BoNT clinical trial update: Sialorrhea.

Sialorrhea is the excessive accumulation of saliva, a prevalent symptom among a number of neurologic conditions in both pediatric and adult patients. Over the years, the management of sialorrhea has evolved and included a variety of interventions, ranging from nonpharmacologic, pharmacologic, and surgical treatment options. The most common option for treatment has been the use of botulinum toxin injections in the management of sialorrhea. While there have been several clinical trials to assess the efficacy of botulinum toxin in the treatment of sialorrhea, the largest randomized control trials to date have been with incobotulinumtoxin (2019) and rimabotulinumtoxin (2020) which show consistent reduction in salivary flow rate and improvement in clinical outcomes with comparable duration of treatment effectiveness. In this update, we review the evolution of treatment and injection methods for sialorrhea among many neurologic diseases. We discuss the challenges in evaluating and measuring efficacy in clinical trials for sialorrhea and compare the contemporary botulinum toxin clinical trials in the treatment of sialorrhea.

Overestimation of core infarct by computed tomography perfusion in the golden hour.

A nonagenarian patient developed a right middle cerebral artery syndrome during recovery after a right internal carotid artery (ICA) balloon angioplasty. Emergent head computed tomography (CT) revealed no acute ischemic changes; CT angiography (CTA) and CT perfusion (CTP) demonstrated a right ICA occlusion with a large right hemispheric predicted core infarct by cerebral blood flow thresholds and minimal mismatch volume. She underwent complete reperfusion in <45 min from symptom onset. Magnetic resonance imaging brain obtained within 48 h showed a decreased infarct volume as that estimated by CTP. This case emphasizes the limitations of estimating the ischemic core with CTP in the golden hour with ultra-early reperfusion and suggests that CTP thresholds should not be used to exclude patients from treatment in the very early time window.