Neurology Practice Changers 2014

Bret S. Stetka, MD; Andrew N. Wilner, MD


December 08, 2014

In This Article

Editor's Note: New treatments, new theories, new definitions, and pesky proteins made 2014 an exciting year in neurology. Based primarily on Medscape Medical News coverage and input from our expert advisors, what follows are notable important advances in the field of neurology from the past year, starting with some welcome advances in stroke management.

Stroke Updates

Several studies published in 2014 moved stroke care forward—and, in one case, into an ambulance. Presented at the International Stroke Conference in February, and again at the American Academy of Neurology's 66th Annual Meeting, the Field Administration of Stroke Therapy-Magnesium phase 3 clinical trial (FAST-MAG)[1] assessed whether or not prehospital administration of magnesium within 1 hour of acute ischemic stroke is neuroprotective.

Study author Jeffrey L. Saver, MD, professor of neurology and director of the stroke center at UCLA, and colleagues enrolled 1700 patients and involved a staggering 60 emergency departments, 315 ambulances, 40 emergency services agencies, and nearly 3000 paramedics in the study. Paramedics were asked to quickly enroll patients into the study using phone-based emergency consent and to administer magnesium sulfate in the field. Unfortunately, the trial was negative; however, many experts lauded it for proving the feasibility of early, prehospital stroke treatment, so much so that it was included in the "Top Research to Watch" session at the AAN meeting.

Cryptogenic No More

Two studies[2,3] published in June in the New England Journal of Medicine set out to determine whether a certain portion of cryptogenic strokes are actually caused by atrial fibrillation. The first study, led by David Gladstone, MD, PhD, of Sunnybrook Health Sciences Centre in Toronto, and colleagues used an external event trigger monitor for 30 days, with the primary endpoint being an episode of atrial fibrillation lasting 30 seconds or more. The other group, headed by Tommaso Sanna, MD, of Catholic University of the Sacred Heart Institute of Cardiology in Rome, used a small implantable sensor that detected instances of atrial fibrillation—again lasting 30 seconds or longer—over 6 months, 12 months, and 3 years.

Gladstone and colleagues found that in patients who had undergone the 30 days of monitoring, the rate of atrial fibrillation was 16%, compared with only 3% among those who had received a standard work-up without event monitoring. In Sanna and colleagues' study, atrial fibrillation was detected in 9% of patients at 6 months and 12.5% at 1 year, compared with 1.5% and 2%, respectively, in unmonitored patients.

Together, the studies suggest that the rate of atrial fibrillation in patients with cryptogenic stroke is higher than previously thought. As stroke expert Dr Mark Alberts, vice-chair, Department of Neurology and Neurotherapeutics at UT Southwestern Medical Center in Dallas, Texas, reported on Medscape, " the end of the day, both studies tell us that the occurrence of atrial fibrillation in patients with cryptogenic stroke is high; [this] is important, and in many cases it could lead to a change of therapy."

However, Alberts also expressed caution: "What neither study tells us is whether, at the end of treatment, this makes a difference in terms of preventing strokes. This will require larger studies, with more patients treated for longer periods of time."


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