Acta Neurologica Scandinavica最新文献

Objective

Alzheimer′s disease (AD) involves impaired clearance of metabolic waste, including amyloid-β, potentially related to glymphatic dysfunction. Low-intensity ultrasound (LIUS) may facilitate solute clearance in the brain. This pilot study examined whether LIUS affects amyloid-β deposition and cognitive performance in early-stage AD, and whether MRI-derived changes in putative glymphatic activity could represent a possible underlying mechanism.

Methods

This prospective pilot study (September 2022–February 2023) enrolled 10 amyloid-positive participants who underwent 4 weeks of LIUS treatment, including five apolipoprotein E4 (APOE4) carriers and five noncarriers. LIUS treatment involved sessions over 4 weeks. Magnetic resonance imaging (MRI) and amyloid PET scans were used to quantitatively analyze glymphatic activity, blood–brain barrier (BBB) integrity, microbleed occurrence, and amyloid deposition changes. Cognitive changes were assessed using neuropsychological tests.

Results

All participants completed treatment without any significant adverse events. Neuropsychological testing demonstrated cognitive function improvements. Amyloid-β deposition decreased mainly in APOE4 carriers following LIUS. In addition, post-LIUS, the cerebral cortex showed increased putative glymphatic activity, although statistical significance was not maintained after multiple-comparison correction. No significant changes were observed in BBB integrity, microbleed occurrence, or brain volume.

Conclusion

LIUS was safe and demonstrated both cognitive improvement and reduced amyloid deposition in early-stage AD. These effects may reflect several biological actions of LIUS, including the possibility of glymphatic enhancement. Further studies with larger cohorts and appropriate control groups are warranted to confirm these findings and draw more definitive conclusions.

Trial Registration

Clinicaltrial.gov identifier: NCT05633095

Objectives

Testing for brain death/death by neurologic criteria includes proof of irreversible loss of all brain functions. Intravenously administered atropine can serve as a complementary clinical test. This study determines the cut-off value, sensitivity, and specificity of the atropine test and examines implications for the safety of existing scientific guidelines.

Methods

A prospective multicenter observational study included patients who received atropine (2 mg intravenously) as part of an investigation for brain death/death by neurologic criteria. Data from brain death/death by neurologic criteria protocols, vital signs records, and diagnostic reports were collected in order to calculate the sensitivity and specificity of the atropine test per se and in comparison to the standard tests.

Results

The study included 394 examinations in 257 patients (51.6 years, SD 16.3 years, 123 men, and 134 women) with suspected brain death/death by neurologic criteria.

In brain-dead patients, there was no increase in heart rate above 10 bpm (i.e., specificity of 100% of a positive atropine test > 10 bpm). Although of low sensitivity (17%) in proving residual brain function, the atropine test is twice as sensitive in revealing remaining brain functions as mandatory clinical tests (corneal, cough, and pupillary reflex p < 0.05, apnea test and unresponsiveness to pain p < 0.10).

Conclusion

A cut-off value of 10 bpm achieves very good specificity, but only low sensitivity. However, the sensitivity of the atropine test was more than twice as high as that of all mandatory tests. Therefore, we suggest considering the simple atropine test in brain death/death by neurologic criteria diagnostics at least where brain perfusion investigations are not used.

Background and Aims

Precise prehospital identification of cerebrovascular diseases (CVD) is essential for timely decisions concerning recanalization therapy for acute ischemic stroke (IS). This study described the stroke chain by analyzing patients transported by emergency medical services (EMS) with a stroke code, focusing on the EMS process regarding both CVD recognition and final recanalization decisions.

Methods

This retrospective, population-based, observational study analyzed all consecutive patients transported by EMS with suspected acute CVD in the Helsinki University Hospital service area during a 4-month period, irrespective of transport priority or receiving hospital. Prehospital and hospital patient records were combined, and the cohort was cross-checked with the database of given recanalization therapies. Sex-related and regional differences were assessed.

Results

Out of 1411 transports, 702 (50%) CVD diagnoses were identified. Of 521 high-priority transports, 317 (61%) received a CVD diagnosis and 98 (19%) recanalization therapy. Any recanalization therapy was given to 97/415 (23%) IS patients and to 91/211 (43%) IS patients transported with high priority. There were no significant sex-related or regional differences concerning diagnostic accuracy or treatment decisions. Altogether, 92% of the EMS transports ultimately leading to recanalization therapy were assigned high-priority stroke code.

Conclusions

The Finnish EMS system seems relatively accurate in identifying cerebrovascular disease; of all stroke-code transports, every second patient received a CVD diagnosis. Of the high-priority transports, 19% led to recanalization decisions. We observed no signs of gender or regional inequity. Most patients who received recanalization therapy were correctly identified by the EMS and transported with high priority, but this inevitably came at the expense of specificity.

Background

This study presents a comprehensive analysis of the trends and challenges in cluster headache research from 1936 to 2022, highlighting the increasing study trend and the significant contributions from the United States, Italy, and England. The study identifies the most important journals, productive authors, and centers in the field, shedding light on the defects and challenges in pathophysiology, genetics, diagnosis, treatment, and study methods of cluster headaches.

Methods

Utilizing a bibliometric approach, the study examines the thematic and conceptual structural map, identifying key areas of focus in the pathophysiology, genetics, and neuroimaging studies of cluster headaches. The study also delves into the treatment phases and guidelines for cluster headaches, emphasizing the need for evidence-based and physiopathology-based treatment approaches.

Results

The findings highlight the genetic and neuroimaging research gaps, the role of the hypothalamus, and the morphological alterations in the brain associated with cluster headaches. The study also discusses the limitations and challenges in the research and treatment of cluster headaches, emphasizing the need for improved clinical trial methodologies and treatment efficacy.

Conclusion

The study concludes by underscoring the critical need for further research to address the limitations and challenges in understanding the pathophysiology, improving treatment efficacy, and enhancing the quality of life for individuals with cluster headaches. The study recommends future research with a comprehensive perspective to address the complexities and insufficiencies in the current understanding and treatment of cluster headaches.

Introduction

The Coronavirus Disease 2019 (COVID-19) pandemic has had a profound impact on healthcare systems globally, necessitating significant adaptations in the management of chronic conditions such as multiple sclerosis (MS). In Sweden, where a unique approach to pandemic mitigation was adopted, the effects on MS clinical care remain a subject of interest. This population-based study is aimed at assessing changes in MS clinical care during the COVID-19 era compared to the prepandemic period.

Methods

Using the data from the Swedish MS Registry, encompassing the periods from January 29, 2018, to February 29, 2020 (pre-COVID-19 era), and from March 1, 2020, to April 1, 2022 (COVID-19 era), we analyzed MS incidence rates, clinic visits, relapse rates, initiation of disease-modifying treatments (DMTs), and dosing intervals for infusion medications. Statistical analyses, including interrupted time series and mixed Poisson regression models, were employed to assess changes in outcomes while adjusting for relevant covariates.

Results

Our analysis included 19,959 MS patients. While there was a decrease in MS diagnoses during the pandemic period, this difference was not statistically significant. In contrast, a significant reduction in frequencies of physical clinical visits and relapse rates compared to the prepandemic period was evident. Treatment strategies shifted, with decreased utilization of anti-CD20 therapies and increased use of platform and other high-efficacy non–anti-CD20 DMTs. Dosing intervals for infusion medications were also extended during the COVID-19 era.

Conclusion

The findings underscore the substantial impact of the pandemic on MS clinical care practices and data capture in Sweden. Understanding these changes is crucial for monitoring or quality control of MS care, informing future research endeavors which access the Swedish MS Registry to measure disease outcomes in this population. The study highlights the responsiveness of healthcare systems in adapting to important challenges while emphasizing the importance of ongoing monitoring and adaptation in MS management practices.

Background/Aim

Sexual dysfunction (SD) is a prevalent yet underrecognized concern among women with multiple sclerosis (MS), substantially affecting quality of life. This study was aimed at investigating the magnetic resonance imaging (MRI) correlates of SD, with a particular focus on the spinal cord (SC), and to explore associations between SD and other disability metrics.

Methods

SD was assessed using the Female Sexual Function Index (FSFI) questionnaire, administered to 251 female patients with multiple sclerosis (PwMSs). All PwMSs underwent brain and cervical SC MRI at 3T, alongside EDSS, assessment of depression, fatigue, cognition, manual dexterity, and gait. Quantitative brain and SC MRI measures were obtained, including global and regional brain volumes, SC volume, and lesion counts in the brain and SC. Associations between quantitative MRI metrics, disability, and SD were analyzed using partial correlation, controlling for age and disease duration. Subsequently, the predictive value of MRI and clinical variables for SD severity was evaluated using linear regression models adjusted for age and disease duration.

Results

The response rate was 58.5%, with 32.7% PwMS meeting the criteria for SD. PwMS with SD exhibited significantly reduced right and left cingulate (p = 0.03 and 0.04) volumes. However, no significant correlations were observed between SD severity and quantitative MRI measures when controlling for age and disease duration. Fatigue and depression demonstrated moderate correlations with overall SD severity (rho = −0.491/−455, p < 0.001). Shorter 2-min walking test distance was associated with a higher risk of SD (p = 0.029). Sensory dysfunction (p = 0.025) and depression (p < 0.030) were the only independent predictors of SD severity.

Conclusion

Among MRI predictors of SD, we identified only a reduction of cingulate volume in PwMS with SD. Walking performance, depression, and sensory dysfunction were key predictors for SD presence and severity, highlighting the need for targeted screening for SD in PwMS with these risk factors. Exploring the role of contributing factors (use of antidepressants and medication for neuropathic pain) and interventions, that is, physical exercise, is warranted.

Background and Purpose

Myasthenia gravis (MG) is a complex autoimmune disorder affecting neuromuscular transmission, often leading to diagnostic and therapeutic challenges. Timely identification of “red flags” in diagnosis, therapeutic reassessment, and myasthenic crisis is crucial to optimizing patient outcomes. This Delphi-based consensus is aimed at synthesizing expert recommendations for improving clinical practice in Italy.

Methods

A scientific board of 19 MG specialists and an extended panel of 47 neuromuscular experts participated in a structured Delphi methodology. Over an 11-month period, consensus was developed across four areas: diagnostic red flags, confirmatory instrumental examinations, therapeutic reassessment, and the continuum from exacerbation to impending myasthenic crisis or to crisis. The threshold for achieving consensus was set at ≥ 75% agreement.

Results

Globally, 68 statements reached consensus. Key findings include the identification of “red flags” for suspecting MG, with fluctuating and fatigable muscle weakness serving as primary diagnostic indicators, often involving ocular, bulbar, and respiratory muscles. Instrumental tests, such as repetitive nerve stimulation and antibody assays, were deemed essential for diagnostic confirmation. Therapeutic reassessment in MG is warranted for unsatisfactory symptom control, clinically significant adverse events, new or worsening comorbidities, planning pregnancy, or neoplastic disease. Persistent fluctuations, exacerbations, or triggers like infections should prompt adjustments, aiming to optimize treatment while minimizing risks. High-risk factors and triggers for myasthenic crises, including thymoma and infections, were identified, with arterial blood gas analysis highlighted as critical for crisis management.

Conclusions

This consensus provides actionable recommendations to enhance the identification and management of MG, addressing diagnostic delays, therapy optimization, and crisis prevention. These findings aim to guide clinical practice and foster a systematic approach to managing this heterogeneous disorder.