Adam B. Cohen

The relationships among MRI-defined spinal cord involvement, brain involvement, and disability in multiple sclerosis

To determine the interrelationships between MRI‐defined lesion and atrophy measures of spinal cord involvement and brain involvement and their relationships to disability in a small cohort of patients with multiple sclerosis (MS).

Increased diffusivity in superior temporal gyrus in patients with schizophrenia: A Diffusion Tensor Imaging study

BACKGROUNDnSuperior temporal gyrus (STG) volume reduction is one of the most consistent findings in schizophrenia. The goal of this study was to conduct the first Diffusion Tensor Imaging (DTI) study to investigate altered structural integrity in STG gray and white matter in patients with chronic schizophrenia compared with healthy controls.nnnMETHODSnMagnetic resonance imaging (MRI) and DTI were acquired in 21 male patients with schizophrenia and 22 age-, handedness-, and parental social economic status-matched male comparison subjects. After manual segmentation of gray and white matter, mean diffusivity and fractional anisotropy were measured within STG. Correlational analyses were also conducted to test possible associations between DTI and clinical measures, including positive and negative symptoms of schizophrenia.nnnRESULTSnCompared with controls, patients demonstrated reduced volume, bilaterally, in STG gray matter but not in white matter. For DTI measures, patients showed increased mean diffusivity, bilaterally, in STG gray matter, and in left STG white matter. In addition, mean diffusivity in left STG white matter showed statistically significant correlations with auditory hallucinations and attentional impairments in patients.nnnCONCLUSIONSnThese findings suggest a disruption of tissue integrity in STG gray and white matter in schizophrenia. In addition, increased water diffusivity in left-side STG, which was associated with auditory hallucinations and attentional impairments, suggests the possibility of a disconnection among auditory/language processing regions in schizophrenia.

The American Academy of Neurology's Top Five Choosing Wisely recommendations

Objective: To discuss the American Academy of Neurology (AAN)’s Top Five Recommendations in the Choosing Wisely campaign promoting high-value neurologic medicine and physician–patient communication. The AAN published its Top Five Recommendations in February 2013 in collaboration with the American Board of Internal Medicine Foundation and Consumer Reports. Methods: A Choosing Wisely Working Group of 10 AAN members was formed to oversee the process and craft the evidence-based recommendations. AAN members were solicited for recommendations, the recommendations were sent out for external review, and the Working Group members (article authors) used a modified Delphi process to select their Top Five Recommendations. Results and recommendations: The Working Group submitted 5 neurologic recommendations to the AAN Practice Committee and Board of Directors; all 5 were approved by both entities in September 2012. Recommendation 1: Don’t perform EEGs for headaches. Recommendation 2: Don’t perform imaging of the carotid arteries for simple syncope without other neurologic symptoms. Recommendation 3: Don’t use opioids or butalbital for treatment of migraine, except as a last resort. Recommendation 4: Don’t prescribe interferon-b or glatiramer acetate to patients with disability from progressive, nonrelapsing forms of multiple sclerosis. Recommendation 5: Don’t recommend carotid endarterectomy for asymptomatic carotid stenosis unless the complication rate is low (,3%). Neurology 2013;81:1004–1011 GLOSSARY AAN 5 American Academy of Neurology; ABIMF 5 American Board of Internal Medicine Foundation; CEA 5 carotid endarterectomy;GDP5 gross domestic product;MS5multiple sclerosis; PPMS5 primary progressive multiple sclerosis;RRMS5 relapsing-remitting multiple sclerosis; SPMS 5 secondary progressive multiple sclerosis. Alzheimer disease, Parkinson disease, stroke, and multiple sclerosis affect approximately 15 million people and account for more than

Quality improvement in neurology: Amyotrophic lateral sclerosis quality measures Report of the Quality Measurement and Reporting Subcommittee of the American Academy of Neurology

290 billion in health care spending annually in the United States. The number of people with these neurologic disorders is expected to increase, likely resulting in increased health care spending. Each year, US health care spending increases, putting additional pressure on the national economy and individual consumers. According to estimates from the Centers for Medicare & Medicaid Services, the United States spent

A 3T MR Imaging Investigation of the Topography of Whole Spinal Cord Atrophy in Multiple Sclerosis

2.7 trillion (17.9% of the gross domestic product [GDP]) on health care in 2011. If the growth of health care expenditures is not curtailed, health care spending is projected to constitute 25% of the GDP by 2025, according to the Congressional Budget Office. The Institute of Medicine estimates that

Diffusion-weighted magnetic resonance imaging of bilateral simultaneous optic nerve infarctions

750 billion was spent on wasted medical services, including unnecessary services, inefficiently delivered services, and missed prevention opportunities, in 2009 alone. The rising cost of health care and wasteful spending often affect the consumer directly through increased deductibles and copayments and indirectly through deductions from wages or lost wage increases. From the Neurology Department, Los Angeles Medical Center (A.M.L.-G.), Southern California Kaiser Permanente Medical Group (S.B.P.), Los Angeles; Department of Research & Evaluation (A.M.L.-G.), Kaiser Permanente Southern California, Pasadena; California Pacific Neurosciences Institute (W.E.A.), San Francisco; Department of Neurology (M.J.A.), University of Maryland School of Medicine, Baltimore; Massachusetts General Hospital (A.B.C.), Harvard Medical School, Cambridge; Geisinger Medical Center (M.A.E.), Danville, PA; Humboldt Neurological Medical Group, Inc. (D.J.I.), Eureka, CA; American Academy of Neurology (A.B., R.L., A.G., T.G.), Minneapolis, MN; and University of Kansas Medical Center (G.S.G.), Kansas City. Go to Neurology.org for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article. 1004

Large-Scale Automated Assessment of Radiologist Adherence to the Physician Quality Reporting System for Stroke

Amyotrophic lateral sclerosis (ALS) is a lethal, progressive neurodegenerative disease characterized by loss of motor neurons.1 Patients with ALS lose function in the limbs, speech, swallowing, and breathing muscles. The cause of the disease is still not known for most patients. Approximately 25,000 people in the United States have ALS, and 5,000 people are diagnosed with ALS annually in the United States.1 Most patients die from respiratory failure 2 to 5 years after onset of symptoms. Cognitive dysfunction is seen in 20% to 50% of patients.2 The disease burden for patients and caregivers is enormous. The average cost of care has been estimated at

Quality improvement in neurology: Amyotrophic Lateral Sclerosis Quality Measures

50,000 per patient per year.3

Quality measurement: It's here to stay

BACKGROUND AND PURPOSE: Spinal cord atrophy is a common feature of MS. However, it is unknown which cord levels are most susceptible to atrophy. We performed whole cord imaging to identify the levels most susceptible to atrophy in patients with MS versus controls and also tested for differences among MS clinical phenotypes. MATERIALS AND METHODS: Thirty-five patients with MS (2 with CIS, 27 with RRMS, 2 with SPMS, and 4 with PPMS phenotypes) and 27 healthy controls underwent whole cord 3T MR imaging. The spinal cord contour was segmented and assigned to bins representing each C1 to T12 vertebral level. Volumes were normalized, and group comparisons were age-adjusted. RESULTS: There was a trend toward decreased spinal cord volume at the upper cervical levels in PPMS/SPMS versus controls. A trend toward increased spinal cord volume throughout the cervical and thoracic cord in RRMS/CIS versus controls reached statistical significance at the T10 vertebral level. A statistically significant decrease was found in spinal cord volume at the upper cervical levels in PPMS/SPMS versus RRMS/CIS. CONCLUSIONS: Opposing pathologic factors impact spinal cord volume measures in MS. Patients with PPMS demonstrated a trend toward upper cervical cord atrophy. However patients with RRMS showed a trend toward increased volume at the cervical and thoracic levels, which most likely reflects inflammation or edema-related cord expansion. With the disease causing both expansion and contraction of the cord, the specificity of spinal cord volume measures for neuroprotective therapeutic effect may be limited.

“Bright tongue sign” in ALS

AN 85-YEAR-OLD MAN presentedwithcomplete loss of vision. Duringtheweekprior topresentation,hereportedgraduallyprogressiveblurred anddarkvisioninbotheyeswithdramaticworseningonthedayofpresentation.Hehadnoothersymptoms,includingheadache.Hismedicalhistory was significant for hypertension and peripheral vascular disease. On examination, his blood pressure was elevated. There was no cranial artery tenderness. He was alert withintactlanguageandmemory.Visual acuity was light perception OU. Both pupils were 4 mm and nonreactive to light. Eye movements were normal,andcornealreflexeswereintactandsymmetric.Funduscopicexamination showed bilateral optic nerve head edema with right optic nervesectoralpallorandaleftmacularinfarction(Figure,AandB).The remainderoftheneurologicalexamination was normal. Magnetic resonanceimagingshowedrestricteddiffusion (Figure, C and D) with a reduced apparent diffusion coefficient signal (not shown) within the leftintraorbitalopticnerveandatthe right anterior optic nerve. The platelet count was 1134/µL, the erythrocytesedimentationratewas40mm/h, and the C-reactive protein level was 17.7 mg/L (to convert to nanomoles per liter, multiply by 9.524). COMMENT