Expert Review of Neurotherapeutics最新文献

Introduction: Atypical meningiomas (WHO Grade 2) comprise approximately 18% of all meningiomas and may recur, despite surgical resection. Current evidence, derived from prospective cohort studies and retrospective series, supports the use of radiotherapy in achieving local control in atypical meningiomas. Given the lack of level 1 data, the role of RT in the management of recurrent disease in radiotherapy-naïve or previously irradiated patients remains a subject of ongoing debate, and optimal strategies are yet to be established.

Areas covered: This narrative review examines recent developments in radiotherapy techniques, including dose escalation and particle therapy, alongside advances in imaging and molecular profiling relevant to meningioma management. The authors summarize the existing evidence and provide an updated perspective on the evolving role and value of radiotherapy in treating recurrent atypical meningiomas. This article also proposes a new treatment algorithm. This review is based on a literature search using PubMed to identify relevant studies on recurrent atypical meningioma (WHO grade 2) up to August 2025. Key references from recent guidelines and high-impact studies were also included.

Expert opinion: The authors believe that treatment plans for recurrent atypical meningioma should consider prior radiotherapy exposure. The integration of PET-guided radiotherapy planning and molecular-based risk stratification will allow for personalized treatment plans, setting a framework for its future clinical management.

Introduction: Dravet syndrome is a severe developmental and epileptic encephalopathy presenting in childhood with drug resistant seizures and multiple comorbidities including developmental and cognitive delays. While medical therapy has continued to advance, leading to improved seizure control, outcomes such as seizure freedom remain elusive. As the underlying cause of Dravet syndrome is a genetic channelopathy, epilepsy surgery is rarely considered.

Areas covered: The authors weigh up the potential benefits of surgical therapy when seizure reduction, but not seizure freedom, is expected, discussing the literature related to surgical therapy in patients with Dravet syndrome and other similar genetic conditions.

Expert opinion: In general, people with Dravet syndrome are rarely favorable candidates for epilepsy surgery, yet surgery is not necessarily contraindicated. Meaningful seizure reduction can be achieved in highly selected cases with perhaps the most benefit arising from neuromodulation procedures such as vagus nerve stimulation. It remains uncertain whether seizure reduction following surgery contributes to any non-seizure benefits.

Introduction: Dialysis headache (DH) has a prevalence ranging from 27% to 73% among patients undergoing hemodialysis. Research on its treatment remains limited.

Methods: This systematic review explores the treatment of DH. It was conducted according to the PRISMA statement and registered in PROSPERO (CRD42023493031). The following databases were used: PubMed/Medline, LILACS/Scielo, Cochrane, Scopus, Web of Science, Embase and Google Scholar.

Results: Eight trials were included. One controlled clinical trial showed that watching comedy films during hemodialysis was associated with less headache. Another showed no benefit from drinking coffee. Open-label trials compared different dialysis techniques. There was less headache in profiled hemodialysis (combining sodium and ultrafiltration) than in standard hemodialysis, in hemodialysis using an automatic adjustment in ultrafiltration rate and hemofiltration than in standard hemodialysis. There was no difference between the step and linear sodium profiling programs. An open clinical trial reported a reduction in the intensity and frequency of DH after the use of nortriptyline. A retrospective cohort study reported less DH in patients undergoing online hemodiafiltration (combining diffusion and convection mechanisms) compared to those receiving conventional hemodialysis.

Conclusion: Environmental changes and changes in dialysis techniques may contribute to a lower incidence of DH. Nortriptyline possibly improves DH.

Introduction: Exergaming is increasingly used to target gait and balance impairments in Parkinson's disease (PD), but the durability of effects and comparative efficacy versus active controls remain uncertain. The aim of this work is to evaluate the effectiveness and clinical implications of exergame-based rehabilitation for individuals with PD in randomized controlled trials, including studies with and without follow-up assessments.

Methods: The authors conducted a PRISMA-guided systematic review (PROSPERO CRD42025642840). Eligible studies were RCTs in people with PD comparing exergaming programs with non-exergaming interventions.

Results: Eighteen RCTs (n = 699; 341 exergaming, 358 control) met inclusion criteria; Typical programs spanned 4-12 weeks with 15-60-min sessions, most commonly 6 weeks, delivered predominantly under supervision. The outcomes that improved most consistently were mobility/locomotion (TUG, 6MWT/10MWT, gait speed) and balance. When exergames were compared with active, non-exergaming therapy, effects were generally comparable. Adverse events were rare, and adherence was documented as high where reported; most trials were facility-based with professional supervision. Only three trials included follow-up (≈1-2 months), suggesting short-term retention (~30 days), whereas one 60-day assessment showed return to baseline.

Conclusion: Exergame is a safe, feasible, and effective adjunct for short-term improvement of mobility and balance in PD. However, scarce follow-up limit inferences on long-term maintenance.

Introduction: Insomnia disorder (ID) affects nearly one in three individuals across the lifespan and confers elevated risk for cognitive decline, psychiatric illness, cardiometabolic disease, and neurodegeneration. Despite its recognition as a distinct clinical entity, ID remains underdiagnosed and undertreated. Current diagnostic frameworks fail to capture its neurobiological complexity, and available models inadequately reflect its chronic, heterogeneous, and hyperarousal-driven nature.

Areas covered: We advance the view that ID is fundamentally a disorder of arousal regulation. Converging evidence implicates persistent hyperactivity in salience and executive networks, heightened cortical excitability, and disrupted emotional processing. Genetic susceptibility-most notably polymorphisms in MEIS1, CLOCK, and PER2-interacts with environmental exposures such as prenatal stress and early-life adversity. These gene-environment interactions recalibrate stress-regulatory systems through epigenetic mechanisms, shaping enduring vulnerability. Existing treatments, including CBT-I, pharmacotherapy, neuromodulation, and digital therapeutics, remain limited in their mechanistic precision and generalizability.

Expert opinion: The field requires a decisive shift from symptom-based classification toward precision neuroscience. Integrating circuit-level dysfunction, stress responsivity, and genetic architecture with advanced EEG, neuroimaging, and machine learning will enable biologically grounded subtyping. Such an approach is essential to deliver personalized interventions, identify novel therapeutic targets, and ultimately redefine care in insomnia disorder.

Introduction: Trichotillomania is an impulse control disorder in which individuals fail to resist urges to pull out their own hair and is associated with significant psychiatric comorbidity and functional impairment in affected children, adolescents, and adults. Onset in childhood or adolescence is typical, yet the literature on phenomenology, psychopathology, and treatment outcome involving pediatric samples remains particularly sparse. Efficacious treatments have been developed and found efficacious, most notably cognitive-behavioral interventions known collectively as habit reversal training, although relapse in adults appears to be somewhat common.

Areas covered: Herein, the authors give an overview of the latest developments in the treatment of trichotillomania and provide their own expert recommendations for the management of the condition. This article is based on searches using the PubMed and PsycINFO databases for peer-reviewed articles from 2011 through to April 2025.

Expert opinion: Recent developments in pharmacotherapies, both alone and in combination with cognitive behavioral treatments, hold promise, although further efforts are needed to examine their efficacy, effectiveness, and durability. Dissemination of information about trichotillomania and its treatment remains a critical next step in the field, since many affected individuals and their families experience difficulties with finding local treatment providers with sufficient knowledge to deliver interventions known to reduce hair pulling behaviors and associated symptoms.

Introduction: Refractory migraine (RM) is characterized by a lack of response to both migraine-specific and repurposed treatments, significantly impairing quality of life. Risk factors for RM include, among others, overuse of symptomatic medications, nonadherence to treatment and comorbid conditions that limit the use of anti-migraine medications.

Areas covered: This critical perspective addresses the diagnosis and management of patients with RM. It also highlights the best practices tailored to this complex condition, serving as a valuable tool for physicians.

Expert opinion: Management demands specialized, holistic approach that considers patient preferences and may deviate from conventional evidence-based practices. Diagnosis requires thorough evaluation to exclude conditions like cluster headaches or trigeminal neuralgias. Treatment integrates symptomatic, interim, and prophylactic strategies. Symptomatic options include triptans, ditans, and gepants, often combined with NSAIDs or antiemetics, but gepants are first-line option because of their low risk for medication overuse headache. Interim treatments, intended to bridge to prophylactic therapy, might involve steroids or long acting triptans. Prophylactic treatments favor migraine-specific medications due to their superior tolerability and effectiveness. Non-pharmacological approaches are also encouraged while continuous monitoring and reassessment after initial treatments are essential, recognizing that RM may recur after a temporary improvement phase.