Initial experience with novel CGRP-receptor inhibitor therapy in Migraine in the United Arab Emirates: a retrospective observational study.

BACKGROUND: Erenumab is a calcitonin gene-related peptide (CGRP)-receptor antibody inhibiting CGRP function. CGRP is prominently involved in the pathophysiology of migraine through nociceptive modulation in the trigeminovascular system. This study aims to explore the treatment effect of erenumab in a real-life setting. METHODS: In this retrospective observational study, we analyzed the data of 91 patients with migraine receiving at least three consecutive monthly injections of erenumab and followed up for 3-12 months. The primary objective was to describe the reduction in monthly migraine days throughout the follow-up period. To identify patients who responded to treatment, we analyzed the association between different patient characteristics and their treatment outcomes. RESULTS: Seventy-three patients (80.2%) responded to erenumab treatment, defined as ≥50% reduction of migraine days per month, across all migraine types. It was noted that ethnicity (p-value = 0.015) and older age (p-value = 0.035) were associated with clinically relevant improvement of symptoms. Middle Eastern ethnicity was related to less improvement of symptoms while Europeans were more likely to benefit from erenumab therapy (odds ratio: 12.788, p = 0.037). Patients aged from 31 to 40 and 41-65 years benefited most from erenumab treatment with a response rate of 77.8 and 89.9%, respectively, also confirmed by logistic regression (p = 0.047). Neither gender nor dose increase of erenumab showed association with the reported clinically relevant improvement of the symptoms. An association between clinically relevant improvement of headaches and the type of migraine was also noted. Around 87.9% of patients with episodic migraine responded to treatment, followed by 84.1% of chronic migraine patients and 50% of medication overuse headache patients. Medication overuse headache showed a lower probability of therapy success with erenumab (odds ratio: 0.126, p = 0.039). An improvement of headaches was eminent in patients who received 140 mg erenumab monthly (2 × 70 mg injections) and patients who had one injection every two weeks. CONCLUSIONS: Erenumab is a novel preventive treatment for all migraine types. Clinically relevant improvement of headaches and reduction of monthly migraine days were demonstrated in patients that continued the treatment course. In real-life, a substantial number of patients suspended therapy early, reasons for which need further investigation.

Sudden unexpected death caused by stroke: A nationwide study among children and young adults in Denmark.

Background Stroke is the fifth leading cause of death in young individuals globally. Data on the burden of sudden death by stroke are sparse in the young. Aims The aim of this study was to report mortality rates, cause of death, stroke subtype, and symptoms in children and young adults who suffered sudden death by stroke. Methods We conducted a retrospective, nationwide study including all deaths within Danish borders between 2000-2009 and 2007-2009 in persons aged 1-35 years and 36-49 years, respectively. Two physicians identified all sudden death cases through review of all death certificates. All available autopsy reports and records from hospitals and general practitioners were retrieved and a neurologist identified all sudden death by stroke cases. Results Of the 14,567 deaths in the 10-year period, there were 1,698 sudden death cases, of which 52 (3%) were sudden death by stroke. There was a male predominance (56%) and the median age was 33 years. The incidence of sudden death by stroke in individuals aged 1-49 years was 0.19 deaths per 100,000 person-years. Stroke was hemorrhagic in 94% of cases, whereof subarachnoid hemorrhage was the cause of death in 63% of cases. Seventeen (33%) cases contacted the healthcare system because of neurological symptoms, whereof one was suspected of having a stroke (6%). Conclusions Sudden death by stroke in children and young adults occurs primarily due to hemorrhagic stroke. We report a high frequency of neurological symptoms prior to sudden death by stroke. Increased awareness among healthcare professionals towards stroke symptoms in children and young adults may lead to earlier detection of stroke, and thereby potentially lowering the incidence of sudden death by stroke.

Carotid artery stenting versus no stenting assisting thrombectomy for acute ischaemic stroke: protocol for a systematic review of randomised clinical trials with meta-analyses and trial sequential analyses.

BACKGROUND: In patients with intracranial large vessel arterial occlusion, ipsilateral extracranial carotid artery occlusions or near-occlusions pose a significant hurdle in endovascular management of acute ischaemic stroke. Stenting of the carotid lesion may be beneficial in this situation to provide a stable access for introducing catheters through the carotid lesion into the intracranial vasculature and the target occlusion. Furthermore, carotid stenting may ensure ample blood flow for wash-out of clot material and reperfusion of the ischaemic penumbral tissue. However, antiplatelet therapy administered to prevent stent thrombosis and sudden increase in blood flow after reopening of the carotid lesion may increase the risk for intracranial haemorrhagic complications. This review aims to assess the benefits and harms of carotid stenting vs. no stenting assisting thrombectomy for acute ischaemic stroke. METHODS: International and regional electronic databases will be searched to identify eligible randomised clinical trials. To identify further published, unpublished, or on-going and planned trials searches of Google Scholar, Worldwide Food and Drug Administrations, Worldwide Medicines Agencies, company homepages, reference lists, conference proceedings, and the Science Citation Index cited reference search index will be conducted. Manufacturers of relevant interventional equipment, authors, colleagues, and researchers active in the field will be contacted. No language restrictions will be applied to these searches. Randomised clinical trials will be included for assessing benefits and harms and quasi-randomised studies, and observational studies will be included for assessing harms of the intervention. Meta-analyses will be performed according to the recommendations of the Cochrane Handbook for Systematic Reviews of Interventions, and Trial Sequential Analyses will be conducted to control the risk of random errors and prevent premature statements of superiority of the experimental or control intervention or premature statement of futility. The quality of the evidence will be evaluated with the Grading of Recommendations Assessment, Development, and Evaluation. DISCUSSION: This systematic review of carotid stenting in endovascular management of acute ischaemic stroke in patients with concomitant extracranial carotid lesions and intracranial embolism will assess benefits and harms of this intervention and assesses whether carotid stenting should be encouraged or avoided in acute ischaemic stroke and identify targets for further research. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42016033346.

Thrombectomy assisted by carotid stenting in acute ischemic stroke management: benefits and harms.

Extracranial carotid artery occlusion or high-grade stenosis with concomitant intracranial embolism causes severe ischemic stroke and shows poor response rates to intravenous thrombolysis (IVT). Endovascular therapy (EVT) utilizing thrombectomy assisted by carotid stenting was long considered risky because of procedural complexities and necessity of potent platelet inhibition-in particular following IVT. This study assesses the benefits and harms of thrombectomy assisted by carotid stenting and identifies factors associated with clinical outcome and procedural complications. Retrospective single-center analysis of 47 consecutive stroke patients with carotid occlusion or high-grade stenosis and concomitant intracranial embolus treated between September 2011 and December 2014. Benefits included early improvement of stroke severity (NIHSS ≥ 10) or complete remission within 72 h and favorable long-term outcome (mRS ≤ 2). Harms included complications during and following EVT. Mean age was 64.3 years (standard deviation ±12.5), 40 (85%) patients received IVT initially. Median NIHSS was 16 (inter-quartile range 14-19). Mean time from stroke onset to recanalization was 311 min (standard deviation ±78.0). Early clinical improvement was detected in 22 (46%) patients. Favorable outcome at 3 months occurred in 32 (68%) patients. Expedited patient management was associated with favorable clinical outcome. Two (4%) patients experienced symptomatic hemorrhage. Eight (17%) patients experienced stent thrombosis. Four (9%) patients died. Thrombectomy assisted by carotid stenting seems beneficial and reasonably safe with a promising rate of favorable outcome. Nevertheless, adverse events and complications call for additional clinical investigations prior to recommendation as clinical standard. Expeditious patient management is central to achieve good clinical outcome.

[Cardiac myxomas may cause cerebral aneurysms].

Cerebral aneurysm following a cardiac myxoma is a rare neurological complication. We report a 50-year-old man who developed cerebral aneurysms one year after resection of a cardiac myxoma. Magnetic resonance imaging of the brain showed features of intracranial haemorrhage. Digital subtraction angiography showed several fusiform intracranial aneurysms bilaterally in the middle cerebral artery. Finally, we discuss potential molecular mechanisms of the development of myxomatous aneurysms.