Systematic review of telestroke for post-stroke care and rehabilitation.

Telemedicine for acute stroke care is supported by a literature base. It remains unclear whether or not the use of telemedicine for other phases of stroke care is beneficial. The authors conducted a systematic review of the published literature on telemedicine for the purposes of providing post-stroke care. Studies were included if the title or abstract expressed use of two-way audio/video communication for post-stroke care. From an initial yield of 1,405 potentially eligible hits, two reviewers ultimately identified 24 unique manuscripts to undergo functionality, application, technology, and evaluative (F.A.T.E.) scoring. Each article was classified using a scoring rubric to assess the functionality, application, technology, and evaluative stage. It was found that most post-stroke telemedicine studies evaluated rehabilitation of adults. All primary data manuscripts were small and preliminary in scope and evaluative phase, and median F.A.T.E. score for primary data was 2. The use of telemedicine for post-stroke care is nascent and is primarily focused on post-stroke rehabilitation.

Cerebrospinal fluid angiotensin-converting enzyme for diagnosis of central nervous system sarcoidosis.

BACKGROUND: Sarcoidosis is a multisystem granulomatous disease that may involve the central nervous system (CNS) in many ways, leading to diagnostic difficulties. An accurate diagnostic laboratory test would enhance the evaluation and management of these patients. OBJECTIVE: To determine the diagnostic accuracy of cerebrospinal fluid angiotensin-converting enzyme (ACE) for CNS neurosarcoidosis. METHODS: The objective was addressed through the development of a structured critically appraised topic. This included a clinical scenario, structured question, search strategy, critical appraisal, results, evidence summary, commentary, and bottom line conclusions. Participants included consultant and resident neurologists, a medical librarian, clinical epidemiologists, and content experts in the field of neuroimmunology. RESULTS: Two primary articles were selected for review. Cerebrospinal fluid ACE assay is insensitive (24%-55%) but may be reasonably specific (94%-95%) for CNS neurosarcoidosis. However, existing data are derived from studies with significant methodological and reporting limitations. CONCLUSIONS: The diagnostic accuracy of cerebrospinal fluid ACE for CNS neurosarcoidosis is not clearly established and the test cannot replace tissue diagnosis. Despite its insensitivity, some clinicians might consider the specificity of cerebrospinal fluid ACE, based on existing data, high enough to warrant inclusion in the diagnostic evaluation of patients in whom CNS neurosarcoidosis is being considered. A well-designed prospective diagnostic study seems warranted.

Serum neuron specific enolase to predict neurological outcome after cardiopulmonary resuscitation: a critically appraised topic.

BACKGROUND: Despite a large body of resuscitation research, the optimal timing and approach to prognosticating futility after nontraumatic cardiac arrest remains controversial. Postresuscitation anoxic-ischemic encephalopathy may leave patients cognitively disabled and dependent, minimally conscious, or in a persistent vegetative state. Neurologists are frequently called upon to assess comatose postcardiac arrest patients to communicate accurate prognostic information and to assist in planning the most appropriate level of care. Serum neuron specific enolase (NSE), when used in conjunction with other available prognostic tools, may be a useful tool for predicting clinical outcome in this patient population. OBJECTIVE: Determine the clinical utility of a serum NSE measurement for predicting the neurologic outcome of a survivor after resuscitation from a nontraumatic cardiac arrest. METHODS: We addressed the question through the development of a structured, critically appraised topic. Participants included consultant and resident neurologists, clinical epidemiologists, medical librarian, and clinical content experts in the fields of emergency medicine, cardiac resuscitation, and critical care neurology. Participants started with a clinical scenario and a structured question, devised search strategies, located and compiled the best evidence, performed a critical appraisal, synthesized the results, summarized the evidence, provided commentary, and declared bottom-line conclusions. RESULTS: A single recent prospective cohort study, which assessed the predictive value of serum NSE was selected and appraised. A level of 80 ng/mL was determined to predict persistent coma with a sensitivity of 63% (95% CI, 49%-75%), and a specificity of 100% (95% CI, 97%-100%), positive predictive value (PPV) of 100%, negative predictive value (NPV) of 84%, and a negative LR of 0.37. CONCLUSIONS: The specificity of serum NSE levels >80 ng/mL is sufficiently high that, when it is used with other clinical and electrophysiological data, it could be useful as a prognostic indicator of neurologic outcome after cardiac arrest. Although serum NSE is an appealing, simple, readily available test, prediction of neurologic outcome after resuscitation from cardiac arrest must not rely solely on a serum biomarker, but must be determined in the context of other patient characteristics and neurologic examination findings.

Analysis of the reporting of search strategies in Cochrane systematic reviews.

BACKGROUND: The Cochrane Handbook for Systematic Reviews of Interventions provides instructions for documenting a systematic review's electronic database search strategy, listing elements that should be in the description. Complete documentation of the search strategy allows readers to evaluate the search when critically appraising a review's quality. OBJECTIVE: The research analyzed recently published Cochrane reviews to determine whether instructions for describing electronic database search strategies were being followed. METHODS: Eighty-three new reviews added to the Cochrane Database of Systematic Reviews in the first quarter of 2006 were selected for analysis. Eighteen were subsequently excluded because their searches were conducted only in the specialized registers of Cochrane review groups. The remaining sixty-five reviews were analyzed for the seven elements of an electronic database search strategy description listed in the Cochrane Handbook, using dual review with consensus. RESULTS: Of the 65 reviews analyzed, none included all 7 recommended elements. Four reviews (6%) included 6 elements. Thirty-two percent (21/65) included 5 or more elements, with 68% (44/65) including 4 or fewer. Three included only 2 elements. The 65 reviews represented 41 different Cochrane review groups. CONCLUSION: The instructions from the Cochrane Handbook for reporting search strategies are not being consistently employed by groups producing Cochrane reviews.

Does cervical manipulative therapy cause vertebral artery dissection and stroke?

OBJECTIVE: Does cervical manipulative therapy (CMT) cause vertebral arterial dissection (VAD) and subsequent ischemic stroke? What is the best estimate of the incidence of CMT associated with VAD and ischemic stroke? METHODS: The questions were addressed with a structured evidence-based clinical neurologic practice review. Participants included neuroscience students, consultant neurologists, clinical epidemiologists, medical librarians, and clinical content experts. A critically appraised topic format was employed, starting with a clinical scenario and structured question. The participant group devised search strategies, located and compiled the best evidence, performed critical appraisals, synthesized the results, summarized the evidence, provided commentary, and declared bottom-line conclusions. RESULTS: The search yielded 169 citations, of which 55 were deemed most relevant. From this return, we selected 26 publications of the highest evidence available: 3 case-control studies, 8 prospective and retrospective case series studies, 4 illustrative case reports, 1 survey, 1 systematic review of observational research, 5 reviews, and 4 opinion and expert commentary pieces. Five of the applicable 7 criteria for causation were satisfactorily met and supported weak to moderate strength of evidence for causation between CMT and VAD and associated stroke, especially in young adults. Young vertebrobasilar artery territory stroke patients were 5 times more likely than controls to have had CMT within 1 week of the event date (OR 5.03, 95% CI, 1.32-43.87). No significant associations were found for those > or =45 years of age. The best available estimate of incidence is approximately 1.3 cases of VAD or occlusion attributable to CMT for every 100,000 persons <45 years of age receiving CMT within 1 week of manipulative therapy. CONCLUSIONS: Weak to moderately strong evidence exists to support causation between CMT and VAD and associated stroke. Ultimately, the acceptable level of risk associated with a therapeutic intervention like CMT must be balanced against evidence of therapeutic efficacy. Further research, employing prospective cohort study designs, is indicated to uncover both the benefits and the harms associated with CMT.

Does prophylactic postoperative hypervolemic therapy prevent cerebral vasospasm and improve clinical outcome after aneurysmal subarachnoid hemorrhage?

BACKGROUND: Delayed cerebral vasospasm is a common cause of morbidity and mortality after acute aneurysmal subarachnoid hemorrhage. Hypovolemia and fluid restriction are risk factors for delayed vasospasm; hypervolemic therapeutic approaches are commonly used in patients with subarachnoid hemorrhage to prevent and to treat cerebral vasospasm. OBJECTIVE: To determine if postoperative prophylactic hypervolemic therapy prevents cerebral vasospasm and improves clinical outcome in patients with aneurysmal subarachnoid hemorrhage. METHODS: The objective was addressed through the development of a structured critically appraised topic. This included a clinical scenario, structured question, search strategy, critical appraisal, results, evidence summary, commentary, and bottom line conclusions. Participants included consultant and resident neurologists, a medical librarian, clinical epidemiologists, and content experts in the field of vascular neurology. RESULTS: One randomized controlled trial addressed the questions. There was no difference in the incidence of symptomatic cerebral vasospasm (20% each) or clinical outcome at 14 days and 3 months between the hypervolemic and normovolemic groups. Hypervolemic therapy also had no effect on measures of cerebral blood flow. A second quasi-randomized trial reached the same conclusions. CONCLUSION: Available evidence is insufficient to support use of prophylactic hypervolemic therapy after surgery in patients with aneurysmal subarachnoid hemorrhage. Although completed studies may be insufficiently sensitive (underpowered) to detect a treatment effect, the magnitude of any as yet undetected benefit of prophylactic hypervolemic therapy is likely modest and its risks have not been systematically evaluated.

Adjunctive haloperidol prophylaxis reduces postoperative delirium severity and duration in at-risk elderly patients.

BACKGROUND: Delirium is a potentially life-threatening syndrome that is particularly common in elderly hospitalized patients, especially those with preexisting neurologic disorders. Nonpharmacological tactics can reduce the incidence and severity of delirium in acute care settings and antipsychotic drugs are widely used to treat established delirium. More effective preventive strategies could notably impact morbidity, mortality, and health care costs. OBJECTIVE: To determine whether antipsychotic drug prophylaxis reduces the incidence and severity of postoperative delirium in at-risk elderly patients. METHODS: We addressed the objective through development of a structured critically appraised topic that included a clinical scenario, structured question, search strategy, critical appraisal, results, evidence summary, commentary, and conclusions. Participants included consultant and resident neurologists, a medical librarian, clinical epidemiologists, and content experts in the field of cognitive disorders. RESULTS: One randomized controlled trial addressed the question. In at-risk patients aged >70 years, oral haloperidol 0.5 mg TID, administered from up to 72 hours preoperatively until the third postoperative day, did not alter the incidence of postoperative delirium (15.1%) compared with placebo (16.5%; relative risk 0.91; 95% confidence interval 0.59-1.44). However, the study was underpowered for this primary outcome, possibly because both groups received nonpharmacological delirium prevention strategies. Haloperidol significantly reduced delirium severity ratings, delirium duration (from a mean of 11.8 to 5.4 days), and length of hospital stay in affected participants (from 22.6 to 17.1 day). CONCLUSION: Adjunctive low-dose haloperidol prophylaxis reduces delirium severity, duration, and subsequent hospitalization length in elderly at-risk patients. Further study is needed to determine the optimal pharmacological approach, combination with nonpharmacological strategies, and generalizability to other settings.

The clinical utility of high resolution magnetic resonance imaging in the diagnosis of giant cell arteritis: a critically appraised topic.

BACKGROUND: Giant cell arteritis (GCA) is a relatively common form of systemic vasculitis, known for its predisposition to affect extracranial branches of the carotid artery and associated potential for causing visual loss and stroke. Neurologists need to be vigilant for this disorder, diagnose it early, and institute effective corticosteroid therapy. The differential diagnosis can be broad. Unfortunately, all clinical and laboratory features of GCA are limited by either low sensitivity or low specificity. Temporal artery biopsy remains the gold standard, but it has its own limitations. Noninvasive imaging techniques, like magnetic resonance imaging (MRI), may be capable of detecting the occurrence of GCA. OBJECTIVE: How useful is high resolution MRI as a diagnostic test in establishing the diagnosis of GCA? METHODS: We addressed the question through development of a structured critically appraised topic. Participants included consultant and resident neurologists, clinical epidemiologists, medical librarian, and clinical content experts in the field of neuroradiology, rheumatology, and vascular neurology. Participants started with a clinical scenario and a structured question, devised search strategies, located and compiled the best evidence, performed critical appraisals, synthesized the results, summarized the evidence, provided commentary, and declared bottom-line conclusions. RESULTS: A single study which assessed the diagnostic value of MRI against a reference standard in GCA was appraised. For the MRI, the estimated sensitivity was 81% (95% CI 67-95), specificity was 97% (91-100), positive likelihood ratio (LR) was 26.6 (95% CI 3.8-184.8), negative LR was 0.20 (95% CI 0.10-0.41). The study exhibited several methodological weaknesses which interfered with its validity. CONCLUSIONS: The specificity and positive LR of high resolution MRI are sufficiently high that a positive MRI combined with other clinical and laboratory data consistent with GCA may be useful in diagnosing GCA. Given the relatively low sensitivity of the test, a negative MRI would not be sufficient to rule out the diagnosis of GCA.

Establishing a diagnosis of benign paroxysmal positional vertigo through the dix-hallpike and side-lying maneuvers: a critically appraised topic.

BACKGROUND: Many patients consult neurologists because of vertigo. Benign paroxysmal positional vertigo (BBPV) is one of the most common types of vertigo. Although the clinical presentation of this common condition is straightforward, the diagnosis and diagnostic maneuvers can be challenging. OBJECTIVES: How useful is the Dix-Hallpike test in establishing the diagnosis of BPPV? How useful is an alternative positional test, such as the side-lying maneuver, in the diagnosis of BPPV? METHODS: We addressed the question through development of a structured critically appraised topic. Participants included consultant and resident neurologists, clinical epidemiologists, medical librarian, and clinical content expert in the field of otolaryngology. Participants started with a clinical scenario and structured questions, devised search strategies, located and compiled the best evidence, performed critical appraisals, synthesized the results, summarized the evidence, provided commentary, and declared bottom-line conclusions. RESULTS: A single study comparing the Dix-Hallpike and side-lying tests was identified. For the Dix-Hallpike test, the estimated sensitivity was 79% [95% confidence interval (CI) 65-94], specificity was 75% (33-100), positive likelihood ratio (LR) was 3.17 (95% CI 0.58-17.50), negative LR was 0.28 (95% CI 0.11-0.69). For the side-lying test, the estimated sensitivity was 90% (95% CI 79-100), specificity was 75% (33-100), positive LR was 3.59 (95% CI 0.65-19.67), negative LR was 0.14 (95% CI 0.04-0.46). The study employed very weak methodology, and therefore the results had limited validity. CONCLUSIONS: The Dix-Hallpike test is the standard from which the diagnosis of posterior semicircular canal BPPV is made. Hence evaluations of its diagnostic test properties and utility are challenging. For patients unable to move into the Dix-Hallpike test positions, alternative tests such as the side-lying test can be attempted. These modifications, however, are rarely necessary.

Clinical predictors of psychogenic nonepileptic seizures: a critically appraised topic.

BACKGROUND: Psychogenic nonepileptic seizures (PNES) are often disabling and usually associated with psychiatric disorders and reduced quality of life. Although often suspected based on historical and clinical features, the gold standard for diagnosis of PNES is video electroencephalography. Identification of clinical features that reliably distinguish PNES from ES would be valuable in acute care settings, for patients that have coexisting disorders, and those with multiple event types. OBJECTIVE: To determine the diagnostic value of putative clinical symptoms or signs of PNES against the gold standard of video electroencephalography. METHODS: We addressed the objective through development of a structured critically appraised topic that included a clinical scenario, structured question, search strategy, critical appraisal, results, evidence summary, commentary, and bottom-line conclusions. Participants included consultant and resident neurologists, a medical librarian, clinical epidemiologists, and content experts in the field of epileptology. RESULTS: There were wide variations in the rates of coexisting PNES and epilepsy and study methodology. Ictal stuttering and the "teddy bear" sign were associated with moderate specificity for PNES. However, the presence of pelvic thrusting or ictal eye closure did not accurately distinguish PNES from ES. CONCLUSIONS: The presence of either ictal stuttering or the teddy bear sign is moderately specific but poorly sensitive for PNES. Pelvic thrusting and ictal eye closure are not reliable indicators of PNES. Future studies should establish more precise and reliable definitions of clinical signs and evaluate combinations of such signs in a broad spectrum of patients with PNES and ES spell phenotypes that may be difficult to distinguish, such as spells of unresponsiveness with motor manifestations. Because PNES and ES may coexist, analysis of diagnostic accuracy of clinical features should be performed for individual spells.

Sniffing out Parkinson disease: can olfactory testing differentiate parkinsonian disorders?

BACKGROUND: : Akinetic-rigid syndromes are a heterogeneous group of diseases with overlapping clinical manifestations. A recent American Academy of Neurology practice parameter indicated that olfactory testing was "probably useful" for differentiating idiopathic Parkinson disease (IPD) from other diseases with features of parkinsonism. OBJECTIVE: : To determine the diagnostic accuracy of olfactory testing for differentiating IPD from other parkinsonian disorders. METHODS: : The objective was addressed using a structured, evidence-based, critically appraised topic format. This format includes development of a clinical scenario, focused and answerable clinical question, search strategy, evidence appraisal, reporting and interpretation of results, commentary, and bottom line conclusions. Participants included neurology consultants and residents, clinical epidemiologists, a medical librarian, and neurologists with expertise in movement disorders. RESULTS: : Two studies evaluated the diagnostic accuracy of olfactory testing within a broad spectrum of parkinsonian syndromes. Each study examined different test methods [University of Pennsylvania Smell Identification Test; "Sniffin' Sticks"] and both were compromised by several potential biases in sampling and outcome evaluation. The University of Pennsylvania Smell Identification Test is moderately sensitive (77%; likelihood ratio 0.27) and specific (85%; likelihood ratio 4.9) for differentiation of IPD from non-IPD syndromes, but less specific (62%; likelihood ratio 2.0) for distinguishing IPD from multiple system atrophy. CONCLUSION: : The diagnostic accuracy of olfactory testing for differentiating IPD from other disorders is insufficient to justify its routine clinical use but available evidence is derived from small samples and studies of questionable validity. Recommendations for future research of olfactory testing for diagnosis and disease predication are discussed.

Caffeine for the prevention and treatment of postdural puncture headache: debunking the myth.

OBJECTIVE: Is caffeine effective in preventing and treating postdural puncture headache (PDPH)? METHODS: The question was addressed with a structured evidence-based clinical neurologic practice review via videoconferencing between 3 academic institutions. Participants included consultant and resident neurologists, clinical epidemiologists, medical librarians, and clinical content experts. A critically appraised topic format was employed, starting with a clinical scenario and structured question. Participant groups at each of the 3 institutions independently devised search strategies, located and compiled the best evidence, performed critical appraisals, synthesized the results, summarized the evidence, provided commentary, and declared bottom-line conclusions. RESULTS: Three directly relevant randomized controlled trial articles were selected as the best available evidence for the clinical questions. Two investigated caffeine [oral and intravenous (IV)] as PDPH prophylaxis and 1 (oral) as PDPH treatment. One additional quasirandomized trial (IV) and 1 open-label trial (IV) of caffeine for PDPH treatment were located by reviewing bibliographies. Articles describing the pharmacological basis for caffeine therapy were also identified. No valid pharmacological rationale for caffeine as an antinociceptive agent for PDPH exists. The clinical trials are few in number, small in sample size, methodologically weak or flawed, and either demonstrate no effectiveness, contradictory and conflicting results, or invalid answers. CONCLUSIONS: The wide endorsement for caffeine to prevent and treat PDPH found in textbooks and review articles appears to be unwarranted and insufficiently supported by the available pharmacological and clinical evidence.

Bone marrow stromal cell therapy for ischemic stroke: A meta-analysis of randomized control animal trials.

Background Results of animal studies assessing efficacy of bone marrow stromal cell therapy for ischemic stroke remain inconsistent. Aims The aims are to assess efficacy of bone marrow stromal cell therapy for ischemic stroke in animal studies. Methods Randomized controlled animal trials assessing efficacy of bone marrow stromal cell therapy were eligible. Stroke therapy academic industry round table was used to assess methodologic quality of included studies. Primary outcomes were total infarction volume and modified Neurological Severity Score. Multiple prespecified sensitivity analyses and subgroup analyses were conducted. Random effects models were used for meta-analysis. Results Thirty-three randomized animal trials were included with a total of 796 animals. The median quality score was 6 (interquartile range, 5-7). Bone marrow stromal cell therapy decreased total infarction volume (standardized mean difference, 0.897; 95% confidence interval, 0.553-1.241; P < .001) at follow-up. Overall standardized mean difference between animals treated with bone marrow stromal cell and controls was 2.47 (95% confidence interval, 1.84-3.11; P < .001) for modified Neurological Severity Score; 1.27 (95% confidence interval, 0.72-1.82; P < .001) for adhesive removal test; and 2.13 (95% confidence interval, 0.65-3.61; P < .001) for rotarod test. Significant heterogeneity among studies was observed. Effect of all outcomes stayed significant in various sensitivity analyses and subgroup analyses, except in a few subgroup analyses with small sample size or with short time follow-up. No significant difference between groups was observed except for study location, in which significantly larger estimates were found in Asian countries. On the basis of this meta-analysis, larger sample sizes are warranted for future animal studies. Conclusions Bone marrow stromal cell therapy significantly decreased total infarction volume and increased neural functional recovery in randomized controlled animal models of ischemic stroke.

Implementing evidence-based nursing practice.

A methodology for establishing and supporting evidence-based nursing practice is examined. Description of a clinical and administrative scenario serves as an example of a systematic appraisal of the relevant literature that had implications for clinical practice.

Implementing evidence-based nursing practice.

A methodology for establishing and supporting evidence-based nursing practice is examined. Description of a clinical and administrative scenario serves as an example of a systematic appraisal of the relevant literature that had implications for clinical practice.

IVIG Versus PLEX in the Treatment of Worsening Myasthenia Gravis: What is the Evidence?: A Critically Appraised Topic.

BACKGROUND: Immune therapies such as intravenous immunoglobulin (IVIG) and plasma exchange (PLEX) are first line in the treatment of worsening myasthenia gravis. Although PLEX is favored in myasthenic crisis, IVIG is increasingly used in exacerbations due to cost and ease of administration. OBJECTIVES: To review and critically assess current evidence on the effects of IVIG and PLEX on functional outcomes in patients with worsening myasthenia gravis. METHODS: A structured critical appraisal was conducted on the objective topic. This included a creation of a structured question based on a clinical scenario, comprehensive literature search, selection of evidence for review, and critical appraisal of selected evidence. Evidence was summarized and commentary provided. Participants included consultant and resident neurologists, a medical librarian, clinical epidemiologists, and content experts in the field of neuromuscular neurology. RESULTS: A single-blinded, randomized-controlled trial that compared IVIG and PLEX in 84 patients with worsening myasthenia gravis was selected for review. Primary outcome measure was functional status at 14 days after treatment, as assessed by the Quantitative Myasthenia Gravis Score. Change in Quantitative Myasthenia Gravis Score at day 14 for all subjects was 4.0, without statistically significant differences between IVIG and PLEX groups. CONCLUSIONS: IVIG and PLEX are equally effective in worsening myasthenia gravis. Treatment decisions may depend on several variables, including presence of respiratory distress, medical comorbidities, access to medication, and cost. PLEX will likely remain the treatment of choice in true myasthenic crisis.

Physical activity level and future risk of mild cognitive impairment or dementia: a critically appraised topic.

BACKGROUND: The relationships between physical activity, cognition, and development of neurodegenerative diseases represent an area of intense research interest. Meta-analyses and prospective cohort studies show that greater levels of physical activity are associated with lower dementia risk. Most studies, however, depend on self-report data that are subject to recall and other biases. Obtaining objective and quantitative physical activity data could strengthen observational study validity. OBJECTIVE: To examine the association between objectively measured daytime activity and mild cognitive impairment (MCI) or Alzheimer disease (AD). METHODS: The objective was addressed through the development of a structured, critically appraised topic. We incorporated a clinical scenario, background information, a structured question, literature search strategy, critical appraisal, results, evidence summary, commentary, and bottom line conclusions. Participants included consultant and resident neurologists, clinical epidemiologists, a medical librarian, and behavioral neurology and neuropsychiatry content experts. RESULTS: We selected a prospective, single-center cohort study of 716 cognitively normal elderly participants followed for 3.5 years. Greater levels of physical activity, as measured using wrist actigraphy, were associated with a lower risk of incident MCI or AD (hazard ratio, 0.477; 95% confidence interval, 0.273-0.832). CONCLUSIONS: Objective measurement confirms that greater levels of physical activity are associated with decreased risk of a future diagnosis of MCI or AD. Further studies are needed to confirm the temporal association of exercise and future cognitive health and understand the relevant underlying biological mechanisms.

Amantadine for patients with severe traumatic brain injury: a critically appraised topic.

BACKGROUND: Research into traumatic brain injury (TBI) has increased significantly. Diagnostic testing and therapeutics for patients with severe TBI are 2 areas on which there is increasing focus. Amantadine hydrochloride is one treatment considered to have potential therapeutic value in this patient population. OBJECTIVE: The objective was addressed through the development of a structured critically appraised topic. This included a clinical scenario, structured question, literature search strategy, critical appraisal, results, evidence summary, commentary, and bottom-line conclusions. Participants included consultant and resident neurologists, a medical librarian, clinical epidemiologists, and content experts in the disciplines of neurocritical care and physical medicine and rehabilitation. RESULTS: A multicenter, placebo-controlled, double-blind, randomized controlled trial was selected for review. The trial compared the rate of recovery, as determined by the overall Disability Rating Scale score, in a total of 184 patients with severe TBI. Patients were randomized to either receive amantadine (87) or visually identical placebo (97) over the 4-week study interval. The rate of recovery, as measured by the Disability Rating Scale, was found to be greater in the treatment arm as compared with the placebo arm (difference in slope -0.24 points/wk, P=0.007) over the 4-week treatment interval. CONCLUSIONS: The results from this study demonstrated that amantadine hydrochloride accelerates recovery in patients with severe TBI.

International consensus diagnostic criteria for neuromyelitis optica spectrum disorders.

Neuromyelitis optica (NMO) is an inflammatory CNS syndrome distinct from multiple sclerosis (MS) that is associated with serum aquaporin-4 immunoglobulin G antibodies (AQP4-IgG). Prior NMO diagnostic criteria required optic nerve and spinal cord involvement but more restricted or more extensive CNS involvement may occur. The International Panel for NMO Diagnosis (IPND) was convened to develop revised diagnostic criteria using systematic literature reviews and electronic surveys to facilitate consensus. The new nomenclature defines the unifying term NMO spectrum disorders (NMOSD), which is stratified further by serologic testing (NMOSD with or without AQP4-IgG). The core clinical characteristics required for patients with NMOSD with AQP4-IgG include clinical syndromes or MRI findings related to optic nerve, spinal cord, area postrema, other brainstem, diencephalic, or cerebral presentations. More stringent clinical criteria, with additional neuroimaging findings, are required for diagnosis of NMOSD without AQP4-IgG or when serologic testing is unavailable. The IPND also proposed validation strategies and achieved consensus on pediatric NMOSD diagnosis and the concepts of monophasic NMOSD and opticospinal MS.

A systematic review of telestroke.

BACKGROUND: The use of 2-way audiovisual (AV) technology for delivery of acute stroke evaluation and management, termed "telestroke," is supported by a rapidly growing literature base. A systematic review that provides a comprehensive, easily digestible overview of telestroke science and practice is lacking. PURPOSE: To conduct a systematic review of the published literature on telemedical consultation for the purposes of providing acute stroke evaluation and management. DATA SOURCES: The Ovid Medline, Embase, PsychINFO, CINAHL, PubMed, and Cochrane databases were searched with numerous keywords relevant to telestroke from January 1996 through July 2012. STUDY SELECTION: Studies were included if the title or abstract expressed use of 2-way AV communication for acute stroke evaluation and management. DATA EXTRACTION: Each article was classified using a novel scoring rubric to assess the level of Functionality, Application, Technology, and Evaluative stage (FATE). DATA ANALYSIS: The search yielded 1405 potentially eligible articles, which were independently reviewed by 2 investigators. There were 344 unique studies that met eligibility criteria and underwent full-text review. Ultimately, 145 unique studies underwent FATE assessment and scoring. RESULTS: Most telestroke studies evaluated functionality in the context of acute stroke assessment of adults in emergency departments. Nearly half of all published articles on telestroke were narrative reviews. After exclusion of these reviews, the median FATE score for telestroke primary data was 4. CONCLUSION: Telestroke technology is now part of mainstream clinical stroke practice in North America and internationally. Telestroke reliability, validity, efficacy, safety, clinical, and cost-effectiveness studies reflect maturity in the field, and new post-implementation studies in the pre-hospital setting present welcome and sophisticated advancements in the field.