published between 2019 and 2022
With great interest, we read the review by Markus on personalising the secondary prevention approach to patients with stroke ¹, published in the most recent issue of Practical Neurology. Where we are presented with clinically useful and evidence-based advice for the etiological assessment of patients with acute ischemic stroke (AIS), focusing on lacunar stroke syndromes of a non-lacunar cause, and its appropriate therapeutic management. We consider the article of great importance: a must-read for all physicians who care for patients with AIS since etiological assessment is paramount to dictate the appropriate secondary prevention measures.
The author proposes using the TOAST classification (Trial of Organon 10172 in Acute Stroke Treatment), arguing that classification systems that prime clinical syndromes over pathophysiological mechanisms are less useful. Nevertheless, the author omitted one classification which–partially–resolves the issue: the ASCOD (Atherosclerosis, Small-vessel, Cardiac embolism, Other, Dissection) system ². A comprehensive classification, which allows for more than one aetiology, while giving a degree of a causal relationship to the presence of each category of disease (1 potential, 2 uncertain, 3 unlikely, 0 disease not detected) including incomplete assessment (9 insufficient work-up), while considering some clinical features.
The ASCOD approach permits the identification of patients with diseases that would have been left as indeterm...
The ASCOD approach permits the identification of patients with diseases that would have been left as indeterminate with other classification systems, thus increasing the risk of stroke because of inadequate secondary prevention. Comparisons with other classification systems have shown that ASCO (the predecessor of ASCOD) allows for more than one cause of stroke, with a larger proportion of atherosclerosis and lower of indeterminate and small vessel disease with the potential to magnify cardiac embolism thus leading to overtreatment ³, but with a recurrence risk strongly tied to aetiology regardless of the classification system used ⁴.
However, both of the above mentioned-comparisons have a flaw: they used ASCO as a dichotomic variable, which is not, and is precisely the advantage of ASCOD, that allows individualizing secondary prevention approaches for the most likely aetiology without discarding other possible etiologies, thus decreasing the proportion of indeterminate strokes facilitating inclusion for clinical trials ⁵. The relevance of considering multiple etiologies this has been demonstrated by studies like AMISTAD in which concurrent intra- and extracranial atherosclerosis increased the risk of major adverse cardiovascular events ⁶, and the secondary analysis of SOCRATES, which demonstrated ticagrelor to be superior to aspirin in patients with atherosclerosis regardless of causal link ⁷.
Bottom line, the critical issue is to assess patients with AIS to detect the most likely aetiology responsible for the stroke, without losing sight of possible comorbidities and regardless of the classification system used. In our Hospital, we use ASCOD since it allows neurology residents to consider all potential etiologies, but each centre should individualize to its specific needs.
1. Markus H. Personalising secondary prevention: different treatments for different strokes. Practical Neurology Published Online First: 04 September 2019 doi: 10.1136/practneurol-2018-002006
2. Amarenco P, Bogousslavsky J, Caplan LR, et al. The ASCOD phenotyping of ischemic stroke (Updated ASCO Phenotyping). Cerebrovasc Dis 2013;36(1):1-5. doi: 10.1159/000352050
3. Shang W, Liu J. Stroke subtype classification: a comparative study of ASCO and modified TOAST. J Neurol Sci 2012;314(1-2):66-70. doi: 10.1016/j.jns.2011.10.029
4. Arsava EM, Helenius J, Avery R, et al. Assessment of the Predictive Validity of Etiologic Stroke Classification. JAMA Neurol 2017;74(4):419-26. doi: 10.1001/jamaneurol.2016.5815
5. Sirimarco G, Lavallee PC, Labreuche J, et al. Overlap of diseases underlying ischemic stroke: the ASCOD phenotyping. Stroke 2013;44(9):2427-33. doi: 10.1161/STROKEAHA.113.001363
6. Hoshino T, Sissani L, Labreuche J, et al. Prevalence of Systemic Atherosclerosis Burdens and Overlapping Stroke Etiologies and Their Associations With Long-term Vascular Prognosis in Stroke With Intracranial Atherosclerotic Disease. JAMA Neurol 2018;75(2):203-11. doi: 10.1001/jamaneurol.2017.3960
7. Amarenco P, Albers GW, Denison H, et al. Efficacy and safety of ticagrelor versus aspirin in acute stroke or transient ischaemic attack of atherosclerotic origin: a subgroup analysis of SOCRATES, a randomised, double-blind, controlled trial. Lancet Neurol 2017;16(4):301-10. doi: 10.1016/S1474-4422(17)30038-8
We thank Dr Torres and colleagues for drawing the readers’ attention to the additional value of observing patients with parkinsonian syndromes even before they enter the hospital premises. They focus specifically on the question how neurologists should act when one incidentally spots clear signs of a neurological disease among total strangers in social situations, and they emphasize just how exceptionally difficult this may be for experts in movement disorders, as these conditions can be very visible even to bystanders. Many readers will recognize how compelled one can feel to make a heartfelt recommendation to strangers to seek a neurological consultation, for example when they demonstrate clear-cut signs of Parkinson’s disease or some other neurological condition. However, we have neither acted on the impulse as this would be a serious breach of this person’s privacy. In addition, we need to realize that we are fully ignorant of the person’s context, barriers and motives that have prevented this person – who might already be aware of the signs - from seeking medical attention. We agree that one can only observe, but interfering would be out of line. Indeed, we previously observed a remarkable Parkinson-like gait disorder in Russian president Vladimir Putin and several other highly ranked Russian officials,1 just because we could not suppress our almost innate tendency to analyze movements, in this case when observing the publicly available v...
We thank Dr Torres and colleagues for drawing the readers’ attention to the additional value of observing patients with parkinsonian syndromes even before they enter the hospital premises. They focus specifically on the question how neurologists should act when one incidentally spots clear signs of a neurological disease among total strangers in social situations, and they emphasize just how exceptionally difficult this may be for experts in movement disorders, as these conditions can be very visible even to bystanders. Many readers will recognize how compelled one can feel to make a heartfelt recommendation to strangers to seek a neurological consultation, for example when they demonstrate clear-cut signs of Parkinson’s disease or some other neurological condition. However, we have neither acted on the impulse as this would be a serious breach of this person’s privacy. In addition, we need to realize that we are fully ignorant of the person’s context, barriers and motives that have prevented this person – who might already be aware of the signs - from seeking medical attention. We agree that one can only observe, but interfering would be out of line. Indeed, we previously observed a remarkable Parkinson-like gait disorder in Russian president Vladimir Putin and several other highly ranked Russian officials,1 just because we could not suppress our almost innate tendency to analyze movements, in this case when observing the publicly available video materials of these individuals. An exception could be made for patients who are already part of one’s own clinic, and where a fortunate observation of e.g. this person’s gait outside the hospital may offer additional value to what can be noted within the hospital itself. For example, cobbled stones on the street can elicit occasional stumbles that might be missed on the perfectly even hospital floors. We also find it illustrative to see how difficult it can be for patients to step outside of their car (seats are usually very low, causing great problems for patients with Parkinson’s disease or proximal leg weakness). Finally, we have seen patients manifesting freezing of gait only when they approached the revolving doors of the hospital – these can be a great challenge for people with Parkinson's.
Bastiaan R. Bloem, MD, PhD. (corresponding author)
Radboud university medical centre
Donders Institute for Brain, Cognition and Behaviour
Department of Neurology
Nijmegen, the Netherlands
Rui Araújo, MD.
Neurology Department, Centro Hospitalar e Universitário de Coimbra
Bart P. van de Warrenburg, MD, PhD.
Radboud university medical centre
Donders Institute for Brain, Cognition and Behaviour
Department of Neurology;
Nijmegen, the Netherlands
Anthony E. Lang, MD, FRCPC.
Morton and Gloria Shulman Movement Disorders Clinic and the Edmond J Safra Program in Parkinson’s Disease, Toronto Western Hospital
399 Bathurst Street, Toronto, Ontario
Andrew J. Lees, MD, FRCP, FMedSci.
National Hospital, Queen Square
Reta Lila Weston Institute, University College London
1. Araujo R, Ferreira JJ, Antonini A, Bloem BR. "Gunslinger's gait": a new cause of unilaterally reduced arm swing. BMJ 2015;351:h6141.
As I make my way to the outpatient clinic, late as usual after the morning rounds to start another busy day, an unusual walk in front of me seizes my attention: an elderly lady, with a narrow-based and short-stepped gait, decreased left-arm swing and stooped posture; unable to see her face, I assume she’s heading for the neurology outpatient clinic. Yet she passes by and I lose sight of her on the ophthalmology service. Not a patient of ours, I think to myself. That same night, while having supper at a restaurant with my soon-to-be-wife, I notice a few tables away a man on his seventies celebrating his birthday, surrounded by family. In front of the candle-sparkling birthday cake, I get a glimpse of an unusual face: elevated eyebrows, like on a permanent surprise, unable to direct his gaze to the cake—Procerus sign and vertical gaze paresis—I think to myself, while I notice the stooped posture and global slowness of movements while everyone on the table compliments him—parkinsonism also, definitely progressive supranucl…—“You’re doing that again, leave the man alone.” My train of thought gets wrecked by my fiancee, not being the first time, she knows I tend to distinguish and observe people with abnormal movements. I leave the man alone and finish my supper. -SACT.
It was with exceptional interest that we read “The Waiting Room”, by Araújo et al. recently published online on Practical Neurolo...
It was with exceptional interest that we read “The Waiting Room”, by Araújo et al. recently published online on Practical Neurology(1), where they elaborate on the importance of beginning the neurological examination before the patient enters the doctor's office. An excellent chronicle on many signs that we might have seen but not acknowledged, in a clear and concise manner. However, while reading the article some concerns (unrelated to the quality and value of the article) were brought to our attention. How about outside the clinic or the Hospital?
Should we approach the gentleman or the lady portrayed in the first two paragraphs by author SACT? For neurologists, particularly for movement disorders specialists, patients can be found everywhere. Should neurologists be observant of the Goldwater rule (2), that prohibits psychiatrists to diagnose a subject they have not personally examined, and to communicate that diagnosis without the subjects consent? Are we then only to observe and describe just like James Parkinson did(3)? We observe as a clinical exercise, to describe phenomenology but we would never approach a person in public to invite them to our clinic, or to give an unsolicited diagnosis; that would be preposterous, we have no right to do so. In ‘Do no harm’, Henry Marsh states that neurologists are like kids looking for “strange and obscure diseases, sometimes untreatable, (...) deeply fascinating, and which they collect like rare butterflies and report in their journals(4)”. Yet we feel this description to be quite unfair because phenomenology might seize our attention, but we must strive to be like the great physician that Sir William Osler envisioned, the one who cares about “the patient who has the disease.”.
As a general neurology resident, the movement disorders field seems more and more appealing. The fact that even outside the doctor’s office we can start the diagnostic process, prompted one of the authors (SACT) to write the opening paragraphs, based on real-life experiences, in order to ask for the author’s advice on how to approach this situation; and to encourage more residents into neurology and movement disorders, because of the growing pandemic of neurodegenerative disorders like Parkinson’s disease that is calling us into action(5).
Acknowledgments: SACT would like to thank Mariana Castillo-Torres (Bachelor in Languages for Interpreting and Translation), for her kind assistance on English-language, editing and style.
Contributorship Statement: SACT contributed to the conceptual design of the article with the opening paragraphs and drafting of the manuscript. FFA contributed with the drafting of the manuscript, and a review of intellectually relevant content. IEB contributed to article conception and design, drawing from personal experiences, as well as a review for intellectually relevant content. All authors agreed on the final version of the manuscript.
1. Araujo R, van de Warrenburg B, Lang A, et al. The Waiting Room: neurological observations made outside the movement disorder specialist's consulting office. Pract Neurol 2019 doi: 10.1136/practneurol-2018-002110
2. Lilienfeld SO, Miller JD, Lynam DR. The Goldwater Rule: Perspectives From, and Implications for, Psychological Science. Perspect Psychol Sci 2018;13(1):3-27. doi: 10.1177/1745691617727864
3. Kempster PA, Hurwitz B, Lees AJ. A new look at James Parkinson's Essay on the Shaking Palsy. Neurology 2007;69(5):482-5. doi: 10.1212/01.wnl.0000266639.50620.d1
4. Marsh H. Do no harm: stories of life, death and brain surgery: Hachette UK 2014.
5. Dorsey ER, Bloem BR. The Parkinson Pandemic-A Call to Action. JAMA Neurol 2018;75(1):9-10. doi: 10.1001/jamaneurol.2017.3299