Current Treatment Options in Neurology

PURPOSE OF REVIEW: To summarize recent changes in management and emerging therapies for pregnant neurocritical care patients. RECENT FINDINGS: Diagnostic and treatment options for managing neurologic emergencies in pregnant patients have expanded with both greater understanding of the effects of imaging modalities and medications on pregnancy and application of standard treatments for non-pregnant patients to pregnant populations. Specifically, this includes cerebrovascular diseases (pregnancy-associated ischemic stroke, pregnancy-associated intracerebral hemorrhage, cerebral venous sinus thrombosis), post-maternal cardiac arrest care, seizures and status epilepticus, myasthenia gravis, and fetal somatic support in maternal death by neurologic criteria...

PURPOSE OF REVIEW: This review presents a comprehensive analysis of the current high-efficacy disease-modifying therapies (DMTs) available for treatment of multiple sclerosis (MS). We discuss the existing approved and emerging therapeutics in patients with relapsing and progressive forms of MS using data from clinical trials and observational studies. Treatment considerations in pediatric and pregnant populations are also reviewed. Finally, we discuss the treatment paradigms of the escalation and early aggressive approaches to treatment of MS, with review of ongoing clinical trials to compare these approaches...

PURPOSE OF REVIEW: This review presents the most current recommendations for providing nutrition to the neurocritical care population. This includes updates on initiation of feeding, immunonutrition, and metabolic substrates including ketogenic diet, cerebral microdialysis (CMD) monitoring, and the microbiome. RECENT FINDINGS: Little evidence exists to support differences in feeding practices among the neurocritical care population. New areas of interest with limited data include use of immunonutrition, pre/probiotics for microbiome manipulation, ketogenic diet, and use of CMD catheters for substrate utilization monitoring...

PURPOSE: Extracorporeal membrane oxygen (ECMO) is increasingly used as an advanced form of life support for cardiac and respiratory failure. Unfortunately, in infrequent instances, circulatory and/or respiratory recovery is overshadowed by neurologic injury that can occur in patients who require ECMO. As such, knowledge of ECMO and its implications on diagnosis and treatment of neurologic injuries is indispensable for intensivists and neurospecialists. RECENT FINDINGS: The most common neurologic injuries include intracerebral hemorrhage, ischemic stroke, seizure, cerebral edema, intracranial hypertension, global cerebral hypoxia/anoxia, and brain death...

PURPOSE OF REVIEW: This review presents an overview of the known neurocritical care complications of severe acute respiratory virus 2 (SARS-CoV-2). We present readers with a review of the literature of severe neurologic complications of SARS-CoV-2 and cases from our institution to illustrate these conditions. RECENT FINDINGS: Neurologic manifestations are being increasingly recognized in the literature. Some patients can have severe neurologic manifestations, though the true prevalence is unknown...

PURPOSE OF REVIEW: This review discusses the current treatment trends and emerging therapeutic landscape for patients with neuromyelitis optica spectrum disorder (NMOSD). RECENT FINDINGS: Conventional immune suppressive therapies, such as B cell depletion, have been used for long-term treatment. However, the availability of recent FDA-approved and investigational drugs has made therapeutic choices for NMOSD more complex. SUMMARY: Recent randomized clinical trials have shown that eculizumab, inebilizumab, and satralizumab are efficacious therapies for AQP4 seropositive NMOSD...

PURPOSE OF REVIEW: We review data available for treatment of multiple sclerosis (MS) before, during, and after pregnancy. We present recent data on disease-modifying therapies (DMT) before/during pregnancy and while breastfeeding, with treatment recommendations. RECENT FINDINGS: Observational data support the safety of injectable DMTs (glatiramer acetate, interferon-beta) for use in pregnancy, while some oral DMTs might be associated with fetal risk. Monoclonal antibodies (mAbs) before pregnancy such as rituximab or natalizumab likely do not pose significant fetal risks, but can cross the placenta with neonatal hematological abnormalities if given in the second trimester or later...

PURPOSE OF REVIEW: The fastest-growing group of elderly individuals is the "oldest-old," usually defined as those age 85 years and above. These individuals account for much of the rapid increase in cases of dementing illness throughout the world but remain underrepresented in the body of literature on this topic. The aim of this review is first to outline the unique contributing factors and complications that must be considered by clinicians in evaluating an oldest-old individual with cognitive complaints...

PURPOSE OF REVIEW: Giant cell arteritis (GCA), a medium and large vessel vasculitis occurring in the aged, remains a formidable disease, capable of taking both vision and life, through a multitude of vascular complications. Our understanding of the spectrum of its manifestations has grown over the years, to include limb claudication, aortitis, and cardiac disease, in addition to the more classic visual complications resulting from of ischemia to branches of the external and internal carotid arteries...

PURPOSE OF REVIEW: The purposes of this narrative review are to (1) summarize a contemporary view of cerebral edema pathophysiology, (2) present a synopsis of current management strategies in the context of their historical roots (many of which date back multiple centuries), and (3) discuss contributions of key molecular pathways to overlapping edema endophenotypes. This may facilitate identification of important therapeutic targets. RECENT FINDINGS: Cerebral edema and resultant intracranial hypertension are major contributors to morbidity and mortality following traumatic brain injury...

OPINION STATEMENT: PURPOSE OF REVIEW: In this review, we discuss current treatment options for commonly encountered neuromuscular disorders in intensive care units. We will discuss epidemiology, pathophysiology, and acute and chronic treatment options for myasthenia gravis, Guillain-Barré syndrome, West Nile virus, Botulism, and amyotrophic lateral sclerosis. RECENT FINDINGS: Eculizumab is the newest immunomodulator therapy approved by the Food and Drug Administration in treatment of myasthenia gravis, shown to improve long-term functional outcomes...

PURPOSE OF REVIEW: The purpose of this review is to highlight advances in the management of seizures in brain metastases from solid tumors. RECENT FINDINGS: The highest risk for seizures is in patients with melanoma and lung cancer. There is lack of data on the efficacy of antiepileptic drugs (AEDs), but interactions between enzyme-inducing AEDs and anticancer agents must be avoided. Levetiracetam and valproic acid are the most appropriate drugs. Prophylaxis with AEDs for patients with brain metastases without a history of seizures is not recommended...

PURPOSE OF REVIEW: Mobile stroke units (MSUs) have revolutionized emergency stroke care by delivering pre-hospital thrombolysis faster than conventional ambulance transport and in-hospital treatment. This review discusses the history of MSUs technological development, current operations and research, cost-effectiveness, and future directions. RECENT FINDINGS: Multiple prospective and retrospective studies have shown that MSUs deliver acute ischemic stroke treatment with intravenous recombinant tissue plasminogen activator (IV r-tPA) approximately 30 min faster than conventional care...

PURPOSE OF THE REVIEW: There is strong evidence for a bidirectional association between sleep disorders and Alzheimer's disease (AD). In particular, insomnia may be a potentially modifiable risk factor for AD. The present review summarizes recent advances in treatment of sleep disorders in AD. RECENT FINDINGS: Some studies investigated the efficacy and safety of hypnotic agents as ramelteon and mirtazapine to treat sleep disorders in AD but no significant therapeutic effects have been observed...

PURPOSE OF REVIEW: This review provides the reader with updated information needed to make an accurate diagnosis of radiologically isolated syndrome (RIS), discusses controversies and considerations related to therapeutic intervention in RIS, and summarizes ongoing clinical intervention trials. RECENT FINDINGS: Individuals with RIS lack clinical neurological symptoms but are at risk for the subsequent development of a first clinical neurological event consistent with a diagnosis of multiple sclerosis...

PURPOSE OF REVIEW: The purpose of this review is to summarize and discuss current options and new advances in the treatment of sleep-related hypermotor epilepsy (SHE), focusing on pharmacological and surgical treatments. RECENT FINDINGS: Carbamazepine (CBZ) has traditionally been regarded as the first-line treatment option in SHE patients. In patients showing an unsatisfactory response to monotherapy, topiramate (TPM), lacosamide (LCM) and acetazolamide (ACZ) could be reasonable add-on strategies...

PURPOSE OF REVIEW: Narcolepsy type 1 (NT1) is a chronic and disabling sleep disorder due to the loss of hypocretinergic neurons in the lateral hypothalamus pathophysiologically linked to an autoimmune process. Current treatment is symptomatic, and no cure is available to date. Immunotherapy is considered a promising future therapeutic option, and this review discusses the rationale for immunotherapy in narcolepsy, current evidences of its effects, outcome measures, and future directions...

PURPOSE OF REVIEW: This article provides a brief overview of the history and complexities of brain death determination. We examine a few legal cases that highlight some of the controversies surrounding the validity of brain death tests in light of varying state laws and institutional policy, the appropriateness of making religious accommodations, the dilemma of continuing organ-sustaining support in a pregnant brain-dead patient, and the issue of whether to obtain informed consent from surrogate decision makers before proceeding to testing...

Purpose of review: To elucidate the intertwining of vascular events, vascular disease and vascular risk factors and COVID-19. Recent findings: Strokes are a leading cause of disability and death worldwide. Vascular risk factors are important drivers of strokes. There are unmodifiable vascular risk factors such as age and ethnicity and modifiable vascular risk factors. According to the INTERSTROKE study, the 10 most frequent modifiable vascular risk factors are arterial hypertension, physical inactivity, overweight, dyslipidaemia, smoking, unhealthy diet, cardiac pathologies, diabetes mellitus, stress/depression and overconsumption of alcohol...

Objective: To characterize my experience in the inpatient stroke service in an amusing fashion. Background: The COVID-19 pandemic broke out during my time as a stroke fellow. It was a unique experience. Methods: A non-exhaustive review of my memories as a stroke fellow during the COVID-19 pandemic was performed. I sat down and wrote the article. Then, I illustrated the figure. Results: All results are not statistically significant unless otherwise noted...