Current Opinion in Neurology最新文献

Purpose of review: This article explores the role of optical coherence tomography (OCT) in neurology practice, particularly in diagnosing and monitoring conditions such as papilledema, optic neuritis, and retinal artery occlusion. OCT has been increasingly utilized as a noninvasive and effective tool for detecting and monitoring neuroaxonal damage in the visual pathway, which is important for early intervention and improved patient outcomes across a variety of neurologic conditions.

Recent findings: OCT as an imaging modality continues to demonstrate its utility in quantifying optic nerve and retinal changes reflecting neuroaxonal injury, including, peripapillary retinal nerve fiber layer (pRNFL) thickness and macular ganglion cell layer thickness (or volume). This review focuses on recent evidence regarding the utilization of this modality in diagnosing, monitoring, and quantifying treatment responses in patients with papilledema, optic neuritis, and retinal artery occlusion. Advances in OCT technology, including deep learning algorithms, continue to enhance the diagnostic accuracy and predictive capabilities in the field of neuro-ophthalmology.

Summary: In recent years, OCT has become an essential tool in neuro-ophthalmic assessment, offering precise structural and anatomical assessments that support diagnosis, treatment planning, and monitoring of conditions affecting the visual pathway. Ongoing advances in OCT technology are expected to further enhance its clinical utility.

Purpose of review: This review aims to describe recent advances in low-field (0.064 T) magnetic resonance imaging (LF-MRI) of cerebrovascular disease, including ischemic and hemorrhagic stroke and white matter hyperintensities.

Recent findings: Since 2023, several studies have highlighted the rapidly changing landscape of portable, low-field MRI (LF-MRI) and its applications in stroke and cerebrovascular disease. The advantages of using LF-MRI in these settings are multifold: cheaper and dynamic imaging of this patient population confers closer observation during the acute and chronic stages of cerebrovascular disease. Initial deployments of the device span a variety of acute and emergency settings, including imaging around thrombolytic administration, endovascular reperfusion, intracerebral hemorrhage management, and cardiovascular intensive care. LF-MRI also has an important role in cerebrovascular disease monitoring and prevention, namely white matter hyperintensity (WMH) progression and vascular and Alzheimer's dementia. Early studies suggest reliable sensitivity and specificity for these pathologies. With further improvements to LF-MRI hardware, software and postprocessing on the horizon, we anticipate the device's ability to provide inexpensive and flexible neuroimaging to a wide array of healthcare settings that treat, prevent, and manage cerebrovascular disease.

Summary: Recent studies indicate that LF-MRI promotes rapid, cost-effective, and clinically useful neuroimaging at various clinical timepoints throughout stroke and cerebrovascular disease progression and management.

Purpose of review: Cerebral amyloid angiopathy (CAA) is a common brain disorder among the elderly and individuals with Alzheimer's disease, where accumulation of amyloid-ß can lead to intracerebral hemorrhage and dementia. This review discusses recent developments in understanding the pathophysiology and phenotypes of CAA.

Recent findings: CAA has a long preclinical phase starting decades before symptoms emerge. Its pathophysiology follows consecutive stages of amyloid-ß deposition, decreased vascular reactivity, nonhemorrhagic changes, and ultimately hemorrhages. Although impaired perivascular clearance is the leading hypothesis underlying CAA, several lines of evidence suggest that glymphatic dysfunction also plays a significant role in the disease process. Despite its common pathway, the disease course is variable. Some patients develop more microbleeds, while others develop larger hemorrhages, suggesting a differentiation in vascular remodeling. Some patients with CAA develop a symptomatic immune response, and inflammation could be an important contributor to vascular damage in CAA in general. Furthermore, the prion-like transmission of amyloid-β has been identified as a cause of iatrogenic CAA occurring decades after neurosurgical procedures involving cadaveric dura mater.

Summary: Emerging evidence of sporadic, hereditary, inflammatory, and iatrogenic CAA suggests a complex interplay between brain clearance, inflammation and vascular remodeling leading to a diverse clinical phenotype.

Purpose of review: Spaceflight-associated neuro-ocular syndrome (SANS) encompasses a unique constellation of neuro-ocular findings in astronauts, including optic disc edema (ODE), globe flattening, chorioretinal folds, and hyperopic refractive shift. Although there are numerous neuro-ocular findings in SANS, the purpose of this review is to describe the novel, emerging concepts of the pathogenesis for the ODE specifically in SANS.

Recent findings: While the initial hypotheses on the pathogenesis of ODE in SANS focused on possible elevated intracranial pressures (i.e., papilledema), the most prominent current hypothesis is microgravity-induced cephalad fluid shift. More recent studies however suggest that the pathogenesis of the ODE in SANS is likely multifactorial including possible underlying metabolic and genetic components.

Summary: We review the literature on ODE in SANS including recent work integrating the complex physiologic interactions of microgravity-induced disruption in intracerebral and intraocular fluid dynamics, vascular congestion, cellular stress responses, and genetic predisposition. We believe that the development of ODE in SANS is likely multifactorial in origin, and further understanding of the mechanical, cellular, metabolic, and genetic components is of utmost importance to develop future countermeasures in preparation for possible future crewed missions to the moon, the asteroid belt, and Mars.

Purpose of review: The purpose of this article is to provide a review of neuromyelitis optica spectrum disorder (NMOSD) and myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD), with a focus on what renders optic neuritis "atypical" in these two conditions. Clinical features, diagnostic criteria, and epidemiology are outlined. Acute treatments for optic neuritis, as well as immunotherapy for NMOSD and MOGAD are discussed.

Recent findings: Updates in NMOSD and MOGAD are highlighted, with an emphasis on novel work including the new 2023 MOGAD diagnostic criteria, our evolving understanding on the epidemiology of these conditions, and recently FDA-approved NMOSD treatments. Pipeline therapies are also discussed.

Summary: A thorough history and examination, supported by ancillary testing, continues to be the mainstay of optic neuritis diagnosis. Stratifying typical versus atypical optic neuritis is paramount. Within the atypical category, NMOSD and MOGAD are important considerations. Clues can point towards these diagnoses and guide steps for treatment, which is increasingly becoming targeted to individual diseases, as the pathophysiology is different for these disorders.

Purpose of review: An overview of two ocular diseases, which significantly impact quality of life: thyroid eye disease (TED) and ocular myasthenia gravis (OMG). Additionally, we describe the clinical challenge when they occur simultaneously. We will describe the pathophysiology of both conditions, the currently available diagnostic tools, and the therapies available.

Recent findings: Recent literature has described newer diagnostic modalities, predictors of disease severity and co-occurrence of TED and OMG, and novel therapies. There is also critical analysis of current therapeutics and risk factors.

Summary: The findings from this review suggest a need for heightened clinical awareness and early detection strategies for TED and OMG due to their overlapping clinical presentation. Emerging therapies and diagnostic techniques should be integrated into practice. Further research is warranted to explore the long-term safety and efficacy of novel treatments and the potential genetic links between these conditions.

Purpose of review: The purpose of this article is to discuss the global impact of stroke, the disparities and barriers to implement stroke care, and the global efforts to improve access to acute treatments in low and middle-income countries (LMICs).

Recent findings: Disparities in access to stroke care are influenced by socioeconomic inequalities, geographic disparities, and limited healthcare infrastructure, particularly in LMICs. Effective stroke care requires a coordinated approach involving emergency services, rapid diagnosis, timely treatment, and early rehabilitation. However, there are significant delays in implementing evidence-based practices, particularly in areas where stroke care resources are scarce.Key barriers include geographic disparities, economic constraints, insufficient healthcare infrastructure, low public awareness, and weak policy frameworks. Addressing these challenges requires strengthening health systems, promoting universal health coverage, enhancing public and healthcare provider education, leveraging technology like telemedicine, and fostering international collaboration. Global efforts, including initiatives by the World Stroke Organization, focus on improving stroke care through infrastructure development, workforce training, and policy advocacy.

Summary: These recommended strategies aim to make stroke care accessible and effective for everyone, regardless of location or socioeconomic status, ultimately helping to reduce the global burden of stroke.

Purpose of review: Though simple in its fundamental mechanism - a critical disruption of local blood supply - stroke is complicated by the intricate nature of the neural substrate, the neurovascular architecture, and their complex interactions in generating its clinical manifestations. This complexity is adequately described by high-resolution imaging with sensitivity not only to parenchymal macrostructure but also microstructure and functional tissue properties, in conjunction with detailed characterization of vascular topology and dynamics. Such descriptive richness mandates models of commensurate complexity only artificial intelligence could plausibly deliver, if we are to achieve the goal of individually precise, personalized care.

Recent findings: Advances in machine vision technology, especially deep learning, are delivering higher fidelity predictive, descriptive, and inferential tools, incorporating increasingly rich imaging information within ever more flexible models. Impact at the clinical front line remains modest, however, owing to the challenges of delivering models robust to the noisy, incomplete, biased, and comparatively small-scale data characteristic of real-world practice.

Summary: The potential benefit of introducing AI to stroke, in imaging and elsewhere, is now unquestionable, but the optimal approach - and the path to real-world application - remain unsettled. Deep generative models offer a compelling solution to current obstacles and are predicted powerfully to catalyse innovation in the field.

Purpose of review: This review intends to systematize the diagnostic and treatment approach to cerebral venous thrombosis (CVT), highlighting key studies that have been recently published.

Recent findings: In light of the recent pandemic, new risk factors for CVT have emerged. Contrast-enhanced MRI and susceptibility-weighted imaging have been shown to offer increased sensitivity for detecting cortical vein thrombosis.Dabigatran seems to be as effective and well tolerated as warfarin for long-term anticoagulation. Partial venous recanalization often occurs in patients treated with anticoagulation only, as early as 8 days after treatment onset. For patients with CVT and impending brain herniation, two-thirds of those who undergo decompressive craniectomy survive, with one-third being functionally independent 6 months after diagnosis.

Summary: CVT is an unusual type of cerebrovascular disease that mostly affects women of fertile age. Risk factors should be identified and addressed. Diagnosis relies on confirmation of venous sinus and/or vein thrombosis, usually by CT venography or MRI. Anticoagulation is the cornerstone of treatment. Despite the lack of high-quality evidence, endovascular treatment is often considered in severe cases. Special populations require tailored approaches. About 80% achieve mRS 0-1, but residual symptoms often affect quality of life and the ability to return to work.

Purpose of review: Intracerebral hemorrhage (ICH) is a devastating stroke with limited medical treatments; thus, timely exploration of emerging therapeutic targets is essential. This review focuses on the latest strategies to mitigate secondary brain injury post-ICH other than targeting surgery or hemostasis, addressing a significant gap in clinical practice and highlighting potential improvements in patient outcomes.

Recent findings: Promising therapeutic targets to reduce secondary brain injury following ICH have recently been identified, including attenuation of iron toxicity and inhibition of ferroptosis, enhancement of endogenous resorption of hematoma, and modulation of perihematomal inflammatory responses and edema. Additionally, novel insights suggest the lymphatic system of the brain may potentially play a role in hematoma clearance and edema management. Various experimental and early-phase clinical trials have demonstrated these approaches may potentially offer clinical benefits, though most research remains in the preliminary stages.

Summary: Continued research is essential to identify multifaceted treatment strategies for ICH. Clinical translation of these emerging targets could significantly enhance the efficacy of therapeutic interventions and potentially reduce secondary brain damage and improve neurological recovery. Future efforts should focus on large-scale clinical trials to validate these approaches, to pave the way for more effective treatment protocols for spontaneous ICH.