What’s new in Alzheimer, stroke, and more
From promises of a cancer blood test, to a surefire screening tool for Alzheimer disease regardless of stage, researchers in the neurology field have our heads spinning (pun not intended)! Here are just some of the latest updates from around the world.
Around this time 25 years ago, Alfred G. Gilman and Martin Rodbell shared the Nobel Prize for their discovery of G-protein coupled receptors and their role in cellular signal transduction, which was previously unknown. This discovery paved the way for new insights into diseases in which G-proteins are affected, such as cholera, where the dramatic losses of both salt and water are a direct consequence of the effects of the cholera toxin on G-proteins. Other examples include the hereditary endocrine disorder, and McCune-Albrights syndrome, which is the consequence of overactive G-proteins.
A blood test for cancer? Distinct blood mRNA expression profiles may be markers for cancer-related acute ischemic stroke. Researchers found evidence for a distinctive molecular signature in the blood mRNA expression profiles of patients with cancer-related acute ischemic stroke. In comparing those with cancer-stroke vs those with stroke only and considering cancer-only genes, they found that 438 genes were expressed differently in those with cancer-stroke. In the future, they hope to assess whether blood mRNA will help detect cancer in patients with acute ischemic stroke.
MRI can identify occlusion site and collateral perfusion in acute ischemic stroke. Researchers compared arterial spin labeling (ASL) MRI with digital subtraction angiography (DSA) to identify occlusion site and collateral perfusion in patients presenting with acute ischemic stroke, using DSA as the gold standard. They found a sensitivity of 82.8 with ASL and a specificity of 100% in identifying occlusion site. In identifying collateral flow, these rates were 96.7% and 50.0%, respectively. Inter-rater reliability was also excellent for proximal intra-arterial sign, and was significant in detecting distal intra-arterial sign. They concluded that, in these patients, important diagnostic clues for the detection of arterial occlusion sites and collateral perfusion can be gleaned from ASL imaging of both proximal and distal intra-arterial signs.
A handy way to diagnose underlying neurological disease? Sign us up! Watch for increased levels of cerebrospinal fluid (CSF) biomarkers in patients with neurological symptoms, but no neurological disease. Researchers included 990 patients seeking medical attention for neurological symptoms largely considered to be caused by neurological disease. Nine hundred received a final neurological diagnosis. In these remaining patients, age adjusted CSF-NF-L, CSF-t-tau, and CSF-GFAP levels were normal in 98.9%, 95.6%, and 96.7%, respectively. Researchers concluded that in patients with significant neurological symptoms for which neurological diagnosis cannot be made, CSF markers (NF-L, t-tau, and GFAP) were not increased. Therefore, in any patient with neurological symptoms, but no neurological disease in whom increased levels of these CSF markers are recorded, suspicions of underlying neurological disease should be raised and merit further investigation.
You won’t forget this! Researchers have found an easier way to screen for Alzheimer. Fully automated plasma assays effectively screen for disease-related ß-amyloid status, according to results from two prospective, cross-sectional, multicenter studies. They found that measurement of plasma Aß42 and Aß40 using Elecsys immunoassays accurately predicted Aß status in all stages of Alzheimer disease. They noted the future applications of such screening for Aß positivity, including its use in clinical trials of Alzheimer disease to effectively reduce the number and costs of PET scanning and lumbar punctures in enrolled patients.
Big news from a large, international study: Neuromyelitis optic spectrum disorder (NMOSD) is currently untreatable; however, researchers found that inebilizumab—a humanized IgG monoclonal antibody with high affinity for CD19 may reduce the risk of attacks. In the multicenter, double-blind, randomized, placebo-controlled, phase 2/3 N-Momentum trial conducted in 25 countries, inebilizumab reduced the risk of an attack of NMOSD. More good news is that the side-effect profile/rates were similar to those seen with placebo. Based on these results, the FDA has accepted for review the Biologics License Application for inebilizumab for the treatment of patients with NMOSD.
Watch for rhabdomyolysis in patients on donepezil. This drug—commonly used to manage symptoms of dementias—is associated with a two-fold higher risk of hospitalization for rhabdomyolysis in patients, according to a recent study published in the Canadian Medical Association Journal. Researchers specified that, while the relative risk was small, it was statistically significant. Most hospital admissions were not severe.
For the treatment of Alzheimer disease, researchers showed the promise of transcranial electromagnetic treatment (TEMT) in enhancing memories and cognitive function. TEMT increases functional connectivity within the cingulate cortex, and is purported to penetrate the brain to disperse both amyloid-beta and tau deposits. Researchers shared results from their open-label clinical trial in eight patients with mild to moderate Alzheimer disease in the Journal of Alzheimer’s Disease. After only 2 months of treatment, done in-home, seven patients showed enhanced cognitive performance as measured by Alzheimer’s Disease Assessment Scale-Cognitive Subscale (ADAS-cog) score.
Heard of universal vaccines? Get ready for a universal treatment for neurodegenerative diseases. Researchers have made a potentially enlightening discovery in patients with neurodegenerative diseases. They found a potentially new approach to reduce nerve-cell apoptosis in several neurodegenerative diseases, and published their results in Nature Neuroscience. In patients with Alzheimer disease, Huntington disease, and amyotrophic lateral sclerosis, researchers found that two types of normally protective cells—specifically, glial cells—may be responsible for initiating neuronal destruction. In this pre-clinical study, they used the peptide P110 to block Drp-1-induced mitochondrial fission in damaged cells. Sustained P110 treatment through a subcutaneous pump over several months lowered both microglial and astrocytic activation and inflammation in the brains of mice.
New in Patient Management
Be on alert for covert stroke. Researchers of the NeuroVISION study—conducted in over 1,100 patients aged 65 years or older who underwent elective major noncardiac, noncarotid surgery—found that perioperative covert stroke occurred in 7% of patients, and was associated with an increased risk of cognitive decline at 1 year.
And, speaking of stroke: Hold back on intensive glucose control in your acute stroke patients, say researchers of the SHINE randomized clinical trial. Intensive treatment of hyperglycemia with insulin infusion toward a target glucose of 80-130 mg/dL does not improve 90-day functional outcomes compared with subcutaneous insulin on a sliding scale with a target glucose of 80-179 mg/dL, according to results published in JAMA. The research team also found that patients in the intensive treatment group were more likely to require treatment withdrawal due to hypoglycemia and other adverse events. They concluded that there is no place for the intensive treatment of hyperglycemia in the acute stroke setting, although severe hypoglycemia may be treated with standard interventions including subcutaneous insulin.
So many tests, so little time. Antibody testing in children with demyelinating syndromes may be unnecessary, according to a new study. Researchers found that in children with demyelinating syndromes, anti-myelin oligodendrocyte glycoprotein (MOG) autoantibodies are of little use, contrary to what has been suggested by previous researchers. In results published in JAMA Neurology, researchers concluded that treatment decisions for children with chronic immune therapy after their initial episode of a demyelinating syndrome should not be taken based on the persistence of anti-MOG-antibodies. Most children, they found, will remain monophasic regardless of their anti-MOG-antibody status.
Finally, some good news for patients and physicians. Antiplatelet therapy after intracerebral hemorrhage is safe and not associated with all-cause mortality or functional outcomes, according to a meta-analysis of data from the Massachusetts General Hospital ICH registry, the Virtual International Stroke Trials Archive database, and the Yale stroke registry. Although more studies are needed, this is good news because until now, only observational data were available on the benefits of antiplatelet therapy after intracerebral hemorrhage.
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Medical Meetings This Month:
If you didn’t catch the American Neurological Association’s 144th Annual Meeting, we’ve got you covered! Here’s what you missed.
48th Child Neurology Society (CNS) Annual Meeting CME in Charlotte, NC, October 23-26, 2019