Neurological research and practice最新文献

Background: Non-convulsive status epilepticus (NCSE) is a common definitive or exclusion diagnosis in patients with disorders of consciousness (DOC) on neurological or interdisciplinary intensive care units (ICU). Special expertise is required to ensure reliable diagnosis, targeted therapy management, and individual prognostication, particularly as NCSE is identified based solely on clinical and electroencephalographic findings.

Main body: This narrative state-of-the-art review compiles and critically discusses the existing literature on various aspects of NCSE. We focus on the reliable initial diagnosis and further monitoring of NCSE using the Salzburg criteria and the 2HELP2B score, therapy options beyond current guideline recommendations, and prognosis assessment using established scores and metrics, such as STESS, SACE, EMSE, and END-IT. With compact tables and clear illustrations, comprehensive insights are presented in a concise structure to provide clear guidance for daily practice.

Conclusion: NCSE is a common and complex disease entity observed in the ICU that requires dedicated and specialised diagnostics, therapy, monitoring, and outcome assessment. Evidence-based recommendations are now available for each of these critical processes to guide caregivers and relatives. However, the availability of continuous (cEEG), quantitative (qEEG) electroencephalography in the ICU and expertise in its interpretation are limiting factors in many clinical settings. This problem is becoming increasingly pronounced due to the reduced or complete lack of reimbursement for c/qEEG in the context of intensive care medicine in many countries.

Background: Atrial fibrillation (AF) is a common condition in older adults, often associated with increased risks of cognitive decline and frailty. White matter hyperintensities (WMH), visible on neuroimaging and quantified by the Fazekas score, have been linked to both cognitive and physical impairments. However, the relationship between WMH, cognitive decline, and frailty in older adults with AF remains relatively underexplored.

Methods: This study analyzed data from 86 participants in the SAGE-AF cohort, a two-year prospective multicenter cohort study of older adults with AF, who also had neuroimaging performed for clinical indications. WMH severity was assessed by independent reviewers using Fazekas scores from brain imaging. Cognitive function was measured using the Montreal Cognitive Assessment (MoCA), and frailty was assessed at baseline as well as 1- and 2-year follow-up visits by trained examiners as part of the SAGE-AF study protocol. Participants were characterized based on the severity of their white matter hyperintensities and compared to baseline and two-year cognitive and physical functional status. Longitudinal regression models were used to adjust for demographic, clinical, and geriatric covariates.

Results: Participants with higher Fazekas scores (grades 2-3) demonstrated significantly lower baseline and follow-up MoCA scores and were more likely to meet frailty criteria over a two-year follow-up period. After adjusting for multiple factors known to influence cognitive decline, greater white matter hyperintensity (Fazekas grades 2-3) remained associated with a 2.6-fold increased risk of cognitive impairment at (p = 0.04) and a 2.7-fold increased risk of frailty at (p = 0.02).

Conclusion: Higher Fazekas scores are related to cognitive decline and frailty in older adults with AF, emphasizing WMH as a critical biomarker for aging-related impairments. Neuroimaging tools like Fazekas scoring could enhance risk stratification and inform targeted interventions for this vulnerable population.

Background: Chronic pain represents the defining and quality-of-life limiting feature in patients with cancer pain (CP) or chronic non-cancer pain (CNCP) and is often treated with opioids. Over time, opioid use is frequently accompanied by necessity of an increasing dose due to pharmacological tolerance and progress of the underlying diseases. The potential side effects were found to correlate with accelerating doses. More recently, the opioid crisis in the United States has drawn attention to the adverse effects and toxicities. Until today it is unclear what high-dose opioid therapy is and guidelines are inconsistent regarding an evidence-based threshold.

Objectives: This systematic review and meta-analysis aim to determine a threshold for high-dose opioid therapy. A systematic literature search was conducted in 4 databases from earliest publication available until May 2025. Studies were eligible if participants with CP or CNCP were able to self-titrate their opioid dosage to reach a sufficient pain relief.

Methods: 4305 records were screened. Nineteen included studies with a total of 3111 participants investigating eight different opioids were included. The studies were assessed for risk of bias. Results were synthesised as oral morphine equivalents (OMEs).

Results: The meta-analysis found a weighted mean of 74.7 mg OME per day and the 97.5% percentile corresponded to about 138 mg/d (range 134-139 mg/d) as a "high dose". In CNCP the limit was 78 mg/d (range 74-78 mg/d), whereas in CP it reached 288 mg/d (range 280-289 mg/d; p < 0.01).

Conclusion: Despite the overall moderate risk of bias of the included studies and the heterogeneity in underlying pain conditions, the reference range of typically prescribed dosages in a broad study population could be investigated. These systematically derived thresholds may enhance physicians' awareness in carefully tailoring opioid treatments and thereby contribute to improved pharmacotherapy safety.

Prospero identifier: CRD42020219256.

Background: With the global prevalence of hyperuricemia and gout rising, accumulating evidence has linked acute gout flares to a transient rise in major adverse cardiovascular events, including myocardial infarction and stroke. However, the reverse association, whether acute stroke is associated with an increased incidence of gout flares, has been inadequately investigated. The aim of this single-center cohort study, coupled with a systematic review and meta-analysis, was to evaluate the incidence and characteristics of gout flares in the early post-stroke period.

Methods: A systematic review and meta-analysis of published studies was conducted, incorporating data from a cohort of acute stroke patients admitted to a tertiary care stroke center. Eligible studies reported in-hospital gout flares among patients with acute ischemic or hemorrhagic stroke. Pooled estimates were calculated using random-effects models. The systematic review was pre-registered in PROSPERO (CRD420251061747).

Results: We identified three studies (one involving only acute ischemic stroke, two including both ischemic and hemorrhagic stroke), encompassing a total of 13,722 acute stroke patients, including our institutional cohort. The pooled incidence of in-hospital gout flares was 4% (95% CI, 2-6%; I²=88.1%). The pooled mean time to flare onset was 6.3 days post-stroke (95% CI, 4.09-8.44; I²=96.6%), and 64% of flares involved the paretic limb (95% CI, 33-90%; I²=62.1%). Among flare patients, 85% were male (95% CI, 40-100%; I²=84.5%), 97% had ischemic stroke (95% CI, 94-99%; I²=0%), and 61% were newly diagnosed with gout or hyperuricemia during hospitalization (95% CI, 48-73%; I²=0%). In our cohort, 50% and 12.5% of flare patients presented with delirium and aphasia, respectively; all patients received colchicine treatment with complete symptom resolution.

Conclusions: Gout flares occur in one out of every 25 acute stroke patients, particularly in men presenting with acute ischemic stroke within the first week after symptom onset, and frequently involve the paretic limb. In over half of cases, the flare uncovers previously undiagnosed gout or hyperuricemia, emphasizing the need for systematic evaluation, particularly in patients with delirium or impaired communication, where diagnosis may be delayed. Early colchicine initiation warrants consideration given its anti-inflammatory effects and potential to reduce stroke recurrence.

Post-COVID can be associated with neurological symptoms such as neuropathy or fatigue. Histological analysis of affected nerves is rarely described and post mortem study of the brain and peripheral nerves are carried out only in few cases.In the case report, we describe the clinical and neuropathological findings of a 75-year-old female patient who presented with a motor and sensory axonal neuropathy after a SARS-CoV-2 infection seven weeks before and suddenly died. Laboratory testing of serum and CSF revealed no signs of systemic vasculitis or infectious diseases. A post mortem investigation was performed. Samples from the brain including the cranial nerves, peripheral nerves and skeletal muscles from different regions were analysed.The brain revealed lymphocytic cells predominantly in the basal ganglia and brain stem with involvement of the cranial nerves. Interestingly, a CNS involvement was not observed during lifetime. The sensory and motor peripheral nerves revealed a severe axonal neuritis. Skeletal muscle showed a neurogenic atrophy.This case report highlights that a post-infectious autoimmune disorder with CNS and PNS involvement should be considered in patients with post-COVID. The diagnosis of an ongoing inflammation may influence the treatment options.

Background: Numerous uncontrolled observational studies suggest that early spinal decompression and stabilization within 24 h of spinal cord injury (SCI) improve neurological recovery, forming the basis for recently published best practice guidelines. In this study, we aim to investigate current surgical practices in trauma centers across Germany, Austria, and Switzerland and to elucidate trauma- and patient-related factors influencing the timing of spine surgery.

Methods: We identified patients aged 16 years or older with traumatic SCI and permanent neurological deficits from the TraumaRegister DGU^® of the German Trauma Society (2008-2022). Trauma severity was assessed using the Abbreviated Injury Scale. Patients were categorized based on the timing of spine surgery (early surgery: day of admission; late surgery: subsequent days) and functional impairment (moderate vs. severe, based on the Glasgow Outcome Scale). Multivariate regression analyses were conducted to correlate patient and trauma-related factors with these endpoints.

Results: A total of 9938 patients with SCI at cervical, thoracic, and lumbar levels were identified. Among the 5025 patients who underwent spine surgery, 69% were operated on the day of admission, while 31% received surgery on subsequent days. Elderly patients (≥ 60 years) had a higher likelihood of delayed surgery (odds ratio [OR] 0.68-0.76). Trauma-related factors, including high cervical SCI, significant injuries beyond the spine, traumatic brain injury, and signs of hemorrhage, were strongly associated with late surgery (OR 0.38-0.83; p < 0.05). Conversely, patients with complete SCI or SCI at the thoracic or lumbar levels were more likely to undergo early surgery (OR 1.45-1.8; p < 0.001). Severe functional impairment was associated with advanced age (≥ 70 years), complete SCI, high cervical SCI, concomitant traumatic brain, signs of hemorrhage and comorbidities (OR 1.27-4.59; p < 0.01), whereas SCI at thoracic (OR 0.8) and lumbar (OR 0.4) levels correlated with moderate functional impairment (p < 0.01).

Conclusion: The majority of SCI patients in trauma centers across Germany, Austria, and Switzerland undergo early spinal surgery, reflecting adherence to best practice recommendations. Timing of surgery is significantly influenced by patient age and trauma complexity. Delays are more common in elderly patients and those with high cervical injuries or associated trauma, underscoring the need for individualized surgical decision-making. Given the strong correlation between injury severity, surgical timing, and functional impairment, future guidelines should refine criteria for early intervention to further optimize neurological recovery.

Background: Glioma-associated epilepsy (GAE) is a frequent and clinically significant complication in neuro-oncological practice. Its prevalence varies across glioma subtypes and is influenced by tumor biology, cortical involvement, tumor size, extent of resection, and disease progression. Despite its substantial impact on quality of life and clinical outcomes, GAE remains underrepresented in neurological and neuro-oncological guidelines. Moreover, novel findings in molecular subtyping and their relevance to tumor biology and GAE pathogenesis are not yet adequately reflected in clinical frameworks. Here, we aim to provide a comprehensive synthesis of epidemiology, pathophysiology, and management strategies for GAE based on the recent advances in glioma biology, cancer neuroscience, and epileptology.

Main body: This review highlights recent insights into the epidemiology, clinical impact, pathophysiology, and therapeutic strategies for GAE. We focus on both lower-grade gliomas, in which GAE is most prevalent over lifetime-particularly in tumors harboring isocitrate dehydrogenase (IDH) mutations-as well as high-grade gliomas where GAE remains a clinically relevant and complex issue. In addition to diffuse glioma subtypes, this review also addresses low-grade epilepsy-associated tumors (LEAT), a distinct and heterogeneous group with an inherently high risk of seizures. The pathomechanisms of GAE are reviewed with regard to glioma subtype-specific alterations of the tumor metabolism, neuroinflammation, increased glutamatergic activity, as well as the interaction between tumor cells and non-neoplastic cells. Key pathways implicated in both GAE and tumor biology include the IDH and mTOR signaling and a range of tumor related somatic mutations. With regard to the prognostic and therapeutic significance of GAE, we highlight the essential importance of accurate molecular tumor classification. In addition to reviewing common and tumor-specific side effects of anti-seizure medication (ASM), the emerging role of therapeutic approaches targeting both tumor growth and epileptogenesis is discussed.

Conclusion: Glioma (subtype) specific mechanisms of epileptogenesis and selection of ASM is an emerging topic with future potential to improve the therapy of GAE and tumor growth alike.

Epilepsy affects over 50 million individuals worldwide, a significant proportion of whom are women with epilepsy (WWE) of childbearing age. This population faces unique challenges related to hormonal fluctuations, e.g., during life stages such as breastfeeding or menopause. Antiseizure medications (ASMs) further complicate reproductive health by influencing menstrual function, contraception, pregnancy outcomes, bone health, and menopausal transition due to their teratogenic potential and hormonal interactive effects. Consequently, treatment strategies for WWE must consider these interactions and the risks associated with ASMs during pregnancy. This review aims to consolidate current data and guidelines for managing WWE throughout their reproductive years. These findings emphasize the importance of preconception counseling to optimize ASM regimens, ensuring both maternal well-being and fetal safety. Key recommendations from major international pregnancy registries are summarized to guide clinicians in selecting ASMs that minimize the risk of congenital malformations while maintaining effective seizure control. Additionally, this review explores the role of folic acid supplementation in preventing neural tube defects and outlines contraceptive options tailored for WWE. In conclusion, comprehensive education on the implications of epilepsy for reproductive health is crucial for WWE. By fostering informed decision-making through personalized counseling and careful medication management before, during, and after pregnancy, healthcare providers can significantly improve outcomes for both mothers and their children.

Background: Mechanical thrombectomy (MT) is a highly effective treatment for large vessel occlusion (LVO) ischemic stroke. However, a substantial share of patients have lethal outcome within 3 months. Individualization of outcome prognostication is needed to support clinical decision-making throughout the care pathway after MT. We investigate predictors of lethal outcome in patients with nonfatal LVO, defined by discharge alive from primary treating hospital, in a large prospective registry study of MT under routine care conditions.

Methods: 6,518 patients with nonfatal LVO treated by MT enrolled in the German Stroke Registry-Endovascular Treatment from May 2015-December 2021 were analysed with regard to lethal outcome by 3 month follow-up. Univariate group comparisons and multiple logistic regression analysis were performed to identify patients with high odds for survival or lethal outcome.

Results: We report 11.6% (757/6,518) 3 month mortality following hospital discharge after LVO treated by MT. Besides better functional outcome at discharge (modified Rankin scale < 4, odds ratio, OR [95% confidence interval, CI]: 2.38 [1.71-3.32], p < 0.001; National Institute of Health Stroke scale < 8, OR [95%CI]: 3.45 [2.55-4.66], p < 0.001), intravenous thrombolysis (OR [95%CI]: 1.48 [1.17-1.88], p = 0.001), successful recanalization (OR [95%CI]: 1.43 [1.08-1.90], p = 0.014) and discharge to a neurorehabilitative facility (versus nursing home: OR [95%CI]: 0.39 [0.26-0.58], p < 0.001; versus home: OR [95%CI]: 0.69 [0.49-0.97], p = 0.032) were independent predictors of survival. Predictors of lethal outcome were older age (OR [95%CI]: 1.09 [1.07-1.10], p < 0.001), male sex (OR [95%CI]: 1.24 [1.00-1.55], p = 0.049), premorbid disability (OR [95%CI]: 1.47 [1.08-2.02], p = 0.016), active smoking (OR [95%CI]: 1.51 [1.06-2.14], p = 0.023), anticoagulation therapy prior to LVO (OR [95%CI]: 1.45 [1.09-1.92], p = 0.010), stroke etiology, general anaesthesia during MT (OR [95%CI]: 1.31 [1.02-1.69], p = 0.035) and intracerebral haemorrhage (OR [95%CI]: 1.50 [1.13-1.99], p = 0.005).

Conclusions: Lethal outcome after hospital discharge within 3 months after MT is frequent, accounting for more than one quarter of overall 3-month mortality after MT of LVO. Predictors of survival enable individual outcome prognostication, which assists clinical decision-making with regard to surveillance concerning complications, rehabilitative resource allocation and counselling about goals of care.

Trial registration: ClinicalTrials.gov (Identifier: NCT03356392, Date of registration: 2017/11/22).

This letter to the editor aims to comment on the article « User expectations and experiences of an assistive robotic arm in amyotrophic lateral sclerosis: a multicenter observational study » recently published by Spittel et al. (Neurol Res Pract, 6(1), 42).