Update in Neurology ACP 2017

47 Pages·2017·3.79 MB·English

by  Partners Information Systems

The Brigham Department of Neurology
Martin A. Samuels, Chairman
Director, Brigham and Women’s Institute for the Neurosciences
Miriam Sydney Joseph Professor of Neurology
Harvard Medical School
Sydney
Miriam
Samuels
Joseph
Conflict of Interest Disclosure
NONE
Update in Neurology
ACP 2017
Martin A. Samuels, MD, MACP
Chairman, Department of Neurology
Brigham and Women’s Hospital
Miriam Sydney Joseph Professor of Neurology
Harvard Medical School
Update in Neurology 2017
• Stroke and Cerebrovascular Diseases
• Neuromuscular Diseases
• Movement Disorders
• Traumatic Brain Injury
• Nociception, Pain, Suffering and Opioids
• Autoimmune Neurology
• Neurocardiology
Stroke and Cerebrovascular Diseases
• Since 2015 endovacular Rx is an option
• Some trials terminated early; small sample size
• Meta-analysis of five trials
– 1287 participants
– Primary outcome: disability at 3 months
– Mean age 67 year; 47% female
– Median time to trial entry = 196 minutes
– Median time to arterial puncture = 238 minutes
– Median time to reperfusion = 286 minutes
– 71% proximal MCA; 22% distal internal carotid
– Results
• Disability increased with Rx delay
• 3 hours: OR = 2.79; risk difference = 39.2%
• 6 hours: OR = 1.98; risk difference = 30.2%
• 8 hours: OR = 1.58; risk difference = 0
• Risk reduction persisted through 7 hours, 18 minutes
• Conclusions: benefit for about 6-7 hours post stroke

Badhiwala JH et al. Endovascular thrombectomy for acute ischemic stroke: a
meta-analysis. JAMA 2015; 314: 1832.
Neuromuscular Diseases
• Acquired myasthenia gravis (MG) is caused by binding of
autoantibodies to acetylcholine receptors
• Thymectomy in non-thymomatous cases was controversial
• Randomized trial of 126 patients with generalized non-
thymomatous MG of less than 5 years duration
• All were class II-IV (generalized) with anti-receptor Abs
• Results: Thymecomy patients
– had lower MG score compared to prednisone alone
– Had lower average requirements for alternate-day prednisone
– Required less immunosupprsssion with azathioprine
– Were less likely to be admitted for exacerbations
• Conclusion: Thymectomy improves outcome in acquired
generalized MG, but is not a cure

Wolfe GI et al. Randomized trial of thymectomy in myasthenia gravis. N
Engl J Med 2016; 375: 511.
Movement Disorders
• Braak hypothesis: abnormally folded protein (α-
synuclein) carried from the gut by nerves to CNS;
vagus a major pathway
• Swedish and Danish National Patient Registries
queried and results were similar
• Results: Up to 20 years post truncal vagotomy, there
is a lower risk of Parkinson disease; not true for
selective (gastric) vagotomy
• Conclusions: Data support the Braak hypothesis of
the pathogenesis of PD, but vagotomy is not
recommended as a treatement for PD
Svensson E et al. Vagotomy and subsequent risk of
Parkinson disease. Ann Neurol 2015; 78: 522-529

Movement Disorders
• Braak hypothesis: abnormally folded protein (α-
synuclein) carried from the gut by nerves to CNS;
vagus a major pathway
• Swedish and Danish National Patient Registries
queried and results were similar
• Results: Up to 20 years post truncal vagotomy, there
is a lower risk of Parkinson disease; not true for
selective (gastric) vagotomy
• Conclusions: Data support the Braak hypothesis of
the pathogenesis of PD, but vagotomy is not
recommended as a treatement for PD
Svensson E et al. Vagotomy and subsequent risk of
Parkinson disease. Ann Neurol 2015; 78: 522-529