Canadian Journal of Neurological Sciences最新文献

Background/objective: The benefit of endovascular treatment (EVT) in acute ischemic strokes (AIS) due to medium vessel occlusion (MeVO) remains unclear, as recent randomized controlled trials (RCTs) have shown neutral results. This meta-analysis examines the pooled efficacy and safety of EVT in MeVO.

Methods: A systematic review and meta-analysis of two RCTs (DISTAL and ESCAPE-MeVO) involving 1073 participants was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. The primary outcome was the risk ratios (RR) of excellent functional outcome, defined as modified Rankin score (mRS) 0-1 at 90 days. Secondary outcomes included mRS 0-2 and symptomatic intracranial hemorrhage (sICH).

Results: The RR implied no significant difference between the two treatment arms; for the primary efficacy outcome, RR (mRS 0-1) was 0.95 (95% CI: 0.81-1.10; I² = 0%), and for the secondary efficacy outcome, RR (mRS 0-2) was 0.98 (95% CI: 0.88-0.09; I² = 10%). The EVT + best medical treatment (BMT) arm demonstrated a higher risk of sICH (RR: 2.39, 95% CI: 1.26-4.53; I² = 0%) and serious adverse events (SAE) (RR: 1.32, 95% CI: 1.11-1.56; I² = 0%), while mortality at 90 days (RR: 1.29, 95% CI: 0.94-1.76; I² = 16%) showed no significant difference.

Conclusions: Our study showed that, in patients with AIS due to MeVO, EVT did not lead to better outcomes at 90 days when compared to BMT and was associated with a higher risk of sICH and SAEs compared to usual care, and this result was confirmed in a trial sequential analysis.

Prospero registration: The study protocol was registered with the International Prospective Register of Systematic Reviews under the registration identification number CRD420250653970.

Objective: Embolization of the middle meningeal artery (EMMA) is an emerging neuroendovascular therapy for chronic subdural hematoma (CSDH). Recently, three landmark randomized trials (MAGIC-MT, EMBOLISE, STEM) were published. We performed a systematic review and meta-analysis of randomized trials for EMMA.

Methods: The authors systematically searched MEDLINE, EMBASE, Cochrane and ClinicalTrials.gov (National Library of Medicine) through March 6, 2025. Prospective randomized controlled trials comparing EMMA and standard care versus standard care alone were included. Primary (symptomatic recurrence, symptomatic progression, major adverse event, neurological deterioration, stroke, myocardial infarction and/or death) and secondary endpoints (serious adverse events, stroke, death from any cause and death from neurological causes) were analyzed. The review was registered on PROSPERO (CRD42024512049).

Results: Four randomized trials (Lam et al., MAGIC-MT, EMBOLISE, STEM) were meta-analyzed. A total of 1468 patients were included. The primary endpoint was met in 50 patients (7.5%) in the EMMA group compared to 106 patients (15.5%) in the control group (RR 0.49 [95% CI, 0.36-0.67]; P < 0.001, I² = 0.0%), with a number needed to treat of 13. There was no difference in serious adverse events (RR 0.88 [95% CI 0.68-1.13]; P = 0.31, I² = 50.2%), stroke (RR 1.51 [95% CI 0.46-5.01]; P = 0.50, I² = 0.0%), death from any cause (RR 1.03 [95% CI 0.37-2.85]; P = 0.95, I² = 58.1%) or death from neurological causes (RR 1.29 [95% CI 0.53-3.09]; P = 0.58, I² = 25.4%).

Conclusions: EMMA is effective in reducing symptomatic recurrence, progression and/or reoperation among patients with CSDH and is not associated with a greater incidence of serious adverse events, stroke or death.

Introduction: Generalized myasthenia gravis (gMG) is a chronic neuromuscular disease that causes muscle weakness and fatigue, severely impairing quality of life. Efgartigimod is a novel drug that is recently approved for treatment of acetylcholine receptor antibody-positive (AChR-Ab+) gMG patients in Canada. In clinical practice, it is expected to be used in AChR-Ab+ gMG patients who continue to experience symptoms despite conventional therapy and primarily replace chronic immunoglobulins.

Methods: A Markov model was developed to estimate costs and benefits (measured as quality-adjusted life years [QALYs]) of efgartigimod and chronic immunoglobulins for AChR-Ab+ gMG patients. The analysis was conducted from the perspective of the Canadian publicly funded healthcare system over a lifetime horizon. The model comprised six health states based on Myasthenia Gravis Activities of Daily Living (MG-ADL) scores: MG-ADL < 5, MG-ADL 5-7, MG-ADL 8-9, MG-ADL ≥ 10, myasthenic crisis or death. Health state transition probabilities were estimated from the ADAPT and ADAPT+ studies, plus a network meta-analysis that compared efgartigimod against chronic immunoglobulins. The MyRealWorld MG study informed utility values. Modeled costs included treatment and administration, disease monitoring, complications from chronic corticosteroid use, exacerbation/crisis management, adverse events and end-of-life care.

Results: Over a lifetime horizon, efgartigimod and chronic immunoglobulins were predicted to have total discounted QALYs of 16.80 and 13.35 and total discounted costs of $1,913,294 and $2,170,315, respectively. Efgartigimod dominated chronic immunoglobulins with incremental QALYs of 3.45 and cost savings of $257,020.

Conclusions: Efgartigimod provides greater benefit in terms of lower costs than chronic immunoglobulins for AChR-Ab+ gMG patients in Canada.

Background: White matter hyperintensities (WMH) on fluid-attenuated inversion recovery MRI sequence are regions where fluid from supplying vessels leaks into brain tissue. Some studies have demonstrated an association between WMH and cognitive decline. Given the common WMH risk factors in our local population, the aim of this study is to examine the relationship of overall and regional WMH with cognition in Hamilton, Canada.

Methods: Adults presenting to Hamilton General Hospital in 2020 with a head MRI and cognitive assessment within 6 months of the MRI were included in our cross-sectional study. MRIs were reviewed, assigning a periventricular (PV), a subcortical (SC) and an overall severity score to each based on the Fazekas scale, ranging from 0 to 3. Montreal Cognitive Assessment (MoCA) scores were used as a measure of cognitive function. Patients with confounding diagnoses were excluded. Multiple regression analyses were conducted between WMH and cognitive scores, adjusting for hypertension, diabetes and smoking.

Results: Multiple regression models revealed R² values of 0.097, 0.050 and 0.036 for overall, PV and SC WMH with MoCA, respectively. There were negative associations between overall Fazekas scores and MoCA (B = -2.11, p < 0.001), PV scores and MoCA (B = -1.46, p < 0.001) and SC scores and MoCA (B = -1.21, p = 0.002).

Conclusion: The association between MRI WMH and cognition supports prognostic use for cognitive decline to limit/delay deterioration. Specifically, stronger PV associations prompt research and perhaps development of revised scales prioritizing PV changes. Implementing this into the field of radiology whereby WMH severity and location assessment becomes a standard within brain MRI reports could improve patient outcomes.

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.