Neurology. Clinical practice最新文献

[This corrects the article DOI: 10.1212/CPJ.0000000000200463.].

Background and objectives: The aim of this study was to explore practice patterns in managing mild cognitive impairment (MCI). The investigation and management of MCI is considered important because it offers the opportunity to potentially stave off conversion to dementia. However, there are few data on current practices/approaches in this area, especially worldwide; such data can help identify potential disparities and anticipate adoption of new therapies.

Methods: We performed a worldwide electronic survey of neurology practitioners through the Practice Current section of Neurology® Clinical Practice with clinical and practice-related questions in November 2019-August 2021 and repeated it in May-October 2023 after the FDA's approval of aducanumab and lecanemab but before the approval of donanemab. Clinical questions addressed access to and utilization of diagnostic investigations, pharmacologic and nonpharmacologic management of MCI, and (in 2023) attitudes toward novel anti-amyloid agents. Responses were compared using the Fisher exact test and multivariable logistic regression adjusted for region, regional income, year of survey response, years in practice, and number of cognitive patients seen annually.

Results: We received 1,257 responses from 95 countries, including 237 cognitive subspecialists and 464 respondents from low-/middle-income countries. On multivariable analysis, cognitive subspecialists were more likely than other practitioners to investigate MCI with a lumbar puncture (aOR 1.90, 95% CI 1.32-2.73), luorodeoxyglucose-PET (FDG-PET) (aOR 1.45, 95% CI 1.00-2.10) and to offer pharmacotherapy if investigations suggested neurodegeneration (aOR 1.92, 95% CI 1.29-2.85). Regionally, respondents from Europe, Latin America, and Asia were more likely than those from the United States/Canada to order FDG-PET (e.g., Europe: aOR 2.38, 95% CI 1.29-4.39) and amyloid PET (Europe: aOR 3.30, 95% CI 1.85-5.87), controlling for reported access to these tests. Pharmacologic and nonpharmacologic approaches were comparable between cognitive subspecialists and other respondents. Despite concerns about safety (77.1% expressed being somewhat or very concerned), attitudes toward prescribing new anti-amyloid agents were similar among all respondents, reflecting a generally favorable attitude (e.g., 62% would prescribe anti-amyloid therapy if it was available).

Discussion: Our results highlight practice differences among cognitive subspecialists and other practitioners worldwide in the management of MCI. Attitudes toward anti-amyloid therapy indicate cautious optimism, with concerns about side effects but a general interest to prescribe.

Background and objectives: Intravenous thrombolysis (IVT) followed by endovascular thrombectomy (EVT) improves functional outcomes in patients with acute ischemic stroke (AIS) caused by large vessel occlusion (LVO). There are limited data on the effect of thrombolysis-to-puncture time (TTP) on outcomes in patients with AIS undergoing IVT plus EVT.

Methods: We selected 1,104 patients receiving IVT + EVT for anterior circulation LVO stroke from 2 prospective nationwide registries (259 cases from ANGEL-ACT in China: November 2017 to March 2019, 845 cases from German Stroke Registry-Endovascular Treatment in Germany: June 2015 to December 2019). Based on the TTP, eligible patients were divided into 4 groups (≤30 min, 31-50 min, 51-70 min, and >70 min). The radiologic and clinical outcomes (e.g., successful recanalization [modified Thrombolysis in Cerebral Infarction score of 2b-3] at final angiogram, modified Rankin Scale [mRS] score of 0-2 at 90 days, any intracranial hemorrhage [ICH], and symptomatic ICH within 24 hours) among the 4 groups were compared by χ² tests for trend and using multivariable logistic regression models.

Results: In the 4 groups from ≤30 min to >70 min, 226, 282, 230, and 366 patients were included, respectively. An increased TTP was associated with a lower chance of successful recanalization (p = 0.016) and mRS score 0-2 (p = 0.002). Compared with the group of ≤30 min, the group of >70 min was less likely to achieve successful recanalization (adjusted odds ratio [OR] = 0.47, 95% CI 0.25-0.89) and the groups of 50-70 min and >70 min had a reduced probability of mRS score 0-2 (adjusted OR = 0.50, 95% CI 0.33-0.78; adjusted OR = 0.56, 95% CI 0.37-0.85). No significant differences were found for any ICH or symptomatic ICH among the 4 groups after adjustment with potential confounders.

Discussion: Delay from thrombolysis to puncture should be minimized when considering bridging IVT before EVT for patients with AIS due to anterior circulation LVO. Further studies are warranted to verify and expand on these findings.

Trial registration information: ClinicalTrials.gov, NCT03370939 and NCT03356392.

Background and objectives: Individuals with Parkinson disease (PD) may face barriers in obstructive sleep apnea diagnosis/management due to sleep being lower priority and sleep disturbances being poorly recognized. Evidence on sleep-medicine service utilization in the PD population is lacking. We conducted a population-based study to identify discrepancies in sleep-medicine resource use (prevalence rates of polysomnograms [PSG] performed and positive airway pressure [PAP] initiated) over a 10-year period between the PD population and the matched non-PD population.

Methods: We conducted a retrospective longitudinal population-based study using health administrative databases in Ontario from 2012 to 2021 in adults with PD to compare overall and annual prevalence rates of PSGs performed and PAP initiated to 1:1 randomly selected propensity score matched controls from the matched non-PD population based on simultaneous exact matching on age, sex, and calendar year and caliper matched propensity scores from a logistic regression model (based on sociodemographic variables and comorbidities) using validated health administrative definitions to identify PD cases and controls. We hypothesized that the PD population has lower rates of PSGs performed and PAP treatments initiated compared with the similar matched non-PD population. We used Poisson regression to estimate annual prevalence rate ratios to determine the relative change in prevalence over the study period between the groups.

Results: Sixty-five thousand, one hundred sixty-seven patients with PD and 11,460,672 controls met our inclusion criteria. We successfully propensity score matched 64,879 PD cases to controls. From 2012 to 2021, there were a higher prevalence of any PSG performed in the PD population (8.2% vs 6.3%, [RR: 1.30, 95% CI: 1.25-1.35], p < 0.001) and no difference in the rates of any PAP initiated in the PD population vs controls (4.0% vs 4.1%, [RR: 0.93-1.03, 95% CI: 0.93-1.03], p = 0.46). For both groups, annual prevalence rates generally increased over time. There was no difference in the annual prevalence rate ratio of any PSG performed or any PAP initiated in the PD population vs controls (1.07 [95% CI: 1.06-1.07] vs 1.07 [95% CI: 1.07-1.08], p = 0.5; 1.10 [95% CI: 1.09-1.11] vs 1.11 [95% CI: 1.10-1.11], p = 0.18, respectively).

Discussion: Sleep-medicine resource utilization in the PD population is at least similar to the matched non-PD population and follows the increase with time observed in the general population.

[This corrects the article DOI: 10.1212/CPJ.0000000000200467.].

Background and objectives: Invasive neurostimulation is rapidly becoming an established option for treatment of neurologic disorders, particularly those that are refractory to pharmacologic treatment. However, there is limited information on the use of neuromodulation during pregnancy. This study explores the safety and clinical outcomes of invasive neuromodulation-specifically vagus nerve stimulation (VNS), deep brain stimulation (DBS), and responsive neurostimulation (RNS)-in pregnant patients with epilepsy and movement disorders.

Methods: Pregnant patients treated with VNS, DBS, or RNS were identified, and charts were reviewed to extract data on maternal epilepsy/movement disorder, treatment, and pregnancy.

Results: A total of 14 patients (9 VNS, 3 DBS, 2 RNS) had 22 pregnancies. Neuromodulation indications included focal epilepsy (n = 6: 3 VNS, 2 RNS, 1 DBS), generalized epilepsy (n = 6: all VNS), and Tourette syndrome (n = 2: both DBS). The average age at implantation was 24.7 years for VNS, 29.6 years for DBS, and 28 years for RNS. Pregnancy complications included miscarriages (n = 4 pregnancies; 1 VNS, 2 DBS, 1 RNS), pre-eclampsia with fetal growth restriction (n = 3: 2 VNS, 1 DBS), and gestational diabetes (2 VNS). In addition, 10 pregnancies (8 VNS, 2 RNS) were complicated by seizure exacerbations. Delivery of eight of the pregnancies (5 VNS, 1 DBS, 2 RNS) was by cesarean section. There were no cases of maternal or neonatal mortality, and there were no major congenital malformations. Owing to exacerbated shortness of breath during the third trimester, 1 patient had her VNS turned off.

Discussion: Pregnancy complications were consistent with previous reports of patients with neurologic disorders. Despite limitations in sample size and confounding factors related to medication use and neurologic diagnosis, our study suggests that implanted neuromodulation devices do not seem to pose a risk of neuromodulation-related teratogenicity. While these data are promising and may provide some reassurance for patient counseling regarding pregnancy, further studies with larger sample sizes are necessary.

Background and objectives: Infections are associated with an increased risk of relapse and pseudo-relapse in persons with multiple sclerosis (MS). However, the relationship with relapses and pseudo-relapses after SARS-CoV-2 infections (COVID) vs other infections in MS is poorly understood. Therefore, we compared the occurrence of relapse and pseudo-relapse after COVID and other infections with noninfected participants with MS.

Methods: In spring 2023, we surveyed participants from the North American Research Committee on Multiple Sclerosis Registry regarding whether they had had a COVID infection, other infections, relapses, and pseudo-relapses. Recent infections, occurring in the 6 months before the survey, were used to categorize participants into groups: recent COVID, non-COVID infection (with no history of ever having COVID), COVID and non-COVID infections, or uninfected.

Results: Of the 4,787 participants eligible for analysis, 2,927 participants were included, of whom 294 (10%) had a recent COVID infection; 853 (29.1%) had 1 recent infection other than COVID; 246 (8.4%) had a recent COVID and non-COVID infection; and 1,534 (52.4%) had no infection with COVID nor any infection within the past 6 months (uninfected). Compared with no infections, non-COVID infection was associated with a 39% increased likelihood of relapse (1.39, 95% CI [1.04-1.87]), whereas a recent COVID infection was associated with a decreased likelihood of relapse (0.45 [0.23, 0.87]), adjusting for covariates. All infection groups were associated with increased odds of pseudo-relapse compared with the uninfected group (non-COVID infections: 1.78 [1.44, 2.20]; COVID infection: 1.80 [1.32, 2.45]; COVID and non-COVID infection: 3.04 [2.24, 4.12]).

Discussion: Because individuals with MS are at increased risk of infections, the association of infections with relapses and pseudo-relapses is clinically important. The high prevalence of acute worsening after infection, regardless of the type of infection, compared with those with no reported infection, needs to be considered in the management of persons with MS.

Background and objective: Post-traumatic epilepsy (PTE) is common, occurring in upward of 1 in 3 patients with severe traumatic brain injury (TBI). There are limited data regarding initial prescription patterns and long-term course of antiseizure medications (ASMs).

Methods: The goal of this study was to describe ASM prescription patterns and pharmacoresistance over time. We performed a secondary analysis of a prospective database of patients with severe TBI treated at a single center from 2002 through 2018. We included patients with PTE, defined as at least one seizure more than 7 days from injury, and at least six-month follow-up after PTE onset. ASMs were categorized as older (e.g., phenytoin) or newer (e.g., levetiracetam). We evaluated ASM prescription patterns and their association with epileptology referral and Glasgow Outcome Scale (GOS) score. We developed a logistic regression to predict pharmacoresistance.

Results: Our cohort included 84 patients with PTE. ASM prescription for longer than 7 days after injury had only moderate correspondence with early post-traumatic seizures or PTE (Cohen Kappa 41%). At PTE onset, most (53%) were treated with newer ASM monotherapy, with 27% on older ASMs and 20% on multiple ASMs. Patients initially prescribed older ASM monotherapy were less likely to maintain their ASM monotherapy (e.g., medication switch/addition and self-wean) compared with those on newer ASMs (odds ratio [OR] 4.6; 95% confidence interval [CI] 1.3-16.7; p = 0.02). Only 23% of patients were referred to specialized epilepsy care despite 54% trialing 2 or more ASMs. Pharmacoresistance was associated with worse GOS outcomes (p = 0.04). Decompressive hemicraniectomy (OR 6.0; 95% CI 1.4-44; p = 0.03) and initial ASM polytherapy (OR 7.2; 95% CI 1.7-34; p < 0.01) predicted pharmacoresistance at 2 years.

Discussion: We provide evidence suggesting that use of newer generation seizure medications is preferable when treating PTE. In addition, we identified early risk factors of pharmacoresistance, which was associated with poor long-term outcomes.

[This corrects the article DOI: 10.1212/CPJ.0000000000200462.].