Migraine pearls The Wand at drinkpure wine.com eliminiates sulfites in wine for people sensitive to wine headaches. Celtic Sea Salt instead of table salt"takes water into cells" to promote hydration, lowers BP and helps headaches.

Pearls Chiari malformation

1.80 percent of patients with cough headache have cm type 1 although only a minority of patients with cm 1 have cough headache. The degree of tonsillar herniation does not correlate

2.  Cm1 presents most often from ages 8 to 9 and from 31 to 46

3.  Spinal cord syndrome occurs in 65 to 84 percent and includes weakness and sensory changes.

4. Brain stem syndrome occurs in 22 to 38 percent and includes blurred vision, horizontal or downbeating nystagmus, and diplopia (upper) or hoarseness , dysphonia, dysarthria, dysphasia, vocal cord paralysis, palatal weakness and tongue atrophy ( lower).

5. Cerebella symptoms occur in 11 percent with dyscoordination, ataxia and dysmetria

6.  Cortical symptom is rare 3 percent with brain fog, depression, generalized weakness and fatigue

7.  Even more rare systemic syndrome , two percent, have chest pain, sob, postural hypotension and syncope

8 presenting symptoms include 82 to 90 percent have suboccipital headache, 78 to 81 percent have posterior neck pain, 60 to 67 have dizziness, 49 percent have nausea.

Others with percent

Weakness. 69

Numbness 56

Altered temperature sensation 52

Unsteady 40

Double vision 13

Swallowing trouble 8

Tinnitus. 7

Dysarthria 3

Dizzy.       3

Hiccups. 1

9.  Ciné mri phase contrast may show elevated high velocity jets upwards and other abnormalities of normal bidirectional csf flow. Technique also can be used to follow cm1. Technique is especially useful to differentiate headaches of cm1 v other causes

Luna G, Alping P, Burman J et al.  Infection risks among patients with multiple sclerosis  treated with fingolimod, natalizumab, rituximabm  and injectable therapies.  JAMA Neurology2020; 77:184-91.

Swedish study examines risk of infections severe enough to cause hospitalization in 6421 MS patients and controls.  The rate of infections among patients taking injectibles was higher than the population 8.9 v 5.2 per 1000 person years. It was higher still in patients taking fingoli,od (14.3), and natalizumab (11.4) and highest among patients taking rituximab (19.7).

MG after dabrafenib and trametinib in metastatic melanoma.  Case report.  Neurology 2020; 94: 322-3/

In this patient, challenge , withdraw and rechallenge brought out MG symptoms and resolved when withdrawn within 24 hours.  {atient was ab positive. These drugs, BRAF and MEK inhibitors  now are standard of care for melanoma.  This is a separate phenomenon from checkpoint inhibitors causing mg 

A Columbian woman in a kindred of patients who developed Alzheimer's disease was homozygote for the Christchurch mutation, which is rare, and maintained cognition into her seventies. She was apo E3 double positive. She had high amyloid but limited tau. This provides a potential target for studies.

Atrial fibrillation and falls: a mechanistic or age confounded relationship?   (editorial) Mayo Clinic Proceedings 95; 2020, pp632-4  AuthorsHu T et al.  

Meta-analysis shows falls and AF are related,  independently of  age.  Odds ratio is about 1.8.  The relationship exists even after pacemaker placement.  Authors cite an AF complex of symptoms that include cognitive dysfunction, endothelial dysfunction and dysautonomia.  

Dermatomyositis with and without anti Mi2 autoantibodies

Pinal-Hernandez I, Mecoli CA, Casal-Dominguez M .  More prominent muscle involvement with dermatomyositis with anti Mi2 autoantibodies. Neurology; 2019; 93e1768-1777
(John Hopkins)

58 patients with antiMi2 positive DM
143 patient with anti Mi2 negative DM
162 patients with antisynthetase syndrome
170 patients with immune mediated necrotizing myopathy (IMNM).

Features of   patients with antiMi2 positive DM: more muscle weakness, less calcinosis , less interstitial lung disease, higher CK level but still stronger with lower CK's than pats with IMNM

Autoimmune meningoencephalitis associated with GFAP IgG antibodies.

Fung B et al.  Autoimmune glial fibrillary acidic protein astrocytopathy: a novel meningoencephalomyelitis.  JAMA Neurol 2016; 73: 1297.

Mayo labs has 134 cases out of 100,000 evaluated for autoimmune and paraneoplastic ab's as part of routine care.  Clinical presentation consists of headache, confusion, behavioral changes, lethargy, blurred vision, and trouble walking.  Exam can show papillitis, CN palsies, myelopathy.  CSF can show pleocytosis, highprotein, OCB'sm high IgG index.  MRI can show leptomeningeal enhancement, gyral enhancement.  At least half relapsed despite corticosteroids.  6/16 developed cancers

Steroid sparing therapy in neurosarcoidosis

Neurology 2016; 13:87:2517 Uncontrolled study of 40 patients with neurosarcoidosis, both central and peripheral nerve.  32 got MTX 20 mg per week, 14 got mycophenolate (MMF) at 2 grams per day (median) 6 had both drugs successively.  In MTX group, 15/32 (46 percent) relapsed v. 11/14 (79 %) in MMF group.  Median survival without relapse was 28 months in MTX group, 11 month in MMF group.  Of note steroid dose at initiation was 40 mg po daily in MTX group, and 20 mg in MMF group, a potential confound.  Both groups had high rates of relapse and better steroid sparing drugs are needed.

Biotinidase deficiency mimicking NMO: initiallyexhibiting symptoms in adulthood

Bottin L, Prud'honS, Giannesini C et al.  Multiple Sclerosis 21 (12) 1604-07 2015.  

Authors present first case of biotinidase deficiency presenting in young adulthood ; children and adolescents may present with vision loss and tetraparesis.  It was due in this case to a novel missense mutation and partly improved with oral biotin therapy.

Seropositive voltage gated calcium channels, utility

Jammoul A, Shayya L, Mente K et al.  Neurology Clinical Practice  2016; 6:409-418.

Authors differentiate "classic" group with limbic encephalitis or neuromyotonia (9.6% of total) and note the others had a panoply of diagnoses that were nonclassic.  The classic group was more likely to have high titers of ab, but there was overlap.  91 % of lcassic and 21 % of nonclassic had levels > 0.25 nM.  75 % of patietns in high level ab group had autoimmune disorders, and 75 % of patients with low level titers did not.  26 % of patients had a remote malignancy (active, remote, solid or hematologic) but not ab titer difference was noted among the groups .

Conclusions:  1.  High VGKC ab levels are found in patients with classic and other autoimmune disorderes,  Low level ab titers are seen in nonspecific and mostly nonautoimmune disorders

2.  The presence of VGKC antibodies rather than the level may serve as a marker of malignancy

Notes this is bad on a chart review of 6,032 patients who underwent evaluation .

The nonclassic group includes PNS and CNS diorders including neuropathy, dementia, ALS, CJD.  Some patietns had nonspecific symptoms such as stutering speech, nausea and vomting and orthostasis without diagnosis of neurologic disease.

Cancers were oftendiagnosed due towhole body CT/PET; 2 patietns had previously unknown cancer (Ovarian and lung).  Cancer occurred more commonly in those over age 45.  Many cases of ab finding were remote by over ten years from actual tumor.

Pearls about GQ1b

Serum and CSF GQ1 ab'sin isolated opthalmoplegic syndromes.  Spatola M, Du Pasquier R, Schluep M, et al.  Neurology 2016; 86:1780-1784

 

pearls about GQ1b from this article

 

1.  Antibodies are specific for Miller Fisher syndrome (MFS); unl;ike NMO-NMOSD, the use of the antibodies does not increase the spectrum of MFS substantially

 

2.  Measurement in CSF offers no additional value over serum

 

3.  Although ON (optic neuritis) can occur as part of the MFS, ISOLATED ON is NOT part of the MFS spectrum

 

4.  In acute opthalmoplegia, only 1/21 had positive antibodies but the antibodies occurred in 1/5 cases of AO of unknown etiology; therefore, the antibody may be useful as part of the evaluation of AO.  The cases with known etiology include diabetes, Tolosa Hunt and opsoclonus myoclonus

 

5. Low serum titers occur in several disorders and are markers of nonspecific damage to ocular motor nerve sheaths, while high concentrations are specific for MFS

 

6. IgG is the most relevant isotype antibody relevant for MFS, and GanglioCombi mixed IgM/IgG correlates well which makes it a viable alternative