CONTINUUM Lifelong Learning in Neurology最新文献

Functional movement disorders such as tremor, dystonia, jerky movement, limb weakness, and gait abnormalities are a common clinical concern for neurologists. This article is a practical guide for neurologists to manage these conditions. The authors describe how the principle of "rule-in" diagnosis, which involves demonstrating the difference between voluntary and automatic movement, can be carried through to explanation, triage, and evidence-based multidisciplinary rehabilitation therapy. New predictive processing models of functional movement disorder can be combined with an understanding of the relevance of comorbidities such as pain, other neurologic conditions, and psychological disorders.

Objective: This article reviews the diagnosis of dementia with Lewy bodies, the prodromal phase of dementia with Lewy bodies, and management of the disease.

Latest developments: The diagnostic criteria and characterization of syndromes for prodromal dementia with Lewy bodies facilitate earlier recognition of individuals at risk of Lewy body dementia. Earlier diagnosis may prevent iatrogenic complications, guide families to seek appropriate resources, and provide an opportunity for future therapeutic interventions in the clinical prodrome. Advances in biomarkers include the detection of phosphorylated α-synuclein in cutaneous nerve fibers and the CSF α-synuclein seed amplification assay.

Essential points: Dementia with Lewy bodies is a complex disease that requires an interdisciplinary approach to optimize diagnosis and management. Frequently occurring copathology, most commonly with Alzheimer disease, leads to greater cognitive decline, increased likelihood of admission to a long-term care facility, and a higher risk of mortality. Use of available biomarkers may better guide appropriate diagnosis and management.

Objective: Tremor is a common presenting concern and is associated with a wide range of potential etiologies. This article reviews the approach to the clinical evaluation of tremor, the diagnosis of essential tremor, differential diagnoses, and management options.

Latest developments: Although new investigational drugs are being studied, no medication besides propranolol has been approved by the US Food and Drug Administration (FDA) as a treatment for essential tremor. Thalamic deep brain stimulation (DBS) has been approved for use since 1997, and refinement of the stimulation target is currently being investigated. Focused ultrasound thalamotomy was approved by the FDA in 2016, and some devices with FDA approval can administer noninvasive transcutaneous afferent patterned stimulation of the median and radial nerves to treat essential tremor. Finally, botulinum toxin injections have shown potential effectiveness for treating head and voice tremors, and methods are currently being refined for potential application in the treatment of upper limb tremors.

Essential points: Tremor is a common neurologic symptom and should be distinguished from other movement disorders that may superficially resemble tremor. In addition, essential tremor, a primary tremor disorder consisting of bilateral upper limb action tremor, is commonly misdiagnosed. A careful history and clinical examination for other neurologic findings, such as bradykinesia, dystonia, or evidence of peripheral neuropathy, can reveal potential alternative etiologies of tremor. Drug-induced tremor and metabolic disturbances should always be considered in patients with recent-onset tremor. Oral pharmacotherapies, including propranolol and primidone, are mainstays of treatment, whereas DBS and focused ultrasound thalamotomy can be offered to alleviate disabling, medication-refractory tremor. Novel oral pharmacologic agents, noninvasive stimulation for tremor, and botulinum toxin injections for hand and head tremor need further study but may serve as potential future treatment options.

Objective: This article serves as a practical guide for the assessment of patients with suspected idiopathic normal pressure hydrocephalus (NPH).

Latest developments: Significant advancements in neuroimaging, biomarker identification, and neurosurgical techniques have considerably improved the diagnostic accuracy and outcomes of treatment for idiopathic NPH. The full triad of gait disturbance, cognitive impairment, and urinary incontinence is not present in all patients and is not a prerequisite to pursuing treatment. Comorbid cervical stenosis is common and may also require surgical intervention.

Essential points: NPH remains a challenging clinical entity with significant overlap in presentation with other neurodegenerative disorders such as Alzheimer disease, vascular dementia, and parkinsonian syndromes, especially progressive supranuclear palsy and dementia with Lewy bodies. Gait tends to be affected first and more severely than other domains in patients with idiopathic NPH. The CSF tap test is a key diagnostic tool where both objective and subjective improvements in symptoms help identify patients likely to have a good outcome after shunt surgery.

Abstract: With the increase in the public's attention to all aspects of brain health, neurologists need to understand their role in raising awareness, advocating for preventive strategies, and promoting brain health for all. This article examines the literature on the physical, mental, cognitive, and social health factors in promoting optimal brain function. In addition, it reviews various modifiable risk factors for neurologic injury, including cardiovascular health, nutrition, sleep, mental health, cognitive engagement, social interaction, and brain injury prevention. In all clinical neuroscience specialties, neurologists should adopt preventive approaches that consider brain health throughout the lifespan. This strategy includes attention to the significant impact of social determinants of health on disparities in brain health and neurologic disorders, underscoring the need for targeted interventions to promote health equity. To achieve brain health equity, neurologists must integrate culturally sensitive care approaches, develop adapted assessment tools, improve professional and public educational materials, and continually innovate interventions to meet the diverse needs of our communities. Achieving brain health for all will require a collaborative multilevel approach to promote and sustain preventive brain health initiatives through individual empowerment, community-based programs, and the integration of brain health into health care policies and practices.

Objective: Idiopathic intracranial hypertension (IIH) is a condition of unexplained increased intracranial pressure. This article provides an overview of the process of diagnosing IIH and summarizes health disparities and potential barriers to care facing patients with IIH.

Latest developments: Population studies have shown that IIH incidence increases with the rising rates of obesity, with subsequent financial burden and potential implications for the health care system. There may be ethnic or racial differences in IIH prevalence, and the degree to which social determinants of health affect these differences requires further exploration.

Essential points: IIH, a syndrome secondary to increased intracranial pressure without an underlying structural cause, can lead to disability, including blindness. Overdiagnosis of IIH has led to overutilization of health care resources. This article presents the criteria for diagnosing IIH, possible biases that may affect clinical reasoning, and approach to early referral to the appropriate clinical experts.