News & Views in 2015

Studies into the relationship between diabetes and amyotrophic lateral sclerosis (ALS) have produced conflicting results. In young patients, diabetes is a consistent risk factor for ALS; in older patients, diabetes protects against ALS in Europe, but increases the risk of ALS in Asia. Environment and genotype might both contribute to this variation.

The detection of an unruptured intracranial aneurysm poses a dilemma for the patient and the physician: an aneurysm rupture is a catastrophic event, but preventive repair is not without risks. The recently updated AHA/ASA guidelines provide some foundation for decision-making by summarizing the available evidence, but several clinically relevant questions remain uncertain.

A large study corroborates the link between depression and increased risk of subsequent Parkinson disease (PD), but whether depression is a risk factor for or a prodromal symptom of PD remains a conundrum. Consideration of nonbiological risk factors and disorders associated with depression aside from PD could elucidate this complex relationship.

Cognitive impairment is a major sequela after stroke. A recent study shows that cognitive impairment is prevalent after ischaemic stroke, even in patients with good functional recovery, and that compromise in different cognitive domains predicts future functional disability. Here, we reflect on how poststroke cognitive impairment is measured and conceptualized.

Bevacizumab is approved for use in recurrent glioblastoma, but whether it benefits patients with newly diagnosed glioblastoma remains unclear. Two new studies further question the use of the bevacizumab in this context, but leave much to be clarified about its optimal clinical application.

Multiple system atrophy (MSA) carries a universally poor prognosis, but the natural history of the disease is not well established. A new study prospectively followed a cohort of patients with MSA across multiple centres in the USA. The results provide valuable insight into progression and survival in patients with MSA.

A surprisingly high rate of nonconvulsive seizures and status epilepticus is found during continuous EEG monitoring in critically ill patients. A recent analysis of data regarding hospitalization and mortality in patients with status epilepticus emphasizes the relevance not only of how status epilepticus is defined, but also of how it is detected.

A recent study has identified a variant of the SLC9A9 gene that is associated with the clinical response to IFN-β treatment. IFN-β induces SLC9A9 expression, resulting in inhibition of proinflammatory T lymphocytes. The findings suggest a key role for this gene in determining the response to IFN-β in patients with multiple sclerosis.

Treatment of older patients with glioblastoma must take into account reduced treatment benefits and increased treatment-related toxicity, as this group of frail patients has a particularly poor prognosis. A new systematic review provides guidance for treating elderly patients, but decision-making in clinical practice faces many challenges.

The list of vascular, lifestyle-related and other risk factors and biomarkers associated with dementia development has constantly grown over the past few years. A recent study emphasizes the importance of risk prediction models for identification of individuals with increased risk of future cognitive impairment who could benefit from preventive interventions.

Class I evidence supports the efficacy of surgical treatment in patients with temporal lobe epilepsy that is refractory to antiseizure medications. One major concern, however, is the risk of memory decline, particularly after temporal lobe resection in the language-dominant hemisphere. A new study evaluates a noninvasive technique to predict these memory deficits.

Primary CNS lymphoma (PCNSL) is uniquely responsive to initial radiotherapy or chemotherapy, but the best therapeutic approach remains uncertain. Recently updated results from a phase III trial do not support the use of radiotherapy in PCNSL, although the analyses had several disappointing limitations.

Seizures after neonatal hypoxia are difficult to treat. A recent antiepileptic safety and dose-finding study examined phenobarbital plus bumetanide, but was stopped owing to apparent futility and increased risk of hearing loss. However, this decision could have been overcautious: 0.2 mg/kg bumetanide reduced seizure burden, and might not have increased hearing loss.

A new study shows that in patients with multiple sclerosis who exhibit active disease despite disease-modifying therapy, a switch to fingolimod is more effective than continuation of IFN-β or glatiramer acetate for preventing relapses and worsening of disability. These data support the utility of treatment escalation to improve disease control.

Local synthesis of IgG in the CNS is present in >90% of patients with multiple sclerosis (MS), and is considered a hallmark of the disease. A recent study has discovered genetic factors associated with intrathecal production of these antibodies, and suggests excessive IgG synthesis as an indicator of an aggressive disease.

In a long-term clinical trial, a responsive neurostimulation system was shown to reduce seizures and improve quality of life in patients with drug-resistant epilepsy. Furthermore, these effects persisted over an extended time period. Will neurostimulation close the treatment gap for patients with refractory epilepsy?

A long-term outcome analysis in patients with lacunar stroke enrolled in the Secondary Prevention of Small Subcortical Strokes trial highlights the relevance of functional disability after small-vessel strokes. These data support the emerging 'burden of disease' concept in individuals with cerebral microangiopathy, and the role of MRI in outcome prediction.

The apolipoprotein E ε4 (APOE^*ε4) allele is a well-established risk factor for cognitive decline, particularly among white individuals. A recent study highlights factors associated with cognitive resilience in both black and white APOE^*ε4 carriers. Despite racial differences in the frequency and impact of APOE^*ε4, resilience factors are similar across races.

A recent review and meta-analysis on pharmacotherapy for neuropathic pain provides a precise update on treatment efficacy and adverse effects. The authors offer revised evidence-based recommendations for first-line therapies and subsequent options, but we still a need to improve individual treatment decisions, including nonpharmacological therapies, in affected patients.

Research into Friedreich ataxia has been hampered by low availability of study participants. Now, a European consortium has released baseline data from a continuing study of 592 patients with Friedreich ataxia, providing information on clinical features and progression. Such large cooperative studies might herald the final battle against this disabling disease.