Can J Neurol Sci
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In 1886, Victor Horsley excised an epileptogenic posttraumatic cortical scar in a 23-year-old man under general anaesthesia and discussed his choice of anaesthesia: "I have not employed ether in operations on man, fearing that it would tend to cause cerebral excitement; chloroform, of course, producing on the contrary, well-marked depression." His concerns regarding anaesthesia are reiterated 100 years later as evidenced by the ongoing controversy over the choice of anaesthetic in surgical procedures for epilepsy. The current controversies regarding the necessity for local anaesthesia in temporal lobe epilepsy operations concern the utility of electrocorticography in surgical decision making, its relationship to seizure outcome and the value of intraoperative language mapping in dominant temporal lobe resections. ⋯ Thus, indications which were previously absolute are now perhaps relative. This article reviews the current indications for craniotomy under local anaesthesia in the surgical treatment of temporal lobe epilepsy.
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Patients with stroke commonly undergo investigations to determine the underlying cause of stroke. These investigations often include ambulatory electrocardiography to detect paroxysmal atrial fibrillation. There is conflicting evidence in the literature regarding whether routine ambulatory electrocardiography should be performed in all or selected stroke patients. This paper reviews the available evidence on (1) the yield of ambulatory electrocardiography in detecting paroxysmal atrial fibrillation in patients with stroke or transient ischemic attack and (2) the effectiveness of anticoagulation in preventing recurrent stroke in patients with paroxysmal atrial fibrillation. ⋯ There is insufficient evidence to recommend for or against the use of ambulatory electrocardiography for the detection of paroxysmal atrial fibrillation in either selected or unselected patients with stroke (C Recommendation). There is fair evidence to recommend therapy with warfarin for patients with stroke and paroxysmal atrial fibrillation (B Recommendation).
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Migraine with and without aura is thought to be genetically complex with aggregation in families due to a combination of environmental and genetic tendencies. Twin studies are most important in establishing the multifactorial nature of migraine with heritability approaching 50%. Familial hemiplegic migraine (FHM) on the other hand is an autosomal dominant, highly penetrant, though rare form of migraine with strong genetic tendency. ⋯ Additional candidate genes causative for migraine might include other calcium channel subunits and related proteins important for neuronal membrane stability. Delineating the cascade of biochemical events leading to hemiplegic migraine will serve as a model for understanding the pathophysiology of more common forms of migraine. The evidence suggesting that some families of migraine with and without aura might also be related to the chromosome 19p locus, chromosome Xq28 locus, or DRD2 receptor polymorphisms is reviewed.
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The management of Parkinson's disease has undergone recent changes with the advent of new therapies, both pharmacotherapy and surgery. Available interventions are discussed. Levodopa remains the mainstay of therapy. ⋯ Atypical neuroleptic agents and ECT for psychiatric syndromes associated with Parkinson's disease are discussed. Algorithms for the management of early disease as well as the management of psychosis in Parkinson's disease are included. Treatment options for advanced disease are tabulated.