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In This Issue of JAMA Neurology
December 2018


JAMA Neurol. 2018;75(12):1453. doi:10.1001/jamaneurol.2017.2671


Behavioral speech therapy is the most efficient treatment for poststroke aphasia, but outcomes are variable, and full recovery is not always achieved. Fridriksson and coauthors performed a large, double-blinded, prospective randomized clinical trial using a futility design including 74 patients with aphasia associated with previous left hemisphere stroke. Patients all completed 15 aphasia treatment sessions dispensed over 3 weeks and were randomized to receive either anodal transcranial direct current stimulation (tDCS) or sham tDCS. The results revealed numerically greater improvement for the anodal tDCS group, suggesting further studies are needed to determine if this treatment is broadly efficacious for poststroke aphasia. Editorial perspective is provided by Cramer.


Continuing Medical Education

It is not clear if direct transfer to endovascular stroke centers (mothership) should be favored over a drip-and-ship approach in suspected acute ischemic stroke. In a theoretical, conditional probability modeling study, Holodinsky and coauthors used existing data from clinical trials of stroke treatment for model generation. Using the variables of probability of ischemic stroke with large-vessel occlusion, transport time, and treatment speed, treatment at the thrombolysis center favored bypass when centers are 60 minutes or fewer apart and treatment speed is slow. With greater transport times between centers or faster treatment at the thrombolysis center, a drip-and-ship approach is favored. Regional organization of stroke triage and transport is necessary to maximize the best patient outcomes. Editorial perspective is provided by Schwamm.


Mild cognitive impairment (MCI) increases the risk of progressive cognitive decline. Black individuals experience MCI at twice the rate of white individuals. In a 2-year randomized clinical trial that included 221 black individuals with MCI, Rovner and coauthors found that behavioral activation (designed to increase cognitive, physical, and social activity) significantly reduced the risk of cognitive and functional decline compared with an attention control treatment. Social determinants of health increased the risk of cognitive decline in black individuals relative to white individuals, and behavioral activation may reduce this health disparity and serve as a new target for therapy.

Acquired autoimmune neuromyotonia (NMT) is a rare disorder, and serologic study results are not positive in all patients. Little is known about possible associations of specific NMT antibodies with additional clinical features, such as pain and autonomic and central nervous system involvement. Vincent and coauthors conducted a cohort study including 38 patients with electrophysiologically confirmed NMT at specialized centers in Sydney, Australia, and Kagoshima, Japan. Pain or paresthesia (53%), autonomic (47%) and neuropsychiatric (26%) features, and sleep disturbance (34%) were frequent, and antibodies to both the voltage-gated potassium channel–complex proteins, contactin-associated protein 2 and leucine-rich glioma inactivated protein 1, were associated with severe disease and the presence of thymoma. In an independent patient-led questionnaire, 56 responders reported pain that could be severe as well as significant effects on employment and quality of life. Neuromyotonia and its associated heterogeneous clinical features need to be recognized so that protocols can be formalized and diagnostic accuracy can be improved.