COMMENTARY

5 Updates in Neurology

Hans-Christoph Diener, MD, PhD

Disclosures

January 20, 2021

This transcript has been edited for clarity.

Dear colleagues, I'm Christoph Diener from the University of Duisburg-Essen in Germany, here to tell you about five interesting neurology studies published in December 2020.

The first study of interest is in neuro-traumatology. People with subdural hematomas are usually treated by surgery. However, there is a hypothesis that perhaps dexamethasone could have an impact on the outcome of this condition, given the presence of inflammation within the dura and leakage of small vessels in chronic subdural hematoma.

In a study published in The New England Journal of Medicine, UK investigators randomized 748 patients with symptomatic chronic subdural hematoma to either dexamethasone or placebo. Of the patients, 94% underwent surgery. The primary outcome was a modified Rankin score between 0 and 3, which was achieved in 84% of patients on dexamethasone vs 90% on placebo, meaning placebo was superior to dexamethasone (P = .01). In conclusion, there is no indication to use corticosteroids in patients with chronic subdural hematoma.

The second study investigated the prehospital use of tranexamic acid in patients with severe traumatic brain injury who were flown by helicopter to a trauma center. Data were analyzed from a registry in the Netherlands, with a primary endpoint of 30-day mortality. Among the 1827 patients analyzed, traumatic brain injury was usually due to a car accident or fall.

The mortality was 37% on tranexamic acid and 30% on placebo (odds ratio, 1.34; P < .001). Given that mortality rates favored placebo, investigators recommended that tranexamic acid should not be used in traumatic brain injury prior to a CT scan.

In summary, we now have seven large studies with more than 32,000 patients where tranexamic acid was compared with either control or placebo in patients with severe traumatic brain injury. Although there is a small decrease in mortality, this drug has no impact on disability. Therefore, the few patients who might benefit from this drug (eg, those receiving it within less than a 3-hour time window) need to be carefully selected.

The next paper, published in the journal Neurology, dealt with the topic of COVID-19 and stroke. Investigators summarized data from 10 studies and an additional 125 single cases.

The authors reported that the incidence of stroke in patients with COVID-19 is between 1.8% and 2%. In approximately 50% of these patients, strokes took the form of large-vessel occlusions due to thrombosis. The rate of in-hospital mortality was about 35%, highest in those of older age, with severe comorbidities, and severe pulmonary manifestation of the disease.

The next paper I’d like to discuss, which was also published in The New England Journal of Medicine, was on the topic of seizure frequency during pregnancy. As you know, antiepileptic treatment is quite often modified at the beginning of pregnancy. The authors wanted to know whether this has an impact on the frequency of seizures. They compared two time periods: pregnancy plus 6 weeks after birth (period 1) and the next 7.5 months after pregnancy (period 2). They recruited 351 pregnant women and 109 controls with epilepsy.

It turned out that seizure frequency was higher by 23% in period 1 during pregnancy compared with period 2. However, this trend was also observed in controls (+25%). In conclusion, we have no indications that changing antiepileptic therapy is the reason why the frequency of seizures is higher during pregnancy.

The final paper of interest was published in Lancet Neurology and dealt with fatigue in patients with multiple sclerosis. This was a very clever study with a four-period crossover design in which 141 patients with multiple sclerosis and fatigue received up to 6 weeks of treatment with each of the following: amantadine, modafinil, methylphenidate, and placebo.

Investigators observed a reduction in fatigue in all four groups but no difference between active drug and placebo. Therefore, at present we have no evidence that amantadine, modafinil, and methylphenidate really are effective treatments in patients with multiple sclerosis and fatigue.

Ladies and gentlemen, December 2020 was a very interesting month for published science regarding how we treat our patients. Hopefully, this trend of interesting new results will continue into 2021. I invite you to view these videos every month in 2021, when I'll be highlighting the studies I consider the most interesting to neurologists.

I'm Christoph Diener from the faculty of medicine at the University of Duisburg-Essen in Germany. Thank you very much for listening and watching.

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