Special considerations in migraine during pregnancy and lactation.

Migraine is estimated to affect 959 million people worldwide and has a female preponderance of 3:1. This is thought to be due to the influence of female hormones as before puberty both sexes are affected equally. The prevalence is highest in women of childbearing age at 24%. It is, therefore, important to have a good understanding of how pregnancy influences migraine and how to advise and manage women with migraine during pregnancy and lactation.

Maternal and fetal outcomes in women with cerebrovascular malformations in pregnancy: A multicentre retrospective cohort study.

OBJECTIVE: To determine maternal, obstetric and neonatal outcomes in a cohort of women with cerebrovascular malformations (CVMs) that include arterial venous malformations (AVMs) and cavernomas. DESIGN: Retrospective cohort study. SETTING: Six specialist centres managing pregnant women with neurological disorders. POPULATION: Sixty-three women with CVMs in 83 pregnancies of ≥20 completed weeks' gestation. METHODS: Retrospective case notes review. MAIN OUTCOME MEASURES: Neurological outcomes including rates of acute cerebral bleeding in pregnancy and reported seizures during pregnancy. Maternal outcomes included number of women with a livebirth and the proportion of women being delivered by caesarean section. RESULTS: Most women had a good pregnancy outcome with high rates of vaginal delivery (73%) at term. There were no maternal deaths. Six women had an acute cerebral bleed, all of whom were delivered by planned caesarean section. In total, ten women had seizures in pregnancy (of whom four also had a bleed). Six (7%) babies were admitted to a neonatal unit. There was no significant difference in outcomes between women with AVMs and those with cavernomas. CONCLUSION: In the majority of cases, pregnancy outcomes were favourable, with most women having a vaginal delivery. All cases of cerebral bleeds that occurred were at a remove from the peripartum period. TWEETABLE ABSTRACT: Women with cerebrovascular malformations have high rates of vaginal delivery.

Resolution of group B streptococcal panspinal epidural abscess in a patient with diabetes after treatment with ceftriaxone and linezolid.

Panspinal epidural abscesses are an extremely rare yet potentially fatal condition. Whether cases are best managed surgically or medically is currently controversial. A 63-year-old patient with diabetes presented initially with abdominal pain, back pain, urinary retention and constipation. He subsequently developed fevers, radicular pain and new-onset weakness in the right leg. MRI confirmed a panspinal epidural abscess extending from C7 to L5, with group B Streptococcus (GBS) cultured on sampling. Due to the significant risks of surgery he was managed conservatively, initially with ceftriaxone, and subsequently in combination with linezolid. Repeat MRI 3 months after presentation revealed complete resolution of the abscess. This case illustrates how conservative management is a valid option for patients with this condition, and supports the use of synergistic linezolid in this scenario. It also highlights how some cases may not initially present with the classically described triad of fever, back pain and loss of neurological function.

Difficult case: rituximab in anti-SRP antibody myositis in pregnancy.

A 30-year-old nulliparous woman presented at 15-week gestation with severe skeletal and respiratory muscle weakness, having been diagnosed with anti-signal recognition particle antibody myositis 3 years before. Remission had previously been induced with rituximab (after failure of standard therapies). She had continued oral prednisolone and rituximab every 6 months but had stopped this when planning pregnancy. At 16-weeks gestation, she restarted corticosteroids and rituximab, with clinical and biochemical recovery and no complications. Rituximab should ideally be given in the first trimester; treatment later in pregnancy increases the risk of neonatal B-cell depletion and cytopenias. The fetal risk from drug therapy must be weighed against the risk to mother and fetus from untreated disease. This report highlights the importance of preconception counselling for disease control and patient education regarding medication safety and early referral to obstetric medicine clinics, to facilitate complex clinical decision-making.

UK consensus on pregnancy in multiple sclerosis: 'Association of British Neurologists' guidelines.

Multiple sclerosis (MS) is more common in women than men and is most commonly diagnosed in early adulthood; thus, many patients will not have completed their families at the time of diagnosis. There is increasing awareness of the importance of early treatment in preventing long-term disability in MS. Delaying treatment until women with MS have completed their families can lead to the development of irreversible disability in at least some cases. It is therefore important to discuss family planning and pregnancy proactively. However, to date there is limited evidence to inform such discussions. We set out to develop consensus guidelines for the treatment of MS in pregnancy to encourage and facilitate discussions in this important area. The guidelines draw on available evidence from drug-specific pregnancy registers and published literature and have been scored by a panel of experts from a variety of disciplines using modified Delphi criteria. They cover prepregnancy counselling, management during pregnancy, delivery and anaesthetic options, postpartum advice and specific advice regarding currently licensed disease-modifying drugs. As the complexity and range of available disease-modifying drugs increase, further data gathering via a UK-wide MS pregnancy register is recommended.

Neurocysticercosis in pregnancy: maternal and fetal outcomes.

Neurocysticercosis (NCC) is a parasitic infection with the larvae of Taenia solium from contaminated pork. It is a leading cause of seizures in the developing world. Symptoms may be secondary to live or degenerating cysts, or previous infection causing calcification or gliosis. Diagnosis is based on clinical presentation, radiological confirmation of intracranial lesions and immunological testing. Management involves symptom control with antiepileptics and antiparasitic agents. Few cases have been described of maternal NCC during pregnancy. We describe a 25-year-old female presenting to a London hospital with secondary generalized seizures. MRI of the brain confirmed a calcified lesion in the right parietal lobe, and she gave a corroborative history of NCC during her childhood in India. She was stabilized initially on antiepileptics, but during her pregnancy presented with breakthrough seizures and radiological evidence of NCC reactivation. She was managed symptomatically with antiepileptics and completed the pregnancy to term with no fetal complications.

Changing the face of learning: ebrain and UCL distance learning diploma in clinical neurology.

ebrain is a groundbreaking e-learning program.(1) It is an exciting and novel interactive online program in clinical neuroscience aimed at hospital trainees, consultants in neurology, and other neuroscience specialties. ebrain was developed in partnership with the Joint Neuroscience Council (JNC), University College London (UCL), the European Federation of Neurological Societies (EFNS), and the European Neurological Society (ENS). At its core is a program of 550 lectures covering the breadth of clinical neurosciences.

Association of cerebral microbleeds in acute ischemic stroke with high serum levels of vascular endothelial growth factor.

OBJECTIVE: To determine whether vascular endothelial growth factor (VEGF) levels are associated with the presence of cerebral microbleeds (CMBs) in patients after acute ischemic stroke. DESIGN: A cross-sectional study that used blood samples obtained within 24 hours of symptom onset from patients who experienced acute stroke to measure VEGF levels by enzyme immunoassay. A validated CMB rating scale was used to analyze acutely acquired magnetic resonance images, with the rater blind to clinical details and VEGF levels. SETTING: Accident and Emergency Department at University College Hospital, London, England. PATIENTS: Twenty patients who experienced acute ischemic stroke. MAIN OUTCOME MEASURES: Presence of CMBs and serum level of VEGF. RESULTS: Five of the 20 patients with acute ischemic stroke (25%) had CMBs. The median VEGF level in the CMB group was significantly higher than that in the group without CMBs (P = .003). CONCLUSION: An increase in vascular permeability secondary to a raised VEGF level may have a role in the genesis of CMBs in patients with acute ischemic stroke.

Value of measuring serum vascular endothelial growth factor levels in diagnosing acute ischemic stroke.

BACKGROUND AND PURPOSE: It has previously been reported that serum levels of vascular endothelial growth factor are raised after acute ischemic stroke compared to healthy controls. The aim of this prospective study was to ascertain whether serum vascular endothelial growth factor measurements could be used to distinguish between acute ischemic stroke and common stroke mimics in the emergency room. METHODS: Blood samples were taken on arrival to hospital and daily for six-days, in 44 patients with suspected ischemic stroke (29 acute infarcts and 15 stroke mimics), arriving within 24 h of symptom onset. Vascular endothelial growth factor levels were measured by enzyme-linked immunoassay. The neurological deficit was recorded daily using the National Institute of Health Stroke Scale. Evaluation of infarct volumes was based on diffusion-weighted magnetic resonance imaging. RESULTS: Serum vascular endothelial growth factor levels were significantly raised in acute ischemic stroke patients on the day of symptom onset and at all other time points, compared to healthy controls (P < 0·01). The sensitivity and specificity of vascular endothelial growth factor for diagnosing acute ischemic stroke on admission to hospital were only 69% and 73%, respectively. Vascular endothelial growth factor levels were also elevated in four out of 15 stroke mimics, including three patients presenting with postictal paresis. CONCLUSIONS: Vascular endothelial growth factor has limited clinical utility in the diagnosis of acute ischemic stroke in the emergency room because levels are also raised in common stroke mimics. Further studies are required to establish the mechanism of vascular endothelial growth factor elevation in postictal paresis.

Hyperacute detection of neurofilament heavy chain in serum following stroke: a transient sign.

Serological biomarkers which enable quick and reliable diagnosis or measurement of the extent of irreversible brain injury early in the course of stroke are eagerly awaited. Neurofilaments (Nf) are a group of proteins integrated into the scaffolding of the neuronal and axonal cytoskeleton and an established biomarker of neuro-axonal damage. The Nf heavy chain (NfH(SMI35)) was assessed together with brain-specific astroglial proteins GFAP and S100B in hyperacute stroke (6 and 24 h from symptom onset) and daily for up to 6 days. Twenty-two patients with suspected stroke (median NIHSS 8) were recruited in a prospective observational study. Evidence for an ischaemic or haemorrhagic lesion on neuroimaging was found in 18 (ischaemia n = 16, intracerebral haemorrhage n = 2). Serum NfH(SMI35) levels became detectable within 24 h post-stroke (P < 0.0001) and elevated levels persisted over the study course. While GFAP was not detectable during the entire course, S100B levels peaked at the end of the observation period. The data indicate that significant in vivo information on the pathophysiology of stroke may be obtained by the determination of NfH(SMI35). Further studies are required to evaluate whether NfH(SMI35) in hyperacute stroke reflects the extent of focal ischaemic injury seen on neuroimaging or is a consequence of more diffuse neuro-axonal damage.

Criteria for a clinically informative serum biomarker in acute ischaemic stroke: a review of S100B.

BACKGROUND AND PURPOSE: Serum S100B has been widely studied as a biomarker in acute ischaemic stroke. The main objective of this review was to appraise the published literature on S100B and determine its clinical applicability. METHODS: Medline was searched to identify studies on S100B (or S-100B) in acute ischaemic stroke. The authors have proposed the criteria for a clinically informative serum biomarker for acute ischaemic stroke, and relevant articles relating to these criteria were then selected. RESULTS: Studies have shown that S100B has a low specificity for acute ischaemic stroke because of its tendency to be raised from extracranial sources. Data regarding S100B kinetics compiled from 6 longitudinal studies show that serum levels are not raised immediately following acute ischaemic stroke and peak 3 days after symptom onset. However, serum S100B levels correlate well with infarct volume and are higher in stroke patients at risk of malignant infarction or haemorrhagic transformation after thrombolysis. In addition, serum S100B levels correlate well with functional outcome. CONCLUSION: The evidence suggests that S100B is not a valuable biomarker for diagnosing acute ischaemic stroke. Instead, it may have a more promising role in non-specialist hospitals, as an additional tool for identifying patients at increased risk of specific early neurological complications after stroke and as a surrogate marker of cerebral damage and functional outcome, particularly in a research setting.

A case of poststreptococcal opsoclonus-myoclonus syndrome.

High antistreptococcal antibody titer (ASOT) was measured in a 31-year-old Caucasian lady presenting with opsoclonus and myoclonus. She was treated with oral steroids and 8 weeks after the onset of symptoms she had a normal ASOT and only mild residual symptoms. This is one of the first cases of opsoclonus-myoclonus syndrome developing, following a streptococcal infection in adults.