Advances in Neurology

[Neuroresident]

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Ok I am going to throw this out for discussion:

With medical advancements made in past one decade which neurology subspeciality has made most improvements in patient care? My vote will go to Multiple Sclerosis. With the introduction of Tysabri and other disease modification therapies I think this field of neurology has made most progress in patient care in last decade. Any second thoughts? What does the more experienced members of this board thinks from their own practice?

 

[Head]

Though the advances in MS therapy are exciting, they wouldn't be my pick. The disease modifying agents only make a modest dent in the number of flairs that patients suffer. In addition, the cost of these drugs remains exorbitant. A recent article in Neurology Today argued that these drugs weren't worth the cost (in the US) if you analyze it in terms of quality of life years saved. The new oral disease modifying agents hitting the market are much more appealing to patients, but are even more expensive.

I would probably choose movement disorders or stroke. Sinemet, a drug that is dirt cheap, transforms a PD patient from someone who is completely handicapped into a (close to) normal member of society. DBS is also extremely effective. Though expensive, it's more of a one time shot as opposed to paying >$10k per year for disease modifying agents.

Stroke therapy is another exciting area. TPA is obviously hugely helpful for the patients that get to the hospital in time. Neuro-intervention for stroke is evolving rapidly, though definitive studies to prove its utility remain lacking. Many new oral anticoagulant drugs are hitting the market that don't require monitoring like coumadin.

 

[Neuroresident]

I was sure that someone is going to bring up stroke and miracle of TPA. But my point is that still a minority of stroke patient actually gets TPA because of time window and access to care issues. Sure it has transformed the whole stroke care scenario dramatically but I think actual benefit that patients have received with the arrival of TPA is minor.

About parkinson, Sinemet was available for a long time so I will not consider it appropriate for this debate. On the other hand DBS is still available to selected few patients. Unlike MS there is still no disease modifiying agent available for PD or for that matter any other neurodegenerative diseases.

I was not aware about the Neurology Today article mentioned. Will look into that.

Sounds like we have a good debate going on. Hopefully others will chime in to 🙂

 

[95439]

I was sure that someone is going to bring up stroke and miracle of TPA. But my point is that still a minority of stroke patient actually gets TPA because of time window and access to care issues. Sure it has transformed the whole stroke care scenario dramatically but I think actual benefit that patients have received with the arrival of TPA is minor.

About parkinson, Sinemet was available for a long time so I will not consider it appropriate for this debate. On the other hand DBS is still available to selected few patients. Unlike MS there is still no disease modifiying agent available for PD or for that matter any other neurodegenerative diseases.

I was not aware about the Neurology Today article mentioned. Will look into that.

Sounds like we have a good debate going on. Hopefully others will chime in to 🙂

Oh come on this isn't a debate it's stroke. A decade ago, you came in with a stroke and you were screwed. There wasn't even concrete evidence about switching antiplatelet agents. Now there's IV tPA, IA tPA, direct thrombectomy, and the stuff coming around the corner is unbelievable. It's the new heart attack. Hypothermia protocols are showing promise, transcranial doppler ultrasound shows promise, telemedicine is being instituted for remote areas. You can predict prognosis based on recovery in the first two weeks. Really, stroke has far and away made the most progress over the last decade, and will likely continue to do so over the next couple of decades as well. Other areas are showing a lot of promise but the research is still very preliminary and isn't going to affect nearly as many people. Remember, stroke is the leading cause of disability in the US.

 

[Mattchiavelli]

Fingolimod also isn't considered to be cost-effective according to the national health of the UK based on the data submitted comparing it to placebo and Avonex... so we'll see where that goes. MS is still a very young disease entity in that before MRI the only way to diagnose it was in an autopsy by finding plaques after rummaging through brains/spinal cords.

Don't forget constraint-induced movement therapy moving to become the standard in stroke rehab. I am curious as to how tPA rates change with the addition of more teleneurology programs. I think stroke (to me) wins out because it rides the coattails of research done for heart disease that is applicable also to stroke, like reasearch into the prevention of atherosclerotic disease and also thrombus formation in heart conditions like chronic a-fib.

 

[neurologist]

Gotta go with stroke, just because of the potential of TPA and other treatments coming down the pike.

Sleep is also a contender -- it's really advanced quite a bit in the last 10 years with development of new PAP technology, surgeries, dental appliances, etc for sleep apnea.

You can predict prognosis based on recovery in the first two weeks.

That's hardly new in the last 10 years . . .

 

[bluntdissector]

Gotta go with stroke

👍

I'm not sure the MS DMTs have a QoL benefit worthy of their cost. Think the increased availability of surgery as a modality for epilepsy (especially in poorer countries) has been good too.

 

[Dr Linta]

http://californiastemcell.com/Hans_Keirstead__SAB_

This one is interesting...

 

[Head]

Oh come on this isn't a debate it's stroke. A decade ago, you came in with a stroke and you were screwed. There wasn't even concrete evidence about switching antiplatelet agents. Now there's IV tPA, IA tPA, direct thrombectomy, and the stuff coming around the corner is unbelievable. It's the new heart attack. Hypothermia protocols are showing promise, transcranial doppler ultrasound shows promise, telemedicine is being instituted for remote areas. You can predict prognosis based on recovery in the first two weeks. Really, stroke has far and away made the most progress over the last decade, and will likely continue to do so over the next couple of decades as well. Other areas are showing a lot of promise but the research is still very preliminary and isn't going to affect nearly as many people. Remember, stroke is the leading cause of disability in the US.

Arthritis is actually the leading cause of disability in the US. Some articles will try to justify the statement by saying stroke is the leading cause of "acquired" disability in the US, as if you caught it like some kind of virus. Sorry, just a pet peave of mine because I see these statements over and over in articles when they're simply not true.

I agree with your take on the exciting advances in stroke.

 

[95439]

Arthritis is actually the leading cause of disability in the US. Some articles will try to justify the statement by saying stroke is the leading cause of "acquired" disability in the US, as if you caught it like some kind of virus. Sorry, just a pet peave of mine because I see these statements over and over in articles when they're simply not true.

I agree with your take on the exciting advances in stroke.

"Peeve" 😀

 

[neurodoc]

I'd have to say the most exciting development has been the use of thrombolytics to treat stroke. I trained in the late '80s/early 90's and there was little we could do for patients with acute stroke symptoms, except to classify the type of stroke (ischemic/hemorrhagic; lacunar/large vessel, etc). We tried all sorts of things (heparin, calcium channel blockers...even having patients breathe into a paper bag to increase CO2 levels...).

Since then I've seen patients recover from massive MCA occlusions with the timely administration of thrombolytics. I can be miraculous!

I've also seen disasters...like patients given TPA who suffer hemorrages...

Thrombolysis is a potent weapon to treat acute ischemic stroke (just as it is for those who treat acute MI). But like any other potent treatment it must be used with caution. The main problem I've noted is that you have to be sure of the diagnosis before giving thrombolytics, and this must be done within a brief time window (hours after onset of symptoms). Most ER's are not staffed by neurologists and the staff who decide to treat stroke per "protocols" have variable disgnostic abilities. I've seen several patients who were given TPA for things like Bell's Palsy and CTS...😱

Nick

 

[95439]

I'd have to say the most exciting development has been the use of thrombolytics to treat stroke. I trained in the late '80s/early 90's and there was little we could do for patients with acute stroke symptoms, except to classify the type of stroke (ischemic/hemorrhagic; lacunar/large vessel, etc). We tried all sorts of things (heparin, calcium channel blockers...even having patients breathe into a paper bag to increase CO2 levels...).

Since then I've seen patients recover from massive MCA occlusions with the timely administration of thrombolytics. I can be miraculous!

I've also seen disasters...like patients given TPA who suffer hemorrages...

Thrombolysis is a potent weapon to treat acute ischemic stroke (just as it is for those who treat acute MI). But like any other potent treatment it must be used with caution. The main problem I've noted is that you have to be sure of the diagnosis before giving thrombolytics, and this must be done within a brief time window (hours after onset of symptoms). Most ER's are not staffed by neurologists and the staff who decide to treat stroke per "protocols" have variable disgnostic abilities. I've seen several patients who were given TPA for things like Bell's Palsy and CTS...😱

Nick

Oh dear lord, for CTS? That's just sad...
I'm currently working on predicting hemorrhagic transformation in acute ischemic stroke based on CT Perfusion and patient demographics. I agree that we need to prevent the major risk of tPA - hemorrhage.
I did forget to mention the one thing over the last decade that seems to challenge stroke in regards to advancements - neuroimaging.

 

[Kazaki]

I'm gonna bump this thread
Recently read a thread from '06 on advances in neurology and everyone spoke about the new wonder drug tPA.
Most drugs for MS and Parkinson's are useless. What's changed since then?