Neurology Today Ranks

Tony Bennett Inspires Hope After a Diagnosis of Alzheimer’s

In revealing his diagnosis of Alzheimer’s disease in 2021, singer Tony Bennett and his family aim to reduce the stigma around the illness and inspire other patients and their families. In the February issue of Brain & Life®, his wife, Susan, explains how music keeps her husband busy and engaged—and more like his old self, the charming performer. People with myasthenia gravis, a progressive neuromuscular disease, just got new treatment options after the US Food and Drug administration approved two medications. In this feature, Brain & Life describes how the new medications work and advises patients on how to choose the right treatment. Tips are offered for covering the cost of these new drugs. As scientists identify more genes that cause neurologic disorders, they may develop tests that target these genes. The magazine looks at how these advances affect conditions like Parkinson’s, epilepsy, Alzheimer’s, and inherited disorders and whether people at risk for them should undergo genetic testing. Brain & Life magazine is free for AAN members in the United States to distribute to patients, who also can subscribe for free. If you would like to adjust the number of copies you receive for your patients or update your clinic address, email BeGreen@WasteFreeMail. com. All members have online access to the magazine articles and additional resources at BrainandLife.org. Please share the website with your patients! 

In the Genes Genetic Research May Finetune Treatment

Smog Fog How Dirty Air Affects Brain Health Myasthenia Gravis New Drugs Offer More Options

It’s music that saves Tony.”

— SUSAN BENNETT, WIFE OF TONY BENNETT FEBRUARY/MARCH 2022 BRAINANDLIFE.ORG

Neurology Today Ranks the Top Stories of 2021

As COVID-19 closes in on its second year, posing new challenges for neurology and other specialties, how does one measure progress? Neurology Today’s annual feature on the best advances of the year, “The News That Mattered in 2021: Neurology Today’s Editorial Board Top Picks,” provides a way forward. This past year’s selections, published in print and online on NeurologyToday.com on January 20, highlight the most noteworthy achievements across subspecialties— from dementia and genetics, sleep and epilepsy, neuromuscular disorders and stroke, movement disorders and neuro-oncology, neurocritical care and ethics, to legislative and wellness initiatives, and more. Look for the studies, initiatives, and developments that moved the field forward and led to important changes in practice—and why they matter. “2021 has proven to be a year when the engines of neurology research and innovation continued to move forward, despite great challenges,” said Neurology Today Editor-in-Chief Joseph E. Safdieh, MD, FAAN, the Gertrude Feil Associate Dean of Curricular Affairs, vice chair of education, and professor of neurology at Weill Cornell Medical College. “The advances highlighted by our editorial board, all leaders in the field, offer up hope for the future of our specialty and for our patients.” 

JANuAry 20, 2022 | NeurOlOGy TODAy | 19

Best advances

the news that mattered in 2021

Neurology Todayeditorial Board Top Picks

article in brief: The Neurology Today editorial board highlights the advances that occurred in 2021 across multiple subspecialties and areas of practice. can memantine improve cognition in down

syndrome?

As 2021 came to a close, studies about COVID-19 continued to dominate across major journals and institutions. But even with another year of the coronavirus and a troubling variant, neurology witnessed the expansion of developments across

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the official news source of the american academy of neurology | neurologytoday.com January 20, 2022 | volume 22 | issue 2

ADvANCED PRACTICE PRACTIONERS

julie a. gurwell, phd, pa-c Associate Professor, Director of Advanced Practice Providers University of Kentucky Louisville, KY The Pick: Cook CL, Schwarz HB. Advanced practice clinicians-neurology’s underused resource. JAMA Neurol 2021; 78(8):903-904. Kreimer S. Professionalism: On training and retaining advanced practice clinicians in neurology. Neurol Today 2021;21(15):1,9. The Findings: These two articles provide an important reminder that advanced practice clinicians can be valued team members of neurology care teams in collaboration with physicians when they are supported and mentored. The articles discuss the intrinsic challenges of

CEREBROvASCULAR DISEASE

james c. grotta, md, faan Director of Stroke Research at the Clinical Institute for Research and Innovation Memorial Hermann-Texas Medical Center, Houston, TX

The Pick: Ebinger M, Siegerink B, Kunz A, et al. Association between dispatch of mobile stroke units and functional outcomes among patients with acute ischemic stroke in Berlin. JAMA 2021;325:454-466. Grotta JC, Yamal J-M, Parker et al. Prospective, multicenter, controlled trial of mobile stroke units. New Engl J Med 2021;385:971-81. The Findings: Previous studies had shown that mobile stroke units, specialized ambulances with CT imaging, personnel, and drugs, integrated with every subspecialty. The selections of the most important advances in 2021 by members of the Neurology Today editorial board highlighted below are not all game-changers, but whether incremental or transformational, they have all moved the field forward in practice and the care of patients.

emergency medical services systems, can accurately diagnose strokes and speed delivery of tissue plasminogen activator (tPA) treatment into the pre-hospital setting. These two studies from Berlin and seven sites in the US were the first large, controlled trials showing that mobile stroke unit management translates to substantially better clinical outcomes as measured by the modified Rankin scale at 90 days. Better results were driven by more and faster tPA treatment, especially in the first “golden” hour after symptom onset. Why It’s Important: The biggest current challenge in acute stroke treatment is getting appropriate treatment to the patient and getting the patient to the appropriate treatment, and doing this as fast as possible. Mobile stroke units are a way to achieve all this by taking the most widely used effective treatment, intravenous thrombolysis, to the patient immediately following the 911 call, and by triaging patients with large vessel occlusions directly to hospitals that can do thrombectomy. The Pick: LeCouffe ND, Kappelhof M, Treurniet KM, et al. A randomized trial of intravenous alteplase before endovascular treatment for stroke. New Engl J Med 2021;385:1833-44

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KPHOTO c STO training and utilizing advanced practice clinicians, as well as offer insights on ways to onboard and engage advanced practice providers to prevent attrition. Why It’s Important: The demand for neurologic care continues to outpace the availability of neurology clinicians.

Advanced practice clinicians can help increase access to neurologic care. Although hiring advanced practice clinician requires a significant financial investment, if integrated strategically, that investment will lead to better provider retention, and subsequent continuity for access to neurology. Suzuki K, Matsumaru Y, Takeuchi M, et al. The effect of mechanical thrombectomy without vs with intravenous thrombolysis on functional outcome among patients with acute ischemic stroke. JAMA 2021;325(3):244-253. Zi W, Qiu Z, Li F, et al. Effect of endovascular treatment alone vs intravenous alteplase plus endovascular treatment on functional independence in patients with acute ischemic stroke. JAMA 2021;325(3):234-243. The Findings: Among patients who qualify for systemic thrombolysis with tPA, about 25 percent harbor clots in the large vessels or large vessel occlusions (LVOs). Endovascular thrombectomy is a powerfully effective treatment for these patients, but tPA usually cannot dissolve these large clots. Consequently, there is uncertainty if tPA should be given or skipped in LVO patients. The LeCouffe study tested non-inferiority and could not exclude that skipping tPA was inferior to giving it. In fact, patients receiving tPA on average had better outcomes than those in whom it was skipped. This was confirmed in a Swiss study, presented but not yet published (SWIFTDIRECT), and in the Suzuki study from

susan fitzgerald Japan. The Zi study, along with a similar study reported last year, both conducted in China, demonstrated non-inferiority Anew study of patients older than 85 who had a recent stroke along with atrial fibrillation (AF) found that the already known benefits for skipping. of direct oral anticoagulants (DOACs) compared with vitamin K antagonists

Why It’s Important: The preponderance held true even for this very old and often frail population.of evidence is that tPA should be given as soon as possible in all patients who qual-Some physicians are hesitant to preify, including those who are candidates scribe the newer direct oral anticoagufor endovascular thrombectomy.lants for stroke prevention in their very elderly AF patients because of fears of The Pick: Halliday A, Bulbulia R, Bonati L, et al. Second asymptomatic carotid surgery trial (ACST-2): A randomised comparison of carotid artery stenting versus carotid endarterectomy. Lancet 2021; 398:1065–1073. The Findings: Previous studies had suggested that carotid stenting was olga rukovets associated with more risk than endarterectomy. In asymptomatic patients, the benefit of either procedure over medical therapy is still in question, so any increased risk would tip the balance. In this large international randomized study of 3,265 patients, serious com-Neurology residents currently complete one month of fulltime clinical training in psychiatry, as required by the Accreditation Council for plications were similarly uncommon Graduate Medical Education (ACGME), after carotid artery stenting and carotid endarterectomy, and the long-term effects on fatal or disabling stroke were comparable. Continued on page 20 PhD candidate in the neurology department and stroke center at University Hospital Basel in Switzerland.

“Based on these findings, more stroke patients could benefit from treatment with direct anticoagulants in the future,” Dr. Polymeris said.

Background information in the new report noted that current guidelines from the American Heart Association/ American Stroke Association recommend DOACs in patients with AF for recurrent stroke prevention in preference to VKAs, based on the results of randomized-controlled trials. But whether that recommendation should apply to the very old is often questioned by doctors and Maimonides Medical Center in Brooklyn, pointed to gaps in both the format and content of psychiatry training for neurologists and called for both to be modernized.

“A large number of disorders, including dementia, fall at the intersection of neurology and psychiatry,” Dr. Jacoby told Neurology Today. “Many disorders that are traditionally the purview of one field or the

idirect oral anticoagulants are safe for very elderly

Patients with stroke and atrial fibrillation

falls and bleeding, instead placing them on older vitamin K antagonists (VKA), aspirin or perhaps nothing at all. The new study, published online November 8 in Annals of Neurology, used real-world data from stroke centers to compare the safety and efficacy of DOAC to VKA by measuring outcomes such as recurrent stroke and intracranial bleeding. “Our data are reassuring in that direct oral anticoagulants maintain their favorable profile in the oldest old with recent stroke, indicating that reluctance to use them in these patients is not justified,” said the study’s lead author, Alexandros Polymeris, MD, a neurology resident and

is it time to update Psychiatry training for neurologists?

Proposals for How to Get It Done but how well does this model prepare other such as Parkinson’s disease, epilepsy, trainees for the disorders they will see in psychotic disorders, and stroke have neuroutine neurologic practice? ropsychiatric manifestations. And there In a Viewpoint published in JAMA are workforce challenges in both specialNeurology on December 6, Daniel Shalev, ties that can make referral and consultaMD, an instructor in medicine and psy- tion difficult. It’s critical that neurologists chiatry at Weill Cornell Medicine in New receive psychiatry training that empowers York, and Nuri Jacoby, MD, an associate them to provide care to patients with psyprofessor of clinical neurology at SUNY chiatric comorbidities,” he said. “Current Downstate Health Sciences University training in

because persons 85 or older were barely represented in the clinical trials and neither were those with very recent ischemic stroke.

Settling that uncertainty is important, especially given Continued on page 30 Continued on page 16

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the Best neurology advances of 2021

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periodicals

NeurologyToday (ISSN 1533-7006), an official publication of the American Academy of Neurology, is published Semi Monthly for the Academy by Wolters Kluwer Health, Inc, at 1800 Dual Highway, Suite 201, Hagerstown, MD 21740-6636. Periodicals Postage Paid at Hagerstown, MD and at additional mailing offices. POSTMASTER: Send address changes to Neurology Today, PO Box 1610, Hagerstown, MD 21740.

Neurology: Clinical Practice Offers Variety of Timely Topics

The new issue of Neurology® Clinical Practice leads with a Special Editorial by Tissa Wijeratne, MBBS, MD, FRACP, FRCP, FAAN, on “Global Advocacy in Action: World Brain Day 2021 dedicated to Stopping Multiple Sclerosis.” Research articles include “Primitive Reflexes and Dementia in Adults with Down Syndrome,” by Jordan Harp, PhD, et al; “Embedded Palliative Care for Amyotrophic Lateral Sclerosis: A Pilot Program and Lessons Learned,” by Kara Bischoff, MD, et al; “Adverse Childhood Experiences in Patients with Neurologic Disease,” by Adys Mendizabal, MD, et al; “Perioperative Neurocognitive Screening Tools for At-risk Surgical Patients,” by Stephen Choi, MSc, MD, et al; and “COVID-19 Outcomes in Hospitalized Patients with Neurodegenerative Disease: A Retrospective Cohort Study,” by Roshni Abee Patel, MD, et al. Published continuously online and in print six times a year, Neurology: Clinical Practice is free to AAN members via the website (and available in print for US members only) who have a current subscription to Neurology. Visit Neurology.org/cp for more information. 

Volume 12, Number 1, February 2022

Neurology.org/CP

A peer-reviewed clinical neurology journal for the practicing neurologist

RESEARCH

Primitive Refl exes and Dementia in Adults With Down Syndrome

RESEARCH

COVID-19 Outcomes in Hospitalized Patients With Neurodegenerative Disease: A Retrospective Cohort Study

RESEARCH

Embedded Palliative Care for Amyotrophic Lateral Sclerosis: A Pilot Program and Lessons Learned

REVIEW

Perioperative Neurocognitive Screening Tools for At-Risk Surgical Patients

Survey Results to Guide Axon Registry Improvements

In an annual survey of Axon Registry® participants in the fall of 2021, 60 percent of survey participants believe the Axon Registry is a “very valuable” or “valuable” resource for their practice and overall participant satisfaction in the Axon Registry remained at 70 percent. Merit Incentive Payment System (MIPS), quality improvement, and maintenance of certification were the three most popular benefits for joining the Axon Registry. Respondents included 87 percent clinicians and 13 percent administrative and non-clinical staff. The survey results show that the COVID-19 pandemic is still impacting quality improvement. Approximately 53 percent of survey respondents stated that the pandemic made quality improvement more difficult. Telehealth and virtual visits were the primary impacts on how the pandemic has affected practice ability to collect data needed to calculate quality measures. The purpose of the annual survey is to receive feedback from participants on improvements the AAN can make to ensure the best experience possible. After receiving participant feedback, the AAN will provide more detailed resources for participating sites, including a data dictionary to ensure accurate documentation. If you have any suggestions or need assistance with the Axon Registry, please contact registry@aan.com. 