BMJ Neurology Open最新文献

Background: Functional neurological disorder (FND) frequently co-exists with chronic pain (CP), notably nociceptive and nociplastic (primary) pain disorders. The considerable overlap implies shared underlying mechanisms because of their similar clinical and epidemiological profiles. Although standard neuroimaging and electrophysiological tests typically show normal results in both FND and primary pain disorders, recent advancements in neuroimaging techniques have begun identifying neural biomarkers common to both conditions, though these findings remain preliminary and require further exploration.

Method: We performed a detailed literature review of studies investigating neural activity in FND and chronic pain using electroencephalogram, magneto-encephalography, functional MRI, positron emission tomography and single photon emission computed tomography. Given the diverse nature of the reviewed studies, the synthesis is presented narratively.

Results: Despite methodological differences, convergent data suggest disrupted neural networks across both FND and CP. Common findings include (1) hyperactivation of sensorimotor networks, (2) altered activity within the default mode network-a critical region for self-referential thought-and (3) dysfunction in emotional processing regions, notably the anterior cingulate cortex and insula. Thalamocortical dysrhythmia was identified as a potential unifying concept, characterised by abnormal theta and beta oscillations that enhance pain perception in CP and trigger functional symptoms in FND. Both conditions also exhibit reduced alpha oscillations, likely amplifying sensory sensitivity and emotional responsiveness.

Conclusion: This review highlights shared neural abnormalities (Triple Network model) and introduces thalamocortical dysrhythmia as a novel explanatory framework linking FND and CP. Future research should target populations with coexisting disorders, potentially paving the way for innovative treatments, including hypnosis and neuromodulation/neurofeedback.

Background: Functional weakness is common, and the prognosis can be poor without treatment. Transcranial magnetic stimulation (TMS) and specialist physiotherapy have each been trialled separately as interventions for functional weakness. We tested a novel approach for treating functional weakness and gait disorder using TMS as a primer before specialist physiotherapy.

Methods: Single-pulse TMS, therapeutic education and limb pressure feedback were used as a primer for immediate specialist physiotherapy. TMS-primed physiotherapy was used for the first time in three consecutive patients with functional limb weakness and immobility.

Results: Two women and one man (aged 30-55 years) with severe functional limb weakness such that they were unable to stand or walk independently, with symptom duration between 3 weeks and 7 years, were studied. All three had a rapid return of voluntary limb movement and achieved unassisted walking within a few hours of a single TMS-primed physiotherapy session. Treatment was well-tolerated, and outcomes were sustained at follow-up.

Conclusions: These cases provide preliminary evidence supporting the efficacy of this approach, which may be further developed with future research. They also illustrate a practical approach for treating a clinically challenging population with severe functional weakness.

Objective: Atrial fibrillation (AF) is an important risk factor for cerebral stroke. We studied whether anticoagulation affected histological age aspects of thrombi retrieved from patients with AF-related stroke.

Methods: In this monocentric study, AF patients according to criteria (Trial of Org 10 172 in Acute Stroke Treatment) with occlusion of the middle cerebral artery were prospectively and consecutively included. They were assigned to three groups: anticoagulation naïve, adequately anticoagulated, and with paused anticoagulation. In addition to patient characteristics and stroke workup, extracted thrombi were histologically classified into different age categories according to their cellular to fibrotic transition.

Results: A total of 244 patients were studied, from which 136 (58 females; 78±9 years) were drug naïve, 34 (15 females; 78±8 years) had paused anticoagulation, and 74 (29 females; 79±9 years) were adequately anticoagulated. Groups did not differ regarding stroke severity at admission (modified Rankin Score, mRS: median, IQR: 5 (1); 5 (0.75); 5 (1), respectively; National Institutes of Health Stroke Scale (NIHSS): median, IQR: 16 (8); 16 (8); 16 (7), respectively). Due to thrombectomy, median scores declined in all groups without differences between groups (mRS: 3.5 (4); 4 (4); 4 (4); NIHSS: 5 (16); 11 (31); 7 (18)). With a small but significant effect (p=0.043), thrombus age differed between the groups due to significantly younger thrombi in the paused medication group as compared with the adequately anticoagulated patients.

Conclusions: Thrombus age distribution seems not to be affected by anticoagulation. The younger thrombi in patients with paused anticoagulation possibly point to a rebound effect needing further investigations.

Background: Evidence is scarce concerning the impact on postpartum relapse activity of disease-modifying therapy (DMT) use during pregnancy after assisted reproductive technology (ART) treatment. We investigated relapse activity before pregnancy, during pregnancy and 3 and 12 months postpartum overall and according to DMT exposure during pregnancy.

Methods: Women with relapsing-remitting multiple sclerosis (MS) from the Danish MS Registry who gave birth after ART from 1995 to 2018 were eligible for inclusion. Annualised relapse rate (ARR) before pregnancy, during pregnancy and postpartum was evaluated using a negative binomial regression model with relapse count as the dependent variable overall and according to DMT exposure during pregnancy. Logistic regression was used to identify predictors of being relapse-free 12 months postpartum.

Results: A total of 111 women, median age 32 years (IQR: 29-35), were included. Overall, ARR (95% CI) was 0.14 (0.08 to 0.24) before pregnancy, 0.13 (0.07 to 0.25) during pregnancy and 0.33 (0.17 to 0.61) 3 months postpartum; rate ratio difference between before pregnancy and postpartum was 2.42 (1.03 to 5.67), and between during pregnancy and postpartum was 2.46 (1.18 to 5.13). Age ≥35 years and no DMT exposure before pregnancy were predictors of being relapse-free 12 months postpartum.

Conclusions: Relapse activity was more than two times higher 3 months postpartum than before and during pregnancy. Stratified for DMT exposure during pregnancy, rate ratios were similar and did not reach statistical significance. Postpartum relapse activity more than doubled from both low ARR (unexposed to DMT during pregnancy) and higher ARR (exposed to DMT during pregnancy) pre-pregnancy.

Abstract:

Background: Given the increasing diversity among neurological patients, standardised protocols are essential for evaluating the severity and complexity of the variety of conditions. The aim of the present work was to standardise the assessment of the severity and complexity of neurological impairment in an acute setting by using a modified version of the Neurological Impairment Scale (mNIS).

Methods: Consecutively hospitalised neurological inpatients underwent a multidimensional standardised assessment of multimorbidity, frailty, functional dependency and neurological impairment using mNIS and other validated scales. Inter-rater reliability of the mNIS total and subscores was evaluated. Construct validity was assessed separately in patients with cerebrovascular disease, performing correlations between corresponding subscores of mNIS, original NIS and National Institutes of Health Stroke Scale. mNIS Complexity Index (mNIS-CI) for neurological severity was used to classify patients into subtle, mild, moderate and severe impairment.

Results: 1081 neurological patients admitted to a neurological ward from the emergency setting were enrolled. The inter-rater reliability was remarkable for mNIS total and subscores (intraclass correlation coefficient 0.90, 95% CI 0.82 to 0.95). The mNIS showed strong construct validity for total and subscores compared with other clinical scales (r 0.47-0.97, p<0.001) and 52.7% of patients scored at least one in one of the four newly listed items. The stratification of patients according to mNIS-CI exhibited high construct validity, distinguishing the extent of impairment and involved domains.

Conclusions: The mNIS is valuable for measuring neurological severity and complexity in acute inpatients and holds significant potential for application in different settings.

Background: Sequelae of the acute phase of coronavirus disease-19, termed long COVID, are characterised by numerous indicators, including neurological symptoms. Functional neurological disorder (FND) can occur with or without various structural diseases. No previous study has examined the relationship between long COVID and FND, with positive signs for FND. This study confirmed positive signs of functional limb weakness (hereafter positive signs) in patients with long COVID.

Methods: This was an observational, retrospective, single-centre study at an outpatient clinic conducted from 1 June 2021 to 31 May 2024. We collected patients' clinical data, including positive signs. The primary outcome was the prevalence of positive signs. Patients with positive signs were followed up over 2 months, and subjective patient perceptions of symptomatic improvements and changes in positive signs were analysed.

Results: Overall, 502 were diagnosed with long COVID, and 100 assessed patients had positive signs. Female sex, time of infection after 2022, comorbidity of psychiatric diseases, fatigue, headache and muscle weakness were statistically significant in patients with positive signs compared with those in patients without positive signs. 89 patients (41 with positive signs and 48 without positive signs) were followed up, and 28 (68.3%) with positive signs and 33 (68.8%) without positive signs reported improvements. Positive signs disappeared in patients with symptomatic improvements but not in patients without symptomatic improvements (p=0.0001).

Conclusions: Positive signs were found in over one-third of patients (33.9%) who were investigated in this study. Some positive signs disappeared concurrently with their symptomatic improvement.

Background: The epidemiology of myasthenia gravis (MG), a rare autoimmune disease, is not completely understood. This retrospective claims analysis assessed the epidemiologic rates of MG in the USA and the characteristics of the incident and prevalent MG populations.

Methods: Patients with MG were identified using Inovalon closed claims data; those with ≥2 International Classification of Diseases, 10th Revision (ICD-10) codes for MG from 2016 to 2019, separated by ≥30 days, were eligible. Patients in the prevalent cohort had continuous insurance coverage from January to December 2019. Patients in the incident cohort had continuous insurance coverage from January 2018 to December 2019 and no MG claims before 2019. Incidence and prevalence rates were adjusted using US census data. Treatment utilisation was assessed in both cohorts and grouped by provider type. Exacerbations were identified using ICD-10 code G70.01; codes occurring ≤30 days following a previous exacerbation code were considered as part of a single event.

Results: The incident cohort included 1442 patients (adjusted incidence: 4.3 per 100000); the prevalent cohort included 14 373 patients (adjusted prevalence: 35.7 per 100 000). In 2019, approximately two-thirds of patients in both cohorts (incident, 67.7%; prevalent, 61.6%) received MG treatments, most commonly acetylcholinesterase inhibitors, followed by oral steroids. Among incident patients with ≥1 year of continuous follow-up (n=1204), 32.1% (n=387) experienced ≥1 exacerbation, with 50% (n=194) having ≥2 exacerbations and 41% (n=159) having an exacerbation as the index MG event.

Conclusions: Estimates of MG incidence and prevalence were comparable to findings from two recent US studies. Acetylcholinesterase inhibitors and corticosteroids remain widely used. Exacerbations occurred in >30% of incident patients with ≥1 year of continuous follow-up, including 13% who had a relapse as their index event. These results highlight the need for earlier detection and use of more effective therapies in the treatment paradigm to achieve sustained disease control.

[This retracts the article DOI: 10.1136/bmjno-2023-000459.].

Abstract:

Introduction: Accurate and timely differentiation of intracerebral haemorrhage (ICH) from other suspected stroke cases is crucial in prehospital settings, where early blood pressure reduction in the ambulance can improve outcomes. This study aims to assess whether combining clinical predictors and glial fibrillary acidic protein (GFAP) in prediction models can effectively distinguish ICH from other suspected stroke cases.

Methods: Data were derived from the Testing for Identification Markers of Stroke trial, a prospective diagnostic accuracy study. Suspected stroke patients within 6 hours of symptom onset were included. Clinical predictors were selected based on known associations with ICH, and a predefined GFAP cut-off of 290 pg/mL was applied. Logistic regression was used to assess the performance of clinical predictors and GFAP, individually and in combination. Internal validation and optimism correction were performed via bootstrapping, and comparisons of the area under the curve (AUC) were conducted using DeLong's test.

Results: We included 209 suspected stroke cases, of which 5% were finally diagnosed with ICH. Clinical predictors alone achieved an optimism-corrected AUC of 0.74 (95% CI 0.60 to 0.88), while GFAP alone resulted in an optimism-corrected AUC of 0.83 (95% CI 0.69 to 0.99). Combining clinical predictors with GFAP significantly enhanced the AUC, yielding an optimism-corrected value of 0.90 (95% CI 0.79 to 0.98). This combined model also demonstrated high predictive accuracy, with an optimism-corrected sensitivity of 60% (95% CI 29.0% to 90.0%) and a specificity of 98% (95% CI 96.1% to 100.0%).

Conclusions: Combining clinical predictors with GFAP shows promise for the prehospital identification of ICH to support transport decision-making and potentially initiate treatment while en route for these patients. Prospective validation using portable point-of-care devices is required to confirm the utility of this approach in the prehospital setting.

Background: Access to endovascular thrombectomy (EVT) for acute ischaemic stroke (AIS) and the outcome disparities in culturally and linguistically diverse (CALD) populations are understudied. South-Western Sydney (SWS), characterised by high prevalence of CALD populations, provides an ideal setting to explore these disparities. This study aimed to assess whether being born in a country where English is not the primary language ('language other than English'; LOTE) affects access to EVT and outcomes for acute ischaemic stroke while also identifying demographic risk factors influencing stroke severity and outcomes.

Methods: A retrospective cohort study was conducted on consecutive patients with AIS who underwent EVT at Liverpool Hospital, Sydney, from 2018 to 2023. Participants were categorised based on country-of-origin Australia/New Zealand/United Kingdom or LOTE. Primary outcomes included time metrics-onset-to-arrival (OTA) and arrival-to-puncture (ATP)-and 3-month modified Rankin Score (mRS). Statistical analyses included multivariate logistic regression to evaluate predictors of functional outcomes.

Results: Of 911 EVT referrals, 721 patients were included. LOTE patients (50.3%) were more likely to have diabetes mellitus (30% vs 16%; p<0.001) and presented with higher stroke severity (median National Institutes of Health Stroke Scale (NIHSS) 17 vs 14; p<0.001). They also experienced shorter ATP (158 vs 174 min; p=0.006). Patients requiring interpreters equally exhibited shorter ATP times (152 vs 170 min; p=0.01) and higher stroke severity. There was no significant disadvantage hailing from the LOTE group in OTA times and in any time metrics for subgroup analyses stratified by primary presenter status. However, LOTE patients had poorer 3-month outcomes (mRS ≤2: 46.5% vs 55.4%; p=0.021), which was associated with higher baseline NIHSS and diabetes in adjusted analyses.

Conclusion: LOTE patients in SWS undergoing EVT were not disadvantaged in hospital time metrics. Poorer 3-month functional outcomes in LOTE patients highlight the need for targeted strategies addressing risk factors, such as diabetes mellitus.