 169) studied ischemic stroke and intracerebral hemorrhage in children. In their population, the most common cause of childhood ischemic stroke was sickle cell disease.

Multiple sclerosis Most patients with relapsing-remitting MS now receive a β-interferon, which is under study in chronic progressive MS. In this context, Goodkin et al. (p. 239) report the benefit of IV methylprednisolone in secondary progressive MS and call for a phase III trial. If conducted, such a trial is likely to be in a different patient population: those takingβ-interferon.

Headache Menstruation-related headache often fails to respond to usual treatment modalities. In a Brief Communication, Newman et al. (p. 307) report an open study with sumatriptan in 20 women. Half of the patients had no further menstruation-related headaches and an additional 40% improved. The study was brief but provides support for a controlled trial. Wang et al. (p. 245) report 25 patients with chronic daily headache who were discovered to have previously unrecognized idiopathic intracranial hypertension (documented by lumbar puncture) without papilledema. Obesity and tinnitus were predictors of IIH and treatment of the increased intracranial pressure may alleviate symptoms.

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