Canadian Journal of Neurological Sciences最新文献

Introduction: Migraine is one of the most common neurological diseases, presenting different characteristics among patients. Therefore, there is a need to identify preventive medications that offer more efficacy and fewer adverse effects. Melatonin is a promising therapeutic alternative in this context due to its analgesic, neuromodulatory and cerebral blood flow regulatory mechanism.

Objective: This study aims to evaluate the efficacy of melatonin treatment compared to placebo and other drugs in reducing migraine episodes' frequency and secondary outcomes by analyzing randomized clinical trials.

Methods: The databases Cochrane, Embase and PubMed were used to search and select relevant studies, according to their specific inclusion criteria. Afterward, the relevant data was extracted, and statistical analysis was conducted with R Studio version 4.3.1, applying appropriate models to maintain heterogeneity within them and produce a combined estimate. Results were interpreted considering potential biases and limitations to form our final statement with the Risk of Bias (RoB 2.0) tool from Cochrane.

Results: A total of nine studies involving 783 patients were included in our analysis. Treatment methods were composed of seven different strategies. The network meta-analysis showed no statistically significant differences related to monthly headache frequency between melatonin and amitriptyline (SD: -1.8; 95% Crl [-5.2, 1.0]); naproxen (SD: -0.98; 95% Crl [-5.5, 3.8]); valproic acid (SD: -0.60; 95% Crl [-5., 3.6]); topiramate (SD: 0.081; 95% Crl [-5.0, 4.7]); propanolol (SD: 1.4; 95% Crl [-3.7, 6.6]) and placebo (SD: 0.49; 95% Crl [-1.6, 2.7]). Other outcomes assessed were the MIDAS score, the mean number of analgesics used and headache duration, in hours, all of which had nonsignificant differences among treatment arms.

Conclusion: This systematic review and network meta-analysis found no substantial support for the efficacy of melatonin treatment in patients with episodic migraine, challenging the assumption of their correlation. Although the results showed no significant association between the disease and melatonin administration, more research is necessary to explore the influence of melatonin in migraine's pathophysiology and further potential indirect mechanisms by which melatonin usage could benefit those who have not responded to conventional therapies.

Objective: Bevacizumab is often used for treatment of recurrent glioblastoma (rGBM), yet there is no consensus on the best methods for its administration and timing. This retrospective study provides the largest Canadian cohort analysis of the experience and outcomes of patients with rGBM treated with bevacizumab.

Methods: We conducted a retrospective cohort study of patients aged 18 or older with rGBM treated in 6 tertiary care level cancer centers in British Columbia (BC) between 2011 and 2019. Patient demographics, tumor characteristics, treatment course, disease outcome and quality of life measures were collected. Overall survival (OS) and progression-free survival (PFS) were used as clinical outcomes.

Results: In our cohort of 272 patients, initiation of bevacizumab within 6 months of radiation treatment improved OS after bevacizumab initiation. Analysis of patients treated in high versus low-volume centers in BC suggested that patients in higher-volume centers were less likely to receive adjuvant chemotherapy with bevacizumab treatment, and more likely to have improved survival after bevacizumab initiation. Bevacizumab was shown in this study to appear to improve symptoms, preserve quality of life and reduce corticosteroid requirements.

Conclusion: This Canadian cohort analysis characterizes bevacizumab treatment practices, survival and quality of life outcomes in rGBM patients in BC. Further investigations are needed to identify the demographic and biomarker characteristics of rGBM patients who would most benefit from bevacizumab treatment.

Background: Patients undergoing craniotomy experience a higher risk of seizures in the ensuing months. Consensus is lacking regarding the appropriate timeframe for safe return to driving following craniotomy in patients not otherwise limited by neurological deficits or a history of epilepsy.

Methods: We performed a systematic literature review on driving recommendations post-craniotomy. We then performed a scoping review on the risk of seizure post-craniotomy and used risk calculations and accepted risk thresholds from the epilepsy literature to develop an evidence-based approach to driving recommendations post-craniotomy.

Results: The systematic review of driving recommendations revealed national guidelines (the United Kingdom, New Zealand, Australia). We transposed risk calculations and accepted risk thresholds from the epilepsy literature (accident risk ratio [ARR] < 2; chance of occurrence of a seizure in the next year < 20%) to patients who undergo a craniotomy. Using data from a large meta-analysis of seizure risk post-craniotomy, we calculated ARRs for various underlying pathologies at different postoperative timepoints and compared them with accepted risk thresholds from the epilepsy literature. We determine that patients who undergo a craniotomy for a higher-risk condition (like high-grade glioma) may resume driving after at least 1 month without seizure, whereas those patients undergoing a craniotomy for lower-risk conditions (like infratentorial pathology) may resume driving without consideration for the risk of seizure.

Conclusion: This systematic review of the literature and evidence-based approach to risk threshold calculations derived from the epilepsy literature provides a preliminary framework to guide clinicians regarding recommendations for return to driving following craniotomy.

Background: Rural areas are often challenged in delivering time-sensitive hyper-acute stroke care. TeleStroke can improve access to time-sensitive reperfusion therapies. We aimed to evaluate our experience with TeleStroke and to explore if it facilitates reperfusion therapy in patients with acute ischemic stroke (AIS).

Methods and analysis: The Manitoba TeleStroke Program was rolled out across seven sites between November 2014 and January 2019. We retrospectively included consecutive patients with suspected AIS within 4.5 hours of onset, between November 2014 to December 2022. Demographic data, process metrics, and outcome measures were collected. The primary outcome was safety and efficacy measured in terms of 90-day modified Rankin score (mRs). A descriptive and analytical analysis was performed.

Results: Of the 1,748 TeleStroke patients (median age 71 years, female 810 [46.3%]), 696 (39.8%) were identified as AIS. Of these, 265 (38.1%) received intravenous thrombolysis. Ninety-day mortality was 53 (20.0%) among those receiving thrombolysis and 117 (44.2%) had a favorable outcome of mRs≤2. Among patients receiving thrombolysis, nine (3.4%) had a symptomatic intracranial hemorrhage. Arrival by ambulance occurred in 1115 (63.8%) cases, median last-seen-normal-to-door time was 121 minutes, and median door-to-needle time was 55 minutes. When comparing "AIS-without thrombolysis" and "AIS with thrombolysis," the median last-seen-normal-to-door was 210 versus 90 minutes (p < 0.001); and the median door-to-CT scanner was 24 versus 22 minutes (p = 0.009).

Conclusion: Intravenous thrombolysis for patients with AIS was found to be effective and safe in the Manitoba TeleStroke Program. Lessons learnt from our study will help improve the TeleStroke program in Manitoba and beyond.

Objective: To evaluate the impact of discharge destination on long-term functional outcomes in patients with aneurysmal subarachnoid hemorrhage (aSAH) and its association with achieving functional independence.

Methods: This retrospective cohort study included patients with aSAH treated endovascularly at a tertiary neurovascular center between October 2019 and November 2024. Patients who died before hospital discharge were excluded. Group comparisons were performed using one-way analysis of variance, Kruskal-Wallis, paired-sample t-tests and Pearson's χ². Multivariable logistic regression was used to assess the association between discharge site and functional independence achievement, adjusting for age, sex, World Federation of Neurosurgical Societies (WFNS) grade and modified Rankin Scale (mRS) score at discharge.

Results: A total of 213 patients (mean age 55.9 ± 13.7 years; 77% female) were included. Hypertension (57.7%) and previous smoking (45.1%) were the most common risk factors. Significant differences in age, sex, WFNS grade and modified Fisher Scale scores were observed across discharge groups. While patients discharged home had better overall outcomes, those with poor WFNS grades showed greater reductions in mRS at 6 and 12 months when discharged to an acute rehabilitation center. Regression analysis demonstrated that discharge to an acute rehabilitation center was independently associated with higher odds of functional independence, while discharge to a primary care hospital decreased these odds.

Conclusion: Discharge to a primary care hospital after aSAH was associated with worse long-term outcomes. In contrast, early transfer to an acute rehabilitation center significantly improved functional independence, particularly among patients with poor baseline neurological status.