The edition · Neurology
Thrombolysis out to 24 hours buys function and costs bleeds, and levodopa is cleared of causing freezing
Fourteen trials and 4,944 patients: imaging-selected thrombolysis beyond 4.5 hours raises excellent outcomes (OR 1.43) and symptomatic haemorrhage (OR 2.51). Meanwhile two cohorts totalling 27,000 patients find the levodopa-freezing association disappears once disease duration and severity are accounted for.
The edition in brief
Five findings and a pearl for the neurology desk. A Bayesian meta-analysis of 77 studies estimates that 25.2% of people presenting with epileptic seizures in Taenia solium endemic regions have neurocysticercosis, with the proportion falling since 2008 for reasons the authors cannot separate from changes in imaging and case definition. A meta-analysis of 28 studies puts the pooled incidence of posterior reversible encephalopathy syndrome in pre-eclampsia and eclampsia at 38.7%, with raised transaminases and lower platelets marking the affected patients - though heterogeneity was 98.5%, so the pooled figure describes the literature rather than any unit. In Parkinson's disease, 25,602 patients in NS-Park and 1,441 in PPMI show that the apparent link between levodopa exposure and freezing of gait does not survive adjustment for disease duration and Hoehn and Yahr stage: adjusted odds ratios of 1.84 (95% CI 0.94-3.61) and 0.76 (0.38-1.51), while disease duration carried odds ratios of 4.4 and 6.97. A metabolomics study of 2,408 people with MRI-confirmed lacunar stroke found 211 metabolites associated observationally, of which only two - glycine and the cholesterol proportion in medium LDL - survived Mendelian randomisation, each tied to a different lacunar subtype. The practice-changer is an updated meta-analysis of thrombolysis beyond 4.5 hours in imaging-selected patients: excellent functional outcome odds ratio 1.43 (1.25-1.63), recanalisation 3.28, no mortality difference, and symptomatic intracranial haemorrhage 2.51 (1.47-4.28). Plus a pearl on establishing time of onset when nobody witnessed it.
A quarter of people presenting with seizures in endemic areas have neurocysticercosis
In endemic settings, treat neurocysticercosis as the most likely identifiable cause of a first unprovoked seizure and image before treating empirically.
PRES in pre-eclampsia tracks with transaminases and platelets
In pre-eclampsia with neurological symptoms, raised transaminases and a falling platelet count should raise PRES - and the imaging pattern is as often frontal as occipital.
Levodopa does not appear to cause freezing of gait once duration and severity are accounted for
Stop restricting levodopa to prevent freezing of gait: after adjustment for disease duration and stage, the association disappears in both cohorts.
Of 211 metabolites associated with lacunar stroke, two survived Mendelian randomisation
Nothing to order or prescribe: this is mechanistic work identifying glycine and medium-LDL composition as candidate causal factors in two distinct lacunar subtypes.
Establishing last known well when nobody watched the clock
Convert the history into a datable anchor rather than an estimate, and for an uncertain or wake-up onset let imaging rather than the clock decide.
Thrombolysis from 4.5 to 24 hours: better function, and two and a half times the symptomatic haemorrhage
In a patient presenting 4.5 to 24 hours from onset, get the advanced imaging rather than excluding on time - and consent them for a higher haemorrhage risk alongside the better functional odds.
Read the rest in the app
You have read your two free briefings this month. The app carries all 27 specialties, every morning, free — and this one is waiting in it.
Scan to keep reading on your phone. No account needed to start.
Tomorrow morning, before your first patient
One edition a day for neurology, written by the desk, every claim tied to its paper. Six minutes.
Get the app — free