Update in Neurology ACP 2017 PDF
Preview Update in Neurology ACP 2017
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
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