Neuro 2020: Sneak peek at clinical advancements; CBD benefits for seizure; and more
It’s the last stretch of holiday panic, and things are hectic. As the year—and decade—come to an end it’s important look back on all that’s happened over the past year, from revolutionary drugs receiving FDA approval, to groundbreaking research in neurology and other fields, there’s no doubt that it’s been a year of medical innovation.
But let’s focus on what’s to come in 2020: Machine learning diagnostics that predict Parkinson disease at over 90% accuracy, a novel therapeutic to replace existing first-line therapy for relapsing multiple sclerosis, and more. 2020 seems to be a promising year in clinical advancement.
So, instead of venturing out to the mall and dealing with all those crazed holiday shoppers (and drivers!), grab a cuppa’ joe and catch up on the latest neuro updates. We’ll give you all that, plus the latest neuro news from this past week.
It was 202 years ago that Parkinson disease was first medically described as a neurological syndrome by James Parkinson. He reported six case sketches, and described the clinical picture as such:
“Involuntary tremulous motion, with lessened muscular power, in parts not in action and even when supported; with a propensity to bend the trunk forward, and to pass from a walking to a running pace: the senses and intellects being uninjured.”
Pretty good, considering that he observed three of these six individuals on the streets of London, one of whom he only saw from a distance, no?
In the News
More than just the winter blues. The brains of children of depressed parents may actually undergo structural changes. In the largest brain imaging study of children ever done in the United States, researchers found structural differences in the brains of those whose parents had depression. These changes were specifically in the right putamen, which is linked to reward, motivation, and feelings of pleasure. In the past, other studies have shown that these kids are more likely to develop depression than those whose parents aren’t depressed. But, it wasn’t until now that we knew why.
In a recently published study, researchers looked at brain images from more than 7,000 children included in the Adolescent Brain Cognitive Development study, and found that a full one-third were at high-risk because they had a parent with depression. In these kids, the right putamen was found to be smaller than in those kids with no parental history of depression. So, what does all this mean? Smaller putamen volumes have been linked to anhedonia, or the lessened ability to experience pleasure—a factor in depression, substance abuse, psychosis, and even suicidal behaviors. These researchers are in the midst of a 10-year follow-up of these children, and plan to find out whether reduced putamen volumes are associated with depression or other mental disorders.
This is your brain on sports. Playing sports—including football, soccer, and hockey—can do great things for your brain, according to a recent study from researchers at Northwestern University. In fact, they found that athletes’ brains are better at blocking out the background noise of the brain to process external sounds.
In this latest study from the Neural Processing of Sound in Sports Concussions and Contact Sports partnership (an NIH-funded collaboration between Brainvolts and Northwestern University Athletics), researchers studied the brain health of 495 Northwestern student athletes and 493 age- and sex-matched controls. They analyzed the ratio of background noise in the brain to the brain’s response to sound as the students listened to speech syllables through earbuds. They found that athletes had larger responses to sound compared with non-athletes, mainly because they could block out the background noise better. Think that’s impressive? What if we told you that the background noise here is actually the background electrical noise of the brain, which the researchers likened to static on the radio? Simply put, athletes’ brains were better at blocking out the brain’s background static, and could better focus in on the important sounds.
What neurological disease usually results in death by the age of 4? Tay-Sachs disease is a rare, inherited disorder that progressively destroys neurons in the brain and spinal cord. It was named after Warren Tay and Bernard Sachs, who—in 1881 and 1887—were the first to describe the characteristic eye abnormality (a cherry-red spot) and the cellular changes of the disease, respectively. The most common form of Tay-Sachs occurs in infancy, and causes slowed development, muscle weakness, loss of motor skills, and exaggerated startle reactions. Children with the severe infantile form of Tay-Sachs disease sadly only live into early childhood, rarely past the age of 4. Tay-Sachs is more common in those of Ashkenazi Jewish heritage (as Bernard Sachs also discovered), in certain French-Canadian communities of Quebec, in the Old Order Amish community in Pennsylvania, and in the Cajun population of Louisiana. So for everyone complaining about getting older, remember this: aging is just a sign that you’re still alive.
Looking ahead to 2020: Parkinson disease. It’s looking like 2020 is the year for wearables. In patients with Parkinson disease, machine learning applications will provide better diagnostic support, as well as better disease monitoring and assessment, according to a review published in Clinical Neurology and Neurosurgery. Simple wearable instruments—combined with supervised machine learning algorithms—will, in the future, provide significant diagnostic support, and have the ability to discriminate between PD patients and healthy subjects, with over 90% accuracy. These wearable sensor devices are affordable and permit patient monitoring in any environment. Using integrated inertial sensors, smartphones will also prove a useful tool for diagnosis. The keys to these technologies are that they are accessible, inexpensive, easy to use, and affordable. In addition, the Artificial Neural Network has the most successful algorithm for early PD diagnostics, with an accuracy above 95% using characteristics taken from gait force patterns. And, for symptom severity prediction, Support Vector Machine (SVM)—on of the most commonly used machine learning algorithms—was the most successful. The best news is—there’s no need to wait for a breakthrough, we’re already there with the technology. Turns out your phone’s good for more than just cute cat videos.
Could insomnia predict later dementia? It just might, according to a recent study published in Aging & Mental Health. In this observational, case-control study, researchers analyzed data from 15,209 patients with dementia (Alzheimer, vascular, mixed, or non-specific subtypes) who were at least 65 years old when they were diagnosed, and matched them with an equal number of age- and sex-matched controls. After checking for insomnia symptoms over a 5-year period that started 10 years before dementia diagnoses, researchers found an adjusted OR for dementia in those with previous insomnia of 1.34 (95% CI: 1.20-1.50). Maybe you should keep this in mind the next time you can’t fall asleep at 3 am.
The eyes are the windows to the…brain? You might want to take a minute—or two—and check the eyes of young athletes after high-acceleration head impacts. Changes in their pupils could give you a quick assessment of the possible brain injury that may have occurred, according to new research published in the Journal of Neurosurgery.
In the study, researchers used quantitative pupillometry to check changes in pupil size and reactivity to light in seven high school football players who experienced these impacts but had no related diagnoses of concussion. The test took only 2 minutes and was done with a hand-held pupillometry device. It revealed significant decreases in pupil dilation velocity, percentage change in pupil diameter, and maximum constriction velocity. Neurocognitive testing after these impacts showed no significant changes, however. Thus, these researchers concluded that clinically asymptomatic high-acceleration head impacts may affect the brain’s reflex pathways, and a simple, easy test using pupillometry could bring to light (pun intended) possible brain injury without the need for more invasive methods.
Looking ahead to 2020: Multiple sclerosis. Ozanimod is an investigational immunomodulatory drug currently in phase 3 clinical trials for the therapy of relapsing multiple sclerosis. Produced by Celgene, ozanimod is currently under FDA review, with a decision expected by March 25, 2020. It may become a first-line oral treatment option as results of a phase 3 clinical trial, published in The Lancet Neurology, showed that ozanimod was significantly more effective than the existing first-line treatment for relapsing MS. In this study, researchers found that oral ozanimod, given once-daily, reduced the progression of disability, brought about fewer MS relapses, and decreased the number of active brain lesions compared with weekly interferon beta-1a injections. Ozanimod also caused fewer treatment-related adverse events than conventional treatment.
The dream of complete revascularization. Neurologists may have just gained a few yards in the push to achieve complete and rapid revascularization in large-vessel occlusion acute ischemic stroke. A recent study has shown that adjunctive treatment with intra-arterial urokinase after failed or incomplete mechanical thrombectomy (MT) may be safe and improve angiographic reperfusion.
When it comes to functional outcomes in patients suffering acute ischemic stroke, there’s a lot riding on complete and successful reperfusion. But, in nearly every tenth patient, reperfusion is not achievable. And even most of those treated successfully don’t achieve Thrombolysis in Cerebral Infarction grade 3 (TICI 3) reperfusion. In their study of 993 consecutive patients (100 treated with intra-intra-arterial urokinase), researchers found that adding intra-arterial urokinase did not up the risk of symptomatic intracranial hemorrhage, but did up the rates of 90-day functional independence. Although larger, randomized trials are needed, it’s nice to know that we may soon have a new way to improve reperfusion and functional outcomes in these patients.
Relapse redux. Adding satralizumab—a humanized monoclonal antibody that targets the interleukin-6 receptor—to immunosuppressant treatment may reduce the risk of relapse in patients with neuromyelitis optica spectrum disorder (NMOSD) compared with placebo. Researchers of this phase 3, randomized, double-blind, placebo-controlled trial compared satralizumab (120 mg) vs placebo in 83 NMOSD patients treated with immunosuppressants. Remarkably, relapse occurred in only 8 of the 41 patients treated with satralizumab vs 18 of the 42 in the placebo group (20% vs 43%, respectively). The new combo did not, however, have any effects on patients’ pain or fatigue levels.
CBD for tuberous sclerosis complex seizures. Highly purified cannabidiol (CBD) in an oral formulation may effectively reduce seizures associated with tuberous sclerosis complex (TSC)—a rare, autosomal dominant genetic disorder—by more than one-third, according to results just presented at the annual meeting of the American Epilepsy Society. TSC patients develop benign tumors in many parts of the body—including the brain—and these can trigger seizures. Researchers of this randomized, double-blind, controlled trial done in 46 sites in 6 countries tested highly purified CBD in oral solution (Epidiolex) at doses of 25 mg/kg/d (CBD25) or 50 mg/kg/d (CBD50) in 148 patients (median age: 11 years) for 16 weeks and compared them with 76 controls.
These were treatment-refractory patients who had tried a median of four antiepileptic drugs, currently taking a median of three. CBD-treated patients had a greater reduction in seizures than controls—49% for the CBD25 and 48% for the CBD50 vs 27% for placebo. More patients treated with CBD also had a 50% or greater reduction in seizures compared with placebo (22%). Improvements in overall condition were seen in 69% of those on CBD25 and 62% on CBD50 compared with 40% who received placebo. Although most patients had adverse events (even in the placebo group), these were mild or moderate in severity, for the most part. Overall, these findings are great news for these patients, who do not have many treatment options.
New in Patient Management
Looking ahead to 2020: Mental health. Mental health conditions will take center stage, according to a recent article in Forbes. Two factors have come into play for this prediction. First, the number of new startups that increase access to care for mental health conditions is rapidly increasing. And second, the stigma surrounding behavioral and mental health conditions has slowly decreased. This is thanks to a number of prominent public figures that have come forward to disclose their personal challenges with addiction, anxiety, depression and bipolar disorder—just to name a few. This mean we can expect to be talking about and treating more mental health conditions in 2020. Your mind will thank you.
Breast is best? Can something as natural as breastfeeding reduce postpartum relapse in women with multiple sclerosis (MS)? The answer is a resounding “yes”! Researchers conducted a systematic review and meta-analysis of 24 studies that included 2,974 women and found that breastfeeding was associated with a 43% lower rate of postpartum MS relapse compared with not breastfeeding. This is welcome news for your MS patients who have just delivered, since the postpartum period is notorious for increased MS relapses.
Stay out of the water. You may want to caution your patients with Parkinson disease (PD) against swimming if they’ve had a deep brain stimulation (DBS) device implanted to control their symptoms. Researchers have just documented the cases of nine people with implanted DBS devices who lost their ability to swim. And, all of them were good swimmers, even after receiving their diagnoses of PD. It was only after they underwent surgical implantation of the DBS device that their swimming skills seemed to decline, despite improvements with other movement symptoms. One of the swimmers—who lived on a lake—almost drowned, and two others who were competitive swimmers had problems swimming. Of these nine individuals, three reported turning off their DBS devices, and immediately regained their ability to swim thereafter.
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Upcoming Medical Meetings
46th Annual Meeting of the Southern Clinical Neurological Society (SCNS) CME, in Naples, FL, January 18-22, 2020
13th Annual Headache Cooperative of the Pacific (HCOP) Winter Conference CME, in Ojai, CA, January 24-25, 2020
12th Annual Symposium on Neurovascular Disease CME, in Santa Monica, CA, January 25, 2020
North American Neuromodulation Society (NANS) Annual Meeting CME, in Las Vegas, NV, January 23-26, 2020