A New Blood Test Can Detect Bleeding in the Brain after a Concussion

This is an important advance as it can dramatically reduce the use of CT scans after concussions. Not only do unnecessary CT scans waste health care dollars but they also expose young athletes to unnecessary radiation. Children and teens, compared to adults, are several times more susceptible to the effects of radiation. Emergency room personnel are under pressure to discharge patients quickly and a CT scan is fast and also serves to comfort anxious parents.

If performed within 12 hours of injury, the new blood test is almost 100% accurate in detecting hemorrhage in the brain. It does not in any way help to diagnose a concussion, as that is based on the description of the event and the patient’s symptoms.

The main drawback is that the “turnaround” time is 4 hours, an eternity for parents and for busy emergency rooms. An important goal is to get results back faster.

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A New Vaccine for Prevention of Shingles Is a Major Advance.

Dermatomal herpes zoster (shingles) has a lifetime risk of over 30% and carries a high risk of post-herpetic neuralgia which can be excruciating and even permanent. Rarely, the virus can disseminate (spread) and may even result in stroke. Further, recent studies have shown that the virus may be the trigger for giant cell arteritis, a disorder which can cause blindness.

There is thus an unmet need for an effective vaccine, especially because Zostavax, approved since 2006 for ages 60 or older, reduces risk by only 50% for ages 50-70, 38% for those 70-80, and 18% over the age of 80. Also, the protection wears off within several years.

The new vaccine, called Shingrix (not a great name), was approved in October 2017 for ages 50 or higher and is also recommended for those who have previously received the older vaccine. In studies comparing the two, Shingrix reduced risk by 90% compared to Zostavax’s 38% in those older than 70. It was 90% effective even for 80 year-olds. The risk of developing post-herpetic neuralgia in those over 60 was reduced 90% compared to 67% for Zostavax. Protection lasted for at least 4 years.

It was not associated with an increased risk of adverse effects, even in people with impaired immunity. It requires two injections two months apart (Zostavax requires only one). It is only slightly more expensive.

Truly, a major advance.

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The FDA Should Approve Marijuana to Treat Spasticity in Multiple Sclerosis

Readers of a review article by Giacoppo and others in Multiple Sclerosis and Related Disorders, 2017, pages 22-31, will probably agree with this statement. Sativex is a branded oromucosal spray containing tetrahydrocannabinol and cannabidiol in a 1:1 ratio. It has been available for years in Canada and has been approved in several European countries since 2013. Combining the two compounds reduces unwanted cognitive effects.

This review was a literature search extending back ten years. Spasticity affects 80% of MS patients, responds poorly to currently available medications and worsens disability and quality of life. 83% of MS-Sativex treated patients had reduction of spasticity. 65% were considered responders in the first month. There was no evidence that other MS symptoms worsened. 60% continued treatment long term. Those who stopped cited lack of efficacy or side effects. 83% thought they benefited.

10%, and usually only for in the first month, had side effects, such as dizziness, fatigue, and dry mouth. Less than 1% had psychiatric side effects, including paranoia, hallucinations, panic, suicidal ideation and cognitive decline. These generally cleared with lowering the dose or stopping treatment. There was no evidence of tolerance, abuse, diversion or addiction.

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Noninvasive Vagal Nerve Stimulation for Cluster headaches

A new device provides noninvasive electrical stimulation of the vagus nerve in the neck to treat episodic cluster headaches. It is call gammaCore and was recently approved by the FDA and will probably be available by prescription in the United States in fall 2017. It is about the size of a cell phone, handheld, applied to the neck at the start of an attack.

Cluster headaches have been called “suicide headaches” because the pain is very intense. They can occur multiple times a day during a cluster. Injectable sumatriptan is almost always very effective within several minutes but may lead to severe adverse effects in people with coronary artery disease or multiple risk factors for that. Also, it is expensive and insurers will not pay for several doses a day. Inhaled oxygen is also effective for most patients. This obviously is less convenient as an oxygen tank is needed and is not covered by Medicare or Medicaid for treatment of cluster headaches. Thus, the gammaCore device is welcome.

There have been 2 “pivotal” trials. Thirty-four percent of patients who use the stimulator experience pain relief in 15 minutes compared 10% who used a sham device. It was effective only for episodic cluster but not for chronic cluster. Patients with episodic cluster, go into remissions whereas those with chronic do not. It is not clear why there was a difference in response as the pathophysiology is the same in both episodic and chronic. Some headache specialists were disappointed that the response rate was only 1/3, “therapeutic gain” is almost 25%. This is considered significant in pain studies

Look for more neuromodulating devices in the future. For cluster, the focus will be on stimulating the sphenopalatine ganglion.

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New Insights into Sudden Death in Epilepsy

A practice guideline, prepared by the American Academy of Neurology, was published recently in Neurology.

SUDEP stands for sudden unexpected death in epilepsy. This has been recognized for many years but the specific risk has not been consistently established. People with epilepsy can die during a seizure, presumably from post- ictal respiratory depression.

SUDEP, according to the guideline, affects 1 in 4,500 children and 1 in 1,000 adults with epilepsy per year. Lifetime risk is obviously higher. Keep in mind that 4,499 of 4,500 children will not be affected and this applies to 999 out of 1,000 adults. This should be the approach in counseling patients and families as after being informed of an adverse event, people commonly overestimate that risk and this may increase anxiety greatly.

Some groups have higher risks. The most important risk factor is the frequency of generalized tonic-clonic seizures. Those with 3 or more per year have a 15-fold higher risk. Nocturnal seizures may increase risk because they are unwitnessed. Use of a remote listening device may help.

Reducing risk of generalized tonic-clonic seizures will obviously reduce risk of sudden death. Factors that further increase risk include never having been treated with an antiepileptic drug, number of drugs used overall, intellectual disability, male sex, and anti-anxiety drug use.

The following factors do not seem to increase risk: overall frequency when this includes all seizure types, medically refractory partial seizures, monotherapy vs polytherapy, frequent changes on antiepileptic drugs, structural lesion on MRI, duration of epilepsy, and age of epilepsy onset.

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Update On Migraine And Stroke

There is good evidence that patients with migraine with aura but not without aura have about a twofold increased risk of stroke. Why this is so, however, is not known. According to a new study, the cause may be cardiac embolism. Patients from the ARIC study of over 15,000 participants, aged 45 to 64 years who had migraine and stroke, were identified. The mean age of the patients was 59 years. Those with migraine with visual aura had increased risk of cardioembolic ischemic stroke of almost fourfold. Those with migraine without aura did not.

Cardioembolism was diagnosed if records showed evidence of heart valve disease, a recent intracardiac thrombus, bacterial endocarditis, cardiac arterial procedure, and especially paroxysmal atrial fibrillation or flutter. Patent foramen ovale was not considered a cardioembolic source. The role of PFO in causing ischemic stroke in patients older than 55 is controversial. It is seen on autopsy in 25% of the general population, though perhaps 50% of patients with “cryptogenic stroke” may have PFO seen on transesophageal echocardiogram.

The authors propose several mechanisms. Migraine with visual aura may promote vasospasm, activate platelet aggregation, and increase concentration of pro-coagulant factors. Secondly, calcitonin gene-related peptide (CGRP), consistently elevated during a migraine attack, also can cause coronary vasodilatation. Perhaps that effect could trigger coronary blood flow or velocity changes and thus increase risk of atrial fibrillation.

Keep in mind that these results may not apply to people younger than 45. The important take-home message is that migraineurs who have visual aura and who have ischemic stroke of unknown cause may have significant probability of paroxysmal atrial fibrillation as the cause. Thus, it seems prudent that they undergo long-term cardiac monitoring, as findings would lead to anticoagulation, which would serve to lower risk of recurrent stroke.

See Neurology, December 13, 2016, pages 2504-2505 and 2527-2532.

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New Insights Into Migraine And Risk Of Stroke

Patients who have migraine with aura, but not those who have migraine without aura, have been found in several studies to have higher risk of cardiovascular disorders, including stroke. That risk may be 2 times that of a control group though low in an absolute sense because patients are relatively young without cardiovascular risk factors.

Now, a new study concluded that this increased risk applies to migraine with and without aura. It involved over 17,000 patients who had unspecified migraine. There was found to be increased risk of myocardial infarction, stroke, angina, or coronary revascularization procedures, and cardiovascular mortality ranging from 37% to 73% higher than the control group, which was women without migraine. Conclusion was that women with migraine of any type should be carefully evaluated for cardiovascular risk factors and treated as needed.

A second recent study came to a different conclusion. This consisted of 172 cases of female twins with and without migraine with aura, 34 twin pairs in which neither had migraine, and 139 controls without migraine. The frequency of silent brain infarcts, seen in several previous studies in perhaps 30% of women with migraine, was the primary outcome. The conclusion was that there was no association between these silent brain infarcts or white matter hyperintensities with migraine with aura.

See British Medical Journal, 2016, 353, with lead author T. Kurth; and Brain, 2016, 139, pages 2015-2030 with lead author D. Gaist.

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Nicotine Patches For Parkinson’s

Eight open-label studies and four placebo-controlled studies addressed this question. Seven of the eight open-label showed improvement in motor symptoms, but the placebo-controlled studies were all negative.

A new study was presented at the 4th World Parkinson Congress by Gabriel Villafane. It involved high doses (90 mg per day) of transdermal nicotine and measured the UPDRS for “off” motor scores. Blinded video rating was done.

At 39 weeks, there was no statistically significant difference in motor scores as well as a quality of life measure. There seemed to be a reduction in levodopa doses, reduction in dyskinesias, and improvement in activities of daily living. As expected, adverse effects were more common in the nicotine group.

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A New Blood Test May Become A Biomarker For Multiple Sclerosis Progression

This measures neurofilament-light chain levels. They are a maker to neuroaxonal damage, as the neurofilaments function as a lattice for axons. In the past, lumbar puncture was needed. Now, a blood test has been developed. This studied patients undergoing treatment with fingolimod. Another study involved patients treated with natalizumab. With treatment, levels of the neurofilament-light chains fell, and this correlated with a milder disease course.

These tests need to be validated further, but it is very exciting if a blood test could help guide treatment decisions.

This information was presented at ECTRIMS 2016. Lead author is Piehl.

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A New Non-Invasive Treatment For Essential Tremor

Essential tremor is common, thought to affect 1 in 10 people over the age of 70, and may be severe, causing significant functional disability. It is difficult to treat. Available medications reduce tremor only partly and do not work in a significant number of patients. Further, they may have adverse effects. They include mainly beta-blockers, primidone, and topiramate or zonisamide, used off-label. Deep brain stimulation is very effective but is obviously invasive, with attendant risks.

Now, a new device has just received FDA approval. It is termed ExAblate Neuro system. Using ultrasound waves, it could ablate the target brain tissue. The study was randomized, double blind, with 76 patients who received the ExAblate treatment or a sham procedure. Placebo patients were later allowed to “cross over.”

Treated patients had an almost 50% improvement in tremor severity and function.

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