Cranial Nerve I Makes a Comeback

Plus Other AAN 2013 Highlights

Andrew N. Wilner, MD


April 02, 2013

Immunotherapy for Alzheimer Disease

The third study is "Initial Findings of a Randomized Double-Blinded Placebo-Controlled Study of Intravenous Immunoglobulin in Mild Cognitive Impairment Due to Alzheimer Disease," by Kile and colleagues.[3] Fifty-two patients (60% women) with a mean age of 72 years were treated every 2 weeks with saline or IVIG at a dose of 0.4 g/kg. Twenty-eight patients completed 12 months of treatment. At the end of the year, there were no statistically significant differences between the placebo group and the IVIG group on the Mini Mental State Exam (MMSE) or the Clinical Dementia Rating Sum of Boxes (CDR-SB). However, MRI atrophy progressed 5.7% in the IVIG group and 8.8% in the placebo group, a statistically significant difference (Table 2).

Table 2. Findings

Group MMSE
(P = NS)
(P = NS)
MRI Atrophy
(P = .028)
Baseline IVIG 26.07 1.79  
IVIG 1 year 25.79 2.71 - 5.7%
Baseline placebo 26.57 1.39  
Placebo 26.29 2.29 - 8.8%

NS = nonsignificant

Many more patients need to be studied to determine whether IVIG is a useful treatment in Alzheimer disease. This study raises the tantalizing question that this immunotherapy could possibly help.

Stroke -- or Not?

The last poster is "Separating Acute Stroke from Stroke Mimics in a TeleStroke Network: Differential Patient Characteristics and Exam Findings," by Ali and colleagues.[4] In this study, 2764 TeleStroke consultations from the Partners TeleStroke Network from 2008 to 2011 were reviewed. Of all patients, 77% had cerebrovascular disease (CVD) and 23% had a non-CVD diagnosis (primarily seizure and migraine). Among patients with CVD, 74% had ischemic stroke, 13% had subacute ischemic stroke, 10% had transient ischemia attack, and 3% had hemorrhagic stroke.

When the CVD and non-CVD groups were compared, the stroke patients were older and significantly different with respect to vascular risk profiles and presentation from patients with a nonstroke diagnosis (Table 3).

Table 3. CVD vs Non-CVD Patients

Variable CVD Non-CVD P value
Age (years) 67.8 56.3 < .001
Female 48.2% 59% < .001
Hypertension 56.3% 39.6% < .001
Hyperlipidemia 20.9% 13.7% .027
Previous stroke 25% 17.3% .024
Atrial fibrillation history 20.6% 6.6% < .001
Seizure history 2.6% 7.6% .002
Facial weakness 63.8% 29.9% < .001
Limb weakness 72.1% 52.3% < .001
Speech disturbance 64.7% 48.2% < .001
Altered mental status 38.9% 32.5% NS

All of these differences were statistically significant. Altered mental status was similar in both groups.

TeleStroke is increasingly used in many hospital networks. Accurate and rapid diagnosis of stroke is important to give tissue plasminogen activator (tPA) to the appropriate patients. It is also important to avoid giving tPA to patients who have not had an acute stroke. The observations in this study draw attention to features that distinguish stroke patients from those who have symptoms of another cause.

Take-Home Messages

The take-home messages from these 4 posters are:

  • Testing olfaction may be the most sensitive way of documenting an abnormal neurologic exam in cases of mild TBI;

  • Symptom progression in Parkinson disease may be related to extranigral brain degeneration;

  • IVIG may be helpful in mild cognitive impairment related to Alzheimer disease; and

  • Stroke mimics have a different profile from those in patients with true ischemic stroke, which may be useful when evaluating patients with TeleStroke.

This is Dr. Andrew Wilner reporting for Medscape from the 65th Annual Meeting of the American Academy of Neurology in San Diego, California. Thank you for listening.