Canadian Journal of Neurological Sciences最新文献

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.

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.