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Teaching Course 19: Controversies in Neurology by Mind Map: Teaching Course 19: Controversies
in Neurology
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Teaching Course 19: Controversies in Neurology

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EFNS Conference overview

Mild Cognitive Impairment

To Treat

S. Knecht, Germany, MCI, Are you in the process of developing dementia?, Yes? - MCI to dementia 10-20%/year, The longer you wait the higher chance, No, the rest, Treat, Causal therapy, repair, Not possible, prevent / slow down, Treatment of vascular risk factors is associated with slower decline in AD,, Deschaintre et al 2009 Neurology, Caloric restriction improves memory in elderly humans, witte et al. 2009 PNAS, Increases memory score, Move and exercise, increase memory score, Symptomatic, improving memory by neuromodulation?, Substantia nigra, dopaminergic system, MCI cognitive impairment in clinical care, Roberts et al Neurology 2010, Cholinesterase inhibitors, Effects: Benarroch 2010, picture 1, Staedt und Riemann, 2007, picture 2, Gais and Born 2004, picture 3, Don't give them at night, as it interferes with memory consolidation, Many studies -- none met primary clinical end point but positive effects were seen on cognitive measures, picture 4, Donepezil treatment of patients with MCI, Doody et al 2009, Donepezil delays progression to AD in MCI subjects with depressive symptoms, Lu et al. Neurology 2009, MCI + depression + donepezil = less conversion in dementia, People with high likelyhood for developing dementia may benefit, Memantine, Others, missed, missed

Not to Treat

J.-M. Annoni, Switzerland, Not enough treatment evidence for standard treatment of MCI, Why not?, MCI is not a valid syndrome, Defined in 1999: Petersen 1995,1999, 5 years before diagnosis of AD a memory drop. Hall et al, Example of another: pre-disease metabolic syndrome, Kendell's criteria for clinical syndromes, picture 6, Different types, picture 7 from Continuum Dementia, The amnestic MCI is more likely to convert to dementia, Majoli 2007, MCI behaves differently in memory clinics and community patients, Farias 2009, Mitchell 2009, Specific therapies usually are unreliable, Prevention of conversion from MCI to dementia, Lower blood pressure (khachaturian,2006), Aspirine? (jonker et al 2003), Cognitive enhancers, Cholinesterase inhibitors, Picture 9, Picture 10, Raschetti 2007, Chelators, Ginko (Birks, 2009), Picture 8 studies, AINS (Etminan,2003), Oestrogens (Scherving 2002), Antioxidants (Lim 2006), Therapies have side effects, Raschetti 2007, There are other approaches, Exercise, Geda 2010, Moderate physical exercise protects, Risk factors, Life style, Conclusion, MCI is a mixture of many syndromes, Specific trials: do not protect against conversion, Therapies have side effects, Interventions: Preventive and lifestyle approaches

Deep Brain stimulation in PD

Shall we do it early?

G. Deuschl., When patients cannot walk anymore, Speech, Studies, Deep brain stimulation plus best medical therapy vs best medical therapy alone for advanced PD (studies), Pallidal vs subthalamic Deep Brain for PD (studies), A RT of Deep-Brain Stimulation for PD (studies), Risks, Picture, Hardware related long term effects, Effects, Speech improved in most studies, Could be valuable argument in yuounger patients, Gait, DBS improves gait and balance parameters in most clinical studies, Postural stability and gait still improved with stimulation in off-medication state, Risk due to stimulation, Psychiatric problems, motor problems, Overall efficacy, Overall Efficacy, Why are there differences in study outcomes?, picture, Wrong comparison?, picture, picture, picture, Picture

Shall we do it late?

Mrs. M. Vidailhet, France, The good things, Despite the overall excellent outcome of neurosurgery in patients, ther is often a contrast between the improvement in motor disability and the difficulties of patients to reintegrate in normal life, patients have high expectations, Does STN meet expectancies, problems reintegrating in normal life, Neurosurgery in PD - A distressed mind in a repaired body?, Schupbach M et al Neurology 2006, Examples, picture, Is the patient early in the evolution of the disease, will he/she be ready to endure some of the adverse events of STN stimulation?, eyelid apraxia, Weiss D et al JNNP 2010, up to 30%, Weight gain, up to 10kg or more, even without increase of food intake, mean increase in BMI 1.14 kg/m2, Impulsive disorders, saleau et al, Apathy, le jeune et al neurology 2009, thobois et al Brain 2010, independent from depression, Motivational changes, Behavioral disorders, krack et al 2001, Conclusion?, The right timing is very important, Young?, can have late disease, Early in disease?, can be old, ideal candiate, Personalised medicine

Stroke

N.G. Wahlgren

Mismatch concept MR / DWI - Pro, 2 million brain cells die for every minute, Dilemma: treat or not to treat based on mismatch concept, <4 hours, 4 hour time window, >4 hours, some patients may benefit, How to find the right patients, imaging, MR-Angio, diagnose occlusion, Cerebral blood flow, MTT, Mean Transit Time, Conventional, DWI, Diffusion Weighted Imaging, Does mismatch represent the penumbra?, Kidwell et al, Not successfull yet, DIAS 1 & 2: desmoteplase in acute ischemic stroke, DEDAS: dose excalation study of desmoteplase in Acute ischemic Stroke, EPITHET pilot / EPITHET trial, to come, Extend, Conclusion, the mismatch concept is RIGHT, There are methodological limitations that need to be solved

J. Sobesky

Mismatch concept MR / DWI - contra, Some pictures follow, Case Vignette, Vignette, pictures, How to delineate core and hypoperfusion?, DWI / false positive DWI, Is DWI ischaemic core?, CBF CBV MTT TTP, PWI - algorhytms, MRI perfusion maps, Does mismatch match penumbra?, picture, Mismatch based on delayed trombolysis, picture, this presentation is not fully covered

The debate