Neurology
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To reverse the profile of abnormal intracortical excitability in patients with ALS by administering drugs that promote GABAergic transmission. ⋯ The demonstration of pharmacologic reversal of hyperexcitability in patients with ALS makes a potentially significant contribution toward understanding the pathophysiology of a disease that has so far eluded an effective cure.
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Patients with advanced Parkinson's disease (PD) frequently suffer disabling motor complications that cannot be satisfactorily controlled with medical therapy. Deep brain stimulation (DBS) has recently been introduced by Benabid and his colleagues in Grenoble, France, as a new surgical procedure for the treatment of PD patients. DBS simulates the effects of a lesion without the need to make a destructive brain lesion. ⋯ Adverse events are associated with the surgical procedure, the device, and stimulation, but the procedure is usually well tolerated. On the basis of these findings, the FDA has recently approved unilateral DBS of the Vim for treatment of tremor in PD and is currently considering approval of DBS for STN and GPi. This article reviews existing information with respect to DBS.
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Research into migraine pathophysiology has been hampered by the episodic nature and unpredictable onset of migraine attacks. Recently, newer imaging techniques have been providing noninvasive methods of studying metabolism and hemodynamics in the brains of migraineurs during and between acute attacks. 133Xe blood flow techniques, transcranial Doppler, and SPECT have all been employed to investigate hemodynamic changes during migraine aura. PET has been useful in the study of migraine without aura, with findings of increased blood flow related to pain in cortical areas and in the medial brainstem. ⋯ Magnetoencephalography studies support the presence of a spreading depression-like phenomenon in migraine with aura. Two groups have used transcranial magnetic stimulation to assess whether neurons in the occipital cortex are hyperexcitable, predisposing patients to develop aura symptoms. Despite conflicting findings, migraine with visual aura appears to be generally associated with transient decreases in regional CBF.
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For many years, tricyclic antidepressants (TCAs) were used as initial therapy for the pharmacologic management of neuropathic pain. First-generation antiepileptic drugs (AEDs) are also used for the treatment of pain, and two drugs in this group, carbamazepine and sodium valproate, have received FDA approval for trigeminal neuralgia and migraine headache, respectively. ⋯ Recently, newer AEDs with more favorable side-effect profiles have been tested in placebo-controlled clinical trials for the treatment of neuropathic pain, including painful diabetic neuropathy and postherpetic neuralgia. The results of these trials, together with advances in understanding the pathophysiology of neuropathic pain, provide the basis for reevaluating some of the commonly accepted paradigms that guide approaches to treatment.