COMMENTARY

The Year in Neurology 2018

Hans-Christoph Diener, MD, PhD

Disclosures

December 28, 2018

Ladies and gentlemen, dear colleagues, I'm Christoph Diener, from the University of Duisburg-Essen in Germany, and I would like to summarize some important results in neurology for 2018.

Let me start with stroke. We now have many more studies that indicate that the management of risk factors and lifestyle changes have an impact on the prevalence of stroke. We have three large-scale studies, which clearly show that aspirin is not effective in primary stroke prevention and only increases the risk of bleeding. Thrombectomy is effective up to 24 hours in selected patients based on brain imaging. We also have the WAKE-UP stroke study, which showed that thrombolysis can be used in a time window of up to 4.5 hours in people with unknown onset of stroke based on MRI imaging.[1]

We now have several studies on the efficacy of patent foramen ovale (PFO) closure in patients below the age of 60 who have a large PFO. This method is effective, but people who also have atherosclerosis should not be treated. Furthermore, we have no idea whether this works in patients older than 60 years. We had the results of the two ESUS (embolic stroke of undetermined source) studies. Rivaroxaban and dabigatran were not superior to aspirin in prevention of recurrent stroke.[2] In cryptogenic stroke in ESUS, rivaroxaban had a higher bleeding risk compared with aspirin, and dabigatran had similar risk.

What is new in movement disorders? We had more subgroup analyses from the EARLYSTIM study, a study with deep brain stimulation in Parkinson's disease. These substudies showed that deep brain stimulation improves not only the symptoms of Parkinson's disease, but also behavioral aspects and depression.[3]

We had the first prospective, randomized, placebo-controlled trial on the efficacy of subcutaneous apomorphine, which is clearly superior to placebo in advanced Parkinson's disease.[4] We now have a number of studies indicating that the gastrointestinal tract could play a major role in the pathophysiology of Parkinson's disease. For example, people with inflammatory bowel disease have a higher prevalence of Parkinson's disease, and the appendix might play a role.

What's new in headache? We now know that migraine is a risk factor for all kinds of vascular diseases. The absolute risk is very low, but we should identify vascular risk factors in people with migraine and treat them. New [treatment options include] monoclonal antibodies against CGRP or the CGRP receptor for the prophylaxis of migraine. These [monoclonal antibodies] are not superior to the present therapy, but they have an excellent side-effect profile. Unfortunately, they are much more expensive than the drugs that we used to have.

What's new in multiple sclerosis (MS)? We have new interesting biomarkers, neurofilament and tau protein, which predict brain atrophy in people with MS. Smoking has a negative effect on the disease and it inhibits the efficacy of immunomodulatory therapy. Now, we have the first positive trial for siponimod in secondary progressive MS.[5] Natalizumab was not effective in this indication. We have the first randomized trial in juvenile pediatric MS, and this trial shows that fingolimod is clearly superior to beta interferon.[6]

In dementia, all of the drug trials failed. The explanation was that the disease probably starts 20-30 years before we see the first symptoms of cognitive impairment. At the moment, we can only promote changes in lifestyle. Healthy nutrition, regular exercise, and treatment of vascular risk factors might be effective in preventing dementia.

In amyotrophic lateral sclerosis (ALS), we had the first small study investigating intrathecal stem cell injection.[7] This study was much too small to provide definitive recommendations. We also have a negative randomized trial showing that rasagiline on top of riluzole has no impact on the prognosis.[8]

The real breakthrough is the therapy for spinal muscular atrophy, both with antisense therapy and gene therapy. They are effective but extremely expensive, unfortunately.

Ladies and gentlemen, 2018 was an exciting year for neurology. We have lots of new information from studies that changed our practice. Hopefully this continues in 2019. I am Christoph Diener from the University of Duisburg-Essen, in Essen, Germany. Thank you for listening and watching.

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