Bret S. Stetka, MD

Disclosures

May 01, 2014

Introduction

Wrapping one's head around the thousands of talks and posters being presented at Philadelphia's Pennsylvania Convention Center this week is nearly impossible. But on Tuesday, April 29, Natalia Rost, MD, MPH, Associate Professor of Neurology at Harvard Medical School and Vice-Chair of the American Academy of Neurology (AAN) Science Committee made navigating the society's 2014 annual meeting a little easier. At the "Top Research to Watch" press conference, Dr. Rost highlighted her top 3 picks for the most groundbreaking work from the meeting's ambitious program.

First is a major potential breakthrough in dementia diagnostics. A study by Dr. Marwan Sabbagh and colleagues[1] from Scottsdale, Arizona, reports that a negative florbetaben PET scan reliably excludes amyloid pathology in patients with cognitive impairment, thereby helping to distinguish between Alzheimer disease (AD) and other forms of dementia. Florbetaben is a radiolabeled tracer that binds highly specifically to beta-amyloid plaques in the brain, a pathologic hallmark of AD. It became the third agent approved by the US Food and Drug Administration (FDA) for imaging amyloid when it was greenlighted in March of this year. The reported correlation between neuroimaging and postmortem histopathologic findings could provide clinicians with a more accurate means of diagnosing dementia, as being able to distinguish AD from non-AD dementias could better inform treatment decisions and help identify patients eligible for clinical trials.

During the Q&A portion of the conference, a reporter asked whether the finding would affect Medicare reimbursement. "This is an interesting and relevant question, and obviously we are hoping that any positive developments in diagnosis will be available to clinicians in the future," replied Dr. Rost, adding, "[while amyloid tracers] haven't been used widely in practice yet...florbetaben widens the field of tools available to us...and will hopefully change the way we practice."

The second featured study heralds good news for those suffering from or managing a puzzling condition with no known cause: idiopathic intracranial hypertension (IIH), or pseudotumor cerebri.[2] IIH primarily affects women in their 20s and 30s and has an incidence of 10 to 20 per 100,000 people, a figure that rises in overweight individuals. The primary problem in IIH is chronically elevated intracranial pressure; patients typically present with headache and vision loss or distortion. The carbonic anhydrase inhibitor acetazolamide is sometimes used to treat IIH, as 'it is known to reduce intracranial pressure. This trial looked at one of the largest doses ever tested -- up to 4 g per day. Symptoms in the women who were treated greatly improved with 6 months of therapy, and the agent was shown to prevent any further vision loss. "This is something that I'm sure will very quickly move into practice," commented Dr. Rost.

Finally, Dr. Rost discussed findings from the Field Administration of Stroke Therapy–Magnesium Phase 3 Clinical Trial (FAST-MAG). [3] The study was originally presented at the International Stroke Conference in February, and although the results were negative, Dr. Rost believes that the trial deserves recognition for its innovative and hopefully reproducible design. Lead author Jeffrey L. Saver, MD, Professor of Neurology and Director of the Stroke Center at UCLA, set out to assess whether the prehospital administration of magnesium within 1 hour of acute ischemic stroke is neuroprotective. Saver and colleagues were able to enroll 1700 patients and involve 60 emergency rooms, 315 ambulances, 40 emergency services agencies, and nearly 3000 paramedics as part of the study -- staggering numbers. The idea was to have paramedics quickly enroll patients into the study using phone-based emergency consent and to administer magnesium sulfate in the field. Unfortunately, magnesium was not shown to be neuroprotective; however, according to Dr. Rost, "The framework of the trial design and the feasibility of administering a medication so early from the time of onset was the remarkable achievement in this trial."

A reporter asked about applying the approach to prehospital thrombolysis. "We think it's very promising," replied Dr. Rost. "There is a lot of exciting work currently ongoing in Europe, and we're about to start testing some of these models in the US. Dr. James Grotta at UT Southwestern is currently implementing a prethrombolysis system." She also commented that while prehospital stroke care might not be possible for all medical centers or regions, advances in ambulances might make it more widely feasible. The prehospital network at UCLA will hopefully lead to similar approaches around the country, moving stroke management from the emergency department to a patient's front door.

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