The Doctor's Channel - Neurology & Neurosurgery

3-pronged treatment improves outcomes in neonatal post-bleeding ventricular dilatation

2010-03-12T20:56:51+00:00

NEW YORK (Reuters Health) - A treatment called DRIFT (Drainage, Irrigation, and Fibrinolytic Therapy) may improve developmental outcomes and survival in preterm infants with posthemorrhagic cerebral ventricular dilatation, new research suggests.

Definitive conclusions can't be drawn as the trial was stopped early, partly due to a higher risk of secondary intraventricular bleeding with DRIFT. But clinically speaking, infants treated with DRIFT were better off two years later than those given standard therapy.

"Premature infants with posthemorrhagic ventricular dilatation have a high rate of severe cognitive and motor disabilities, but no intervention has been shown to improve outcome," lead author Dr. Andrew Whitelaw, from the University of Bristol Medical School, U.K., and colleagues note.

"Secondary cerebral injury may be caused by free radicals, inflammation, and pressure," the authors explain. Drainage, irrigation, and fibrinolysis address all these mechanisms and could potentially improve patient outcomes.

As they report in the April issue of Pediatrics, the researchers randomized 77 preterm infants with posthemorrhagic ventricular dilatation to receive DRIFT (n = 39) or standard treatment (n = 38), which included drainage of cerebrospinal fluid to control ventricular expansion.

By two years of corrected age, 3 children in the DRIFT group and 5 in the control group had died, and 18 and 22 in the DRIFT and control groups, respectively, were severely disabled.

Therefore, rates of the primary endpoint - death or severe disability - were 54% with DRIFT versus 71% with standard care (adjusted OR, 0.25).

"Severe cognitive disability was nearly halved" with DRIFT, the authors report. Specifically, 11 survivors in the DRIFT group (31%) had severe cognitive impairment, versus 19 of 33 (58%) in the control group (aOR, 0.17), as measured by the Bayley Mental Development Index. The median Mental Development Index score in the DRIFT group was also better: 68 vs. <50.

DRIFT did not improve rates of sensorimotor disability, however.

The research team comments that their results "raise a difficult dilemma in trial management." Given that the interim analysis showed increased intracerebral bleeding and no decrease in the need for shunts with DRIFT, "few would have taken responsibility in 2007 for continuing to recruit" to this trial. But today, the authors continue, the two study groups have a difference of more than 18 points on the Mental Development Index score, "which most families and clinicians would rate as important."

With the caveat that their population was small and the trial was stopped early, the researchers still conclude: "Despite an increase in secondary intraventricular bleeding, DRIFT reduced severe cognitive disability in survivors and overall death or severe disability."

Reference:
Pediatrics 2010;125:e852-e858.

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Magnetic stimulation shows promise for migraine with aura

2010-03-08T19:29:41+00:00

NEW YORK (Reuters Health) – A portable magnetic stimulation device is a promising noninvasive, drug-free treatment for acute migraine with aura, according to a March 4th online report in The Lancet Neurology.

However, although the single-pulse transcranial magnetic stimulation (TMS) was more effective than sham treatment, most patients still had some pain, the report indicates.

Transcranial magnetic stimulation has been “tested in individuals with migraine based on the hypothesis that a fluctuating magnetic field…applied to the back of the head, would induce electrical current and disrupt cortical spreading depression,” lead author Dr. Richard B. Lipton, from Albert Einstein College of Medicine, Bronx, New York, and co-researchers explain.

In the current study, Dr. Lipton’s team assessed response rates in 201 patients with migraine with aura who took home the hand-held Cerena Transcranial Magnetic Stimulator for TMS, or an identical sham device.

Over the 3-month study period, patients treated up to three migraine attacks while experiencing aura. Thirty-seven participants did not treat a migraine attack and were excluded from further analysis.

The main outcome -- no pain 2 hours after the first attack – occurred in 39% of TMS patients and 22% of sham treatment patients (p = 0.0179). Rates of sustained pain-free response at 24 hours were 29% vs. 16% and at 48 hours, 27% vs. 13% (p < 0.05 for both).

Non-inferiority analysis indicated that TMS was at least as effective as sham treatment in combating nausea, photophobia, and phonophobia.

No serious device-related events occurred, and the rate and severity of events was comparable in each patient group.

“For patients who commonly have aura as a signal of an impending migraine, treatment with single-pulse TMS may abort progression of the attack and abate disabling pain and other symptoms,” the authors conclude.

Because there is evidence of cortical spreading depression in migraine without aura, it is possible that TMS may be an effective treatment for these headaches as well, they add.

In an editorial, Dr. Hans-Christoph Diener of University Hospital Essen in Germany writes that with more research, “the use of TMS could be a major step forward in the treatment of migraine with aura, particularly in patients in whom presently available drug treatment is ineffective, poorly tolerated, or contraindicated.”

Reference:
Lancet Neurol 2010.

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EMR rebate

2010-03-08T16:09:38+00:00

Micheal Swiernik, MD, Director, Medical Informatics, UCLA, discusses the considerations before purchasing an EMR that suits your workplace, and the costs associated with implementing this into your practice in a cost-effective manner.

Reading:
Terry AL, Chevendra V, Thind A, Stewart M, Marshall JN, Cejic S. Using your electronic medical record for research: a primer for avoiding pitfalls. Fam Pract. 2009 Oct 14.
Joe RS, Kushniruk AW, Borycki EM, Armstrong B, Otto T, Ho K. Bringing electronic patient records into health professional education: software architecture and implementation. Stud Health Technol Inform. 2009;150:888-92.
McGrath D. Using a phased-in incremental approach to EMR implementation. J Med Pract Manage. 2009 May-Jun;24(6):355-7.

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iBrain

2010-03-08T16:05:37+00:00

Gary Small, MD, Director, UCLA Center on Aging, UCLA, discusses his new book, ibrain, and talks about the younger digital generation who do not have the face-to-face communication skills of older generations, and how both generations can learn from each other.

Reading:
iBrain Surviving the Technological Alteration of the Modern Mind By Dr. Gary Small, Gigi Vorgan
van Gerven M, Farquhar J, Schaefer R, Vlek R, Geuze J, Nijholt A, Ramsey N, Haselager P, Vuurpijl L, Gielen S, Desain P. The brain-computer interface cycle. J Neural Eng. 2009 Aug;6(4):041001. Epub 2009 Jul 22. Review.
Guger C, Daban S, Sellers E, Holzner C, Krausz G, Carabalona R, Gramatica F, Edlinger G. How many people are able to control a P300-based brain-computer interface (BCI)? Neurosci Lett. 2009 Oct 2;462(1):94-8. Epub 2009 Jun 21.

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Stem cell use in spine surgery

2010-03-08T15:48:53+00:00

Arya Nick Shamie, MD, Associate Professor of Orthopedic Surgery and Neurosurgery, UCLA David Geffen School of Medicine, discusses the use of stem cells in spinal surgery to grow new bone, thus minimizing the need for painful bone grafts.

Reading:
Smoljanovic T, Siric F, Bojanic I. Complications associated with use of bone-morphogenetic proteins in spinal fusion procedures. JAMA. 2009 Nov 18;302(19):2090-1; author reply 2091
Axelrad TW, Einhorn TA. Bone morphogenetic proteins in orthopaedic surgery. Cytokine Growth Factor Rev. 2009 Oct-Dec;20(5-6):481-8. Epub 2009 Nov 4.
Maeda T, Buchowski JM, Kim YJ, Mishiro T, Bridwell KH. Long adult spinal deformity fusion to the sacrum using rhBMP-2 versus autogenous iliac crest bone graft. Spine (Phila Pa 1976). 2009 Sep 15;34(20):2205-12.

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Strabismus

2010-03-08T15:33:16+00:00

Joseph Demer, MD, Professor of Opthalmology and Neurology, UCLA David Geffen School of Medicine, discusses strabismus and describes mechanical causes versus neurological causes of this eye condition. If the extraocular muscles can be shown by clinical examination to be generating a normal amount of force, then causes such as thyroid opthalmopathy, eye socket trauma or a vascular lesion must be sought. Also to be considered are the ligaments around the extra-ocular muscles.

Reading:
Bosman J, ten Tusscher MP, de Jong I, Vles JS, Kingma H. The influence of eye muscle surgery on shape and relative orientation of displacement planes: Indirect evidence for neural control of 3D eye movements. Strabismus. 2002 Sep;10(3):199-209.
Dickey CF, Scott WE, Cline RA.Oblique muscle palsies fixating with the paretic eye. Surv Ophthalmol. 1988 Sep-Oct;33(2):97-107. Review.
Siepmann K, Herzau V.[Is congenital superior oblique strabismus a paretic disorder?--A magnetic resonance tomographic study] Klin Monbl Augenheilkd. 2005 May;222(5):413-8. German.

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Scans for headaches

2010-03-08T15:29:28+00:00

Andrew Charles, MD, Professor, Director of Headache Research and Treatment Program, UCLA David Geffen School of Medicine, discusses when to get a scan for a headache and the red flags that doctors must watch for. These include new onset of headache in someone over 50, abrupt onset of headache, headache associated with systemic symptoms or neurologic symptoms.

Reading:
Mehle ME, Kremer PS. Sinus CT scan findings in "sinus headache" migraineurs. Headache. 2008 Jan;48(1):67-71.
Knotkova H, Pappagallo M. Imaging intracranial plasma extravasation in a migraine patient: a case report. Pain Med. 2007 May-Jun;8(4):383-7.
Paulson EP, Graham SM. Neurologic diagnosis and treatment in patients with computed tomography and nasal endoscopy negative facial pain. Laryngoscope. 2004 Nov;114(11):1992-6.

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Ethosuximide beats lamotrigine and valproic acid for childhood absence epilepsy

2010-03-05T21:46:36+00:00

NEW YORK (Reuters Health) – Ethosuximide and valproic acid are more effective than lamotrigine for treating childhood absence epilepsy, the most common pediatric epilepsy syndrome, according to a report in The New England Journal of Medicine for March 4.

Of the two favored drugs, ethosuximide may be preferred due to a lower rate of attentional dysfunction, the findings suggest.

Each of the three drugs is often used as initial monotherapy for childhood absence epilepsy, “but definitive evidence of their relative efficacy is lacking,” lead author Dr. Tracy A. Glauser, from Cincinnati Children’s Hospital, Ohio, and colleagues note.

The current study randomized 453 newly diagnosed children to treatment with either ethosuximide (Zarontin), lamotrigine (Lamictal), or valproic acid (Depakote). The researchers increased the dose until the child was seizure free, the maximum allowable or highest tolerable dose was reached, or it was clear that treatment had failed.

At 16 weeks, more than half the children taking ethosuximide (53%) and valproic acid (58%) were free of treatment failure, compared to only 29% of children taking lamotrigine (p < 0.001).

Children on valproic acid had a higher rate of attentional dysfunction than children on ethosuximide: 49% vs. 33% (p = 0.03).

Rates of discontinuation for adverse effects, were similar with the three agents, the report indicates.

“This is an age when the newest therapy is assumed to more effective and better tolerated than older therapies,” Dr. Eileen P. G. Vining, from Johns Hopkins University School of Medicine, Baltimore, comments in a related editorial.

But in this case, she continues, the researchers’ “robust evaluation” of the three anticonvulsants has shown “the winner” to be ethosuximide, a “drug from the 1950s and the oldest of the three.”

Reference:
N Engl J Med 2010;362:790-799,843-845.

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Without thrombolysis, women fare worse than men after stroke

2010-03-04T15:20:25+00:00

NEW YORK (Reuters Health) – Thrombolysis is a must for female stroke patients if they are to achieve the same outcomes as men, according to a March 2nd report in the Neurology.

“Women need to be treated for stroke as soon as possible,” senior author Dr. Michael D. Hill, from the University of Calgary, Alberta, Canada, said in a statement. “We found that women who weren’t treated had a worse quality of life after stroke than men. However, the good news is that women who were treated responded just as well as men to the treatment.”

The findings are drawn from registry data on 2113 stroke patients treated all across Canada, from June 2001 to February 2002 and from June to December 2002. Women accounted for 43.5% of the cohort.

The primary outcomes were the score on the Stroke Impact Scale-16 score and mortality at 6 months.

Without tissue plasminogen activator (tPA), 70% of men but only 58% of had good outcomes, defined as a score of at least 75 on the Stroke Impact Scale-16 (p < 0.001). With tPA thrombolysis, however, women were just as likely as men to have good outcomes.

Mortality was comparable for men and women whether or not tPA was used.

After adjusting for age, stroke severity, and the time from symptom onset to arrival in the emergency department, gender was found to influence the Stroke Impact Scale-16 score, but not mortality.

Exactly why untreated women fare worse than untreated men is unclear, Dr. Hill said in the statement.

Biologic reasons could explain the difference, he noted. Or older women might be less likely than older men to have a surviving spouse who can assist them in their stroke recovery. In addition, post-stroke depression, which can slow recovery, is more common in women.

Reference:
Neurology 2010;74:767-771.

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Surgery favored over stenting for symptomatic carotid stenosis

2010-03-02T20:01:51+00:00

NEW YORK (Reuters Health) - Interim data from a 3-year trial of stenting versus endarterectomy for symptomatic carotid stenosis suggests that for now at least, surgery should remain the procedure of choice.

The report, which appears in the February 26th online issue of The Lancet, presents the 120-day rates of stroke, death, or procedural myocardial infarction (MI) from the ongoing International Carotid Stenting Study (ICSS).

Overall, the ICSS includes 1713 patients randomized to undergo stenting or endarterectomy for symptomatic carotid stenosis.

Dr. Martin M. Brown, from University College London, and colleagues report that by 120 days, the rate of disabling stroke or death in the stenting group was 4.0% compared with 3.2% in the surgery group (HR, 1.28). The corresponding stroke, death, or procedural MI rates were 8.5% and 5.2% (HR, 1.69, p = 0.006).

Compared with surgery patients, patients with stents were nearly twice as likely to have a stroke during follow-up and almost three times as likely to die from any cause.

More procedural myocardial infarctions occurred in the surgery group than in the stenting group (4 vs. 3) - but all of these events in the stenting group were fatal, whereas none of the surgery patients died from procedure-related MI.

Cranial nerve palsy was less common with stenting than with surgery: 1 vs. 45. Likewise, fewer stenting patients had hematomas: 31 vs. 50 events.

In addition, an ICSS substudy that focused on magnetic resonance imaging results -- also appearing online February 26th, but in The Lancet Neurology - found fewer new ischemic brain lesions in the endarterectomy group versus the stenting group.

The substudy featured 124 stenting patients and 107 surgery patients who underwent diffusion-weighted MRI within the week before treatment and 1-3 and 27-33 days afterward.

Lead author Dr. Leo H Bonati from Hospital Basel, Switzerland and colleagues report that in the first few days after treatment, the percentage of patients with new ischemic brain lesions was much higher in the stenting group: 50% vs. 17% (p < 0.0001). The difference was even more pronounced when the analysis was limited to centers that typically use cerebral protection devices: 73% vs. 17%.

At 1 month, 33% of stenting patients had evidence of persistent brain injury, versus 8% of surgery patients (p = 0.0003).

In an editorial in The Lancer Neurology, Dr. Klaus Groschel, from Georg-August-Universitat Gottingen, Germany, comments that the present findings suggest that "the widespread use of carotid stenting, especially its routine use as first-choice treatment for symptomatic carotid stenosis, does not seem to be justified for the time being."

Currently, he notes, the bulk of data supports endarterectomy over stenting. However, he emphasizes that this does not necessarily mean the two approaches can't co-exist, as certain patients may be better served by stenting.

Reference:
Lancet 2010.
Lancet Neurology 2010.

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