Current Treatment Options in Neurology最新文献

Purpose of Review

The research aims to determine the effectiveness of the main approaches in the diagnosis and treatment of trigeminal neuralgia. Analysis, synthesis, comparison, and generalisation were used as methods of studying the object of research.

Recent Findings

According to the results of the study, the most effective method of diagnosis was found to be examination and history taking. Correct performance of these actions allows to find out whether the nature of the patient’s pain is a symptom of trigeminal neuralgia. For this purpose, the location, nature, and triggering factors of the pain are determined. At the same time, pain characteristics are compared to exclude other diseases that are also accompanied by pain in the face. Among the instrumental diagnostic methods, magnetic resonance imaging has proven to be the most effective, allowing to determine the form of neuralgia and its causes. To determine the effectiveness of treatment methods, the parameters of pain relief rate, duration of the therapeutic effect and the presence of side effects were used. The most effective approach in the conservative treatment of trigeminal neuralgia was determined to be a complex drug therapy, including anticonvulsants, muscle relaxants, antispasmodics, and physiotherapy procedures. The most effective method of surgical intervention is microvascular decompression, which provides immediate pain relief in most cases and has the longest-lasting effect compared to other methods.

Summary

Rhizotomy was defined as a less effective procedure, but its advantage was its minimally invasive nature. Even though trigeminal neuralgia is a recurrent disease, the right treatment approach can maximise the duration of remission and return the patient to a normal lifestyle.

Purpose of review

To provide an updated summary on the diagnosis and treatment of patients with malignant cerebral edema after ischemic stroke.

Recent findings

The risk of malignant middle cerebral artery (MCA) stroke is highest in young patients with large vessel occlusion and unsuccessful revascularization. Several scores are available for risk stratification. Treatment includes supportive care, close neurologic monitoring, and hyperosmolar therapy. Yet, the main therapeutic decision is whether to proceed with decompressive craniectomy. Multiple randomized clinical trials and several meta-analyses have demonstrated that decompressive hemicraniectomy is the single most important intervention associated with survival. Survivors may face severe disability regardless of surgical treatment, and the definition of acceptable outcome in this context remains elusive.

Summary

Malignant MCA infarcts are life-threatening and invariably cause disability, most often severe. Neurologic deterioration requires airway management and hyperosmolar therapy. Decompressive hemicraniectomy is a lifesaving procedure; approximately 50% of surgically treated patients younger than 60 years can regain independent ambulation, and one nearly in five may become functionally independent at 1 year. Older patients face a much worse functional prognosis; surgical decisions in these patients should be assessed case by case.

Purpose of review

This review aims to provide a summary of the pathophysiology, clinical presentation and management options for facioscapulohumeral dystrophy (FSHD). We discuss current management options and delve into updates about developments in targeted therapy.

Recent findings

New breakthroughs in FSHD research have led to a further understanding of aberrant DUX4 protein expression in the underlying pathophysiology of FSHD. This has paved the way for the development of targeted therapies aimed at targeting DUX4 expression or its downstream effects. Therapeutic strategies for FSHD primarily target DUX4 through three main avenues: small molecules, antisense oligonucleotide therapeutics and CRISPR-based approaches. This review discusses these strategies further. Presently, all prospective targeted therapies are in the pre-clinical phase, except for losmapimod, which is currently undergoing a phase 3 clinical trial.

Summary

Given the absence of approved disease-modifying treatments for FSHD, the primary approach for management currently involves multidisciplinary supportive measures which are limited. Recent developments in the form of targeted therapies and strategies for the definitive treatment of FSHD indicate a promising era.

Purpose of review

This review aims to provide a critical appraisal of current diagnostic and therapeutic strategies for patients with orbital inflammatory disease (OID). We present the reader with a review of clinical, imaging, laboratory, and biopsy based assessment of OID and review the current treatment modalities utilized including corticosteroids, corticosteroid-sparing (immunomodulatory) agents, radiation, antibiotics, and disease specific therapy.

Recent findings

Two major developments and trends have emerged in the management of orbital inflammation. First, improved understanding and distinction of inflammation subtypes (myositis, dacryoadenitis, or infiltrative) allows for more nuanced workup and treatment. Second, immunomodulatory agents have shown promise in achieving disease control in cases of truly idiopathic or corticosteroid-resistant OID. Together, these advances have led to fewer adverse effects and better efficacy.

Summary

The optimal treatment of OID depends on distinguishing between nonspecific and specific inflammation. Nonspecific inflammation tends to respond to corticosteroid therapy with a lower chance of relapse, while specific orbital inflammation often requires targeting the underlying disease with steroid-sparing therapy and immunomodulatory agents.

Purpose of review

This review describes risk factors for severe skin reactions to antiseizure medications (ASMs), the usage of updated tests to predict those with increased risk of a severe cutaneous reaction, and guides how to choose specific ASMs and dosing to lower the risk for these reactions. Information is given regarding specific mild versus severe reactions, initial diagnostic evaluation, and treatment. A table listing the risk of mild and severe cutaneous reaction risks as well as the management of potential seizures that may occur while stopping the culprit ASM are provided.

Recent findings

Five new ASMs have joined the total of 26 FDA-approved ASMs since 2018. Cenobamate had three patients develop a drug reaction with eosinophilia and systemic symptoms. A lower starting dosing and slower titration have resulted in no further published cases. Based on limited data, rash risk is low for fenfluramine, ganaxalone, and stiripentol. It is low-moderate for Epidiolex. Molecular tests can predict severe reactions.

Summary

Skin reactions are a relatively common side effect of ASMs with aromatic ASMs having the greatest risk. Identifying and informing high-risk patients when to seek medical attention, stopping the culprit ASM when a severe reaction looks possible, and providing appropriate medical triage can reduce morbidity and mortality from severe skin and systemic reactions.

Purpose of Review

Atypical parkinsonism is a term usually used to describe three neurodegenerative parkinsonian disorders: progressive supranuclear palsy (PSP), corticobasal degeneration (CBD), and multiple system atrophy (MSA). In contrast to Parkinson’s disease, these disorders have a poor prognosis and present with a multitude of diverse symptoms, including parkinsonism, dystonia, myoclonus, gait disorders, dysarthria, dysphagia, sleep, cognitive, and behavioral disorders. In the absence of an approved disease-modifying treatment, symptomatic treatment is the mainstay of management. The purpose of this review is to present an overview of the management of these complex disorders, with a particular focus on a holistic and multidisciplinary approach.

Recent Findings

In addition to presenting the most significant pharmacological interventions for symptom management, data regarding non-pharmacological interventions are analyzed. Important non-pharmacological clinical practice questions such as breaking the news, palliative care, and end-of-life issues are discussed, in an effort to present an overview of the management of atypical parkinsonism from diagnosis to the most advanced stages of these diseases.

Summary

Management of atypical parkinsonian disorders includes symptomatic pharmacological and non-pharmacological interventions, in addition to addressing issues such as informing the patient of the diagnosis, palliative care, and end-of-life issues, which require a multidisciplinary approach.

Abstract

Purpose of Review

To care for patients with cerebrovascular disease (CVD), neurointerventionalists, intensivists, and other healthcare providers must be equipped to address associated ethical challenges. This review aims to delineate the applicability of fundamental bioethical approaches to CVD, highlight key ethical issues in CVD care, and delineate an ethical framework to streamline ethical decision-making for people with CVD.

Recent Findings

Three introductory cases are presented. The four key principles of principalism and the approach of narrative ethics are described with reference to CVD. Key ethical considerations include decision-making capacity and informed consent, uncertainty, and resource allocation. A categorization of CVD as emergent/nonemergent and the recommended management as intervention/no intervention helps frame the spectrum of CVD. A different six-pathway may then be taken based on which category the patient case corresponds to.

Summary

Physicians involved in the care of people with cerebrovascular disease must understand how the ethical issues manifest in individual patient cases to ensure appropriate care. The aforementioned ethical framework may aid physicians in providing ethically sound care. All decisions must involve a balance between clinical expertise and patient values and preferences or those articulated by a surrogate to properly respect the wishes of patients with CVD.

Purpose of Review

Bed rest was a treatment recommended for critically ill patients admitted to the intensive care unit (ICU) that aimed to minimize energy expenditure, permit wound healing and minimize somatic stressors. However, evidence demonstrates that bed rest leads to disuse atrophy, which may be compounded by premorbid sarcopenia and ICU-acquired weakness (ICUAW). ICUAW partly results from muscle breakdown and systemic inflammation and may exacerbate critical illness. Coupled with analgosedation, ICUAW may prolong mechanical ventilation (Kho et al. in BMJ Open Respir Res. 2019;6(1) 2019; Maffei et al. in Arch Phys Med Rehabil. 2017;98 2017; McWilliams et al. in J Crit Care. 2018;44 2018; Sarfati et al. in J Crit Care. 2018;46 2018), increase risk of venous thromboembolism (Denehy et al. in Intensive Care Med. 2017;43(1) 2017; Lyles in J Am Geriatr Soc. 1988;36(11) 1988) create dependence on vasopressor agents (Lyles in J Am Geriatr Soc. 1988;36(11) 1988; Fortney et al. in Comprehen Physiol. 1996) restrict joint mobility, and induce pressure injuries. Neurologically injured patients may be at a higher risk of ICUAW than other critically-ill patients, given that neurological injury itself results in weakness, which may be focal or generalized. Early mobilization (EM), typically defined as physical therapy within 72 h of ICU (Cumming et al. in Neurology. 2019;93(7) 2019), may preempt or mitigate these deleterious consequences of critical care.

Recent Findings

Retrospective data suggest that EM protocols reduce ventilator days, decrease venous thromboembolism, avert pressure wounds, and reduce the length of stay. EM may reduce the incidence, duration, and severity of delirium (Morris et al. in Crit Care Med. 2008;36(8) 2008; Needham et al. in Arch Phys Med Rehabil. 2010;91(4) 2010). Larger and more rigorous studies have not demonstrated benefit of EM on outcomes after critical care; some have demonstrated harm. Neurologically injured critical care patients have generally been excluded from early mobilization protocols due to safety concerns that stem from the increased potential for falls, disorders of consciousness, cognitive impairment, intracranial hypertension, and potential dislodgment of intracranial devices. Notably, data from patients with ischemic stroke suggest that EM may also be associated with harm in this group.

Summary

EM may benefit neurologically injured patients once acute ischemia, elevated ICP, and seizures are resolved. Targeting moderate acuity patients may be critical to improving outcomes and optimizing resource utilization in this resource-intensive intervention. The duration of mobility session, optimal frequency of mobility session, and timing of session remain to be determined.

Abstract