Eplontersen for Hereditary Transthyretin Amyloidosis With Polyneuropathy

Importance

Transthyretin gene silencing is an emerging treatment strategy for hereditary transthyretin (ATTRv) amyloidosis.

Objective

To evaluate eplontersen, an investigational ligand-conjugated antisense oligonucleotide, in ATTRv polyneuropathy.

Design, Setting, and Participants

NEURO-TTRansform was an open-label, single-group, phase 3 trial conducted at 40 sites across 15 countries (December 2019-April 2023) in 168 adults with Coutinho stage 1 or 2 ATTRv polyneuropathy, Neuropathy Impairment Score 10-130, and a documented TTR variant. Patients treated with placebo from NEURO-TTR (NCT01737398; March 2013-November 2017), an inotersen trial with similar eligibility criteria and end points, served as a historical placebo ("placebo") group.

Interventions

Subcutaneous eplontersen (45 mg every 4 weeks; n = 144); a small reference group received subcutaneous inotersen (300 mg weekly; n = 24); subcutaneous placebo weekly (in NEURO-TTR; n = 60).

Main Outcomes and Measures

Primary efficacy end points at week 65/66 were changes from baseline in serum transthyretin concentration, modified Neuropathy Impairment Score +7 (mNIS+7) composite score (scoring range, -22.3 to 346.3; higher scores indicate poorer function), and Norfolk Quality of Life Questionnaire-Diabetic Neuropathy (Norfolk QoL-DN) total score (scoring range, -4 to 136; higher scores indicate poorer quality of life). Analyses of efficacy end points were based on a mixed-effects model with repeated measures adjusted by propensity score weights.

Results

Among 144 eplontersen-treated patients (mean age, 53.0 years; 69% male), 136 (94.4%) completed week-66 follow-up; among 60 placebo patients (mean age, 59.5 years; 68% male), 52 (86.7%) completed week-66 follow-up. At week 65, adjusted mean percentage reduction in serum transthyretin was -81.7% with eplontersen and -11.2% with placebo (difference, -70.4% [95% CI, -75.2% to -65.7%]; P < .001). Adjusted mean change from baseline to week 66 was lower (better) with eplontersen vs placebo for mNIS+7 composite score (0.3 vs 25.1; difference, -24.8 [95% CI, -31.0 to -18.6; P < .001) and for Norfolk QoL-DN (-5.5 vs 14.2; difference, -19.7 [95% CI, -25.6 to -13.8]; P < .001). Adverse events by week 66 that led to study drug discontinuation occurred in 6 patients (4%) in the eplontersen group vs 2 (3%) in the placebo group. Through week 66, there were 2 deaths in the eplontersen group consistent with known disease-related sequelae (cardiac arrhythmia; intracerebral hemorrhage); there were no deaths in the placebo group.

Conclusions and Relevance

In patients with ATTRv polyneuropathy, the eplontersen treatment group demonstrated changes consistent with significantly lowered serum transthyretin concentration, less neuropathy impairment, and better quality of life compared with a historical placebo.

Trial Registration

ClinicalTrials.gov Identifier: NCT04136184; EU Clinical Trials Register: EudraCT 2019-001698-10.

Pooled efficacy and safety of eslicarbazepine acetate as add-on treatment in patients with focal-onset seizures: Data from four double-blind placebo-controlled pivotal phase III clinical studies

Purpose

Pooled evaluation of the key efficacy and safety profile of eslicarbazepine acetate (ESL) added‐on to stable antiepileptic therapy in adults with focal‐onset seizures.

Methods

Data from 1703 patients enrolled in four phase III double‐blind, randomized, placebo‐controlled studies were pooled and analyzed. Following a 2 week titration period, ESL was administered at 400 mg, 800 mg, and 1200 mg once‐daily doses for 12 weeks (maintenance period). Pooled efficacy variable was standardized (/4 weeks) seizure frequency (SSF) analyzed over the maintenance period as reduction in absolute and relative SSF and proportion of responders (≥50% reduction in SSF). Pooled safety was analyzed by means of adverse events and clinical laboratory assessments.

Results

SSF was significantly reduced with ESL 800 mg (P < 0.0001) and 1200 mg (P < 0.0001) compared to placebo. Median relative reduction in SSF was 33.4% for ESL 800 mg and 37.8% for 1200 mg (placebo: 17.6%), and responder rate was 33.8% and 43.1% (placebo: 22.2%). ESL was more efficacious than placebo regardless of gender, geographical region, epilepsy duration, age at time of diagnosis, seizure type, and type of concomitant antiepileptic drugs (AED). Incidence of adverse events (AEs) and AEs leading to discontinuation was dose dependent. Most common AEs (>10% patients) were dizziness, somnolence, and nausea. The incidence of treatment‐emergent AEs (dizziness, somnolence, ataxia, vomiting, and nausea) was lower in patients who began taking ESL 400 mg (followed by 400 mg increments to 800 or 1200 mg) than in those who began taking ESL 600 mg or 800 mg.

Conclusions

Once‐daily ESL 800 mg and 1200 mg showed consistent results across all efficacy and safety endpoints, independent of study population characteristics and type of concomitant AEDs. Treatment initiated with ESL 400 mg followed by 400 mg increments to 800 or 1200 mg provides optimal balance of efficacy and tolerability.

Charcot, Mitchell and Lees: neurology free thinkers and their experiences of psychoactive drugs

Three world-famous neurologists, Charcot and Mitchell, in the 19th century, and Lees, in this century, all of whom had great scientific curiosity, experimented with the psychoactive drugs hashish, mescal and yagé, respectively, in an attempt to increase their knowledge of neurological diseases and how the brain works.

Headache Related to a Specific Screen Flickering Frequency Band

The case of a 25-year-old white male, who had migrainous headaches each time he sat in front of his personal computer screen, is described. Changing the screen frequency from 60 to 75 Hz through a Windows command could abolish the headaches. In several surveys, computer screens have been reported to be a migraine trigger. We hypothesize that this environmental trigger may be related to the abnormal flicker fusion thresholds that have been described in migraineurs. It may be that modifying the frequencies of light sources, such as computer screens, could become a non-pharmacological approach to prevent migraine attacks.

Prevalence of Migraine in Noonan Syndrome

A randomized double-controlled trial involving 22 patients with Noonan syndrome (NS) and 22 normal individuals (control group) was carried out to determine the prevalence of migraine in patients with NS. The NS group consisted of 11 males aged 19.55 ± 6.11 years and 11 females aged 18.81 ± 5.47 years. The control group consisted of 11 males aged 19.55 ± 6.6 years and 11 females aged 18.81 ± 5.47 years. Seven NS-group patients reported migraine without aura (MO), and three reported probable MO (PMO). Taken together, these represent a prevalence of migraine in the NS group of 45.5%. Two control-group patients reported MO, a prevalence of 9.09%. The prevalence of migraine was significantly higher in the NS-group patients than in the controls ( P < 0.005), suggesting a positive association between NS and migraine. Nevertheless, further studies are needed to confirm our findings.

Anne Frank's Headache

There are a significant number of famous people who suffered from frequent headaches during their lifetime while also exerting an influence of some kind on politics or the course of history. One such person was Anneliese Marie Frank, the German-born Jewish teenager better known as Anne Frank, who was forced into hiding during World War II. When she turned 13, she received a diary as a present, named it ‘Kitty’ and started to record her experiences and feelings. She kept the diary during her period in hiding, describing her daily life, including the feeling of isolation, her fear of being discovered, her admiration for her father and her opinion about women's role in society, as well as the discovery of her own sexuality. She sometimes reported a headache that disturbed her tremendously. The ‘bad’ to ‘terrifying’ and ‘pounding’ headache attacks, which were accompanied by vomiting and during which she felt like screaming to be left alone, matched the International Headache Society criteria for probable migraine, whereas the ‘more frequent headaches’ described by Anne's father are more likely to have been tension-type headaches than headaches secondary to ocular or other disorders.

Critical Flicker Frequency in Migraine. A Controlled Study in Patients without Prophylactic Therapy

The critical flicker frequencies (CFF) of individuals with migraine with and without aura were determined and compared to those of normal controls. Twenty-six migraine patients, 12 with aura and 14 without aura and 30 healthy controls were included. Migraineurs were tested during a migraine-free period, through both the continuous flicker method (CFM) and the forced choice method (FCM). Migraineurs presented a mean flickering fusion threshold lower than healthy controls with the CFM (40.45 vs. 44.33, respectively; P = 0.019) and with the FCM (34.16 Hz vs. 38.5 Hz, respectively, P = 0.019). Both groups of migraineurs had significantly lower thresholds as compared to controls, migraineurs with aura presenting the lowest thresholds for the fusion of flickering ( P = 0.008 and P = 0.0001 with the CFM and the FCM, respectively). Results confirmed and extended previous observations of abnormal flicker fusion thresholds in migraineurs. We hypothesize that this finding might be related to a shorter cortical stimulation silent period.

Phenytoin-induced isolated chronic, nocturnal dry cough

We report a 72-year-old man with a four-year history of dyscognitive seizures (with occasional secondary generalization) who developed isolated, nocturnal dry cough immediately after being started on PO phenytoin. The cough was not accompanied by any other symptom or sign as his physical exam was completely normal. Further investigation with chest CT and spirometry was unremarkable. This symptom persisted for six months and did not resolve until we weaned him off of phenytoin. According to the Naranjo Adverse Drug Reaction Probability Scale, his cough was classified as being probably (score + 6) related to the use of this antiepileptic drug. To our knowledge, there has been only one study that reported phenytoin-triggered cough. It described a postoperative patient who developed cough and bronchospasm after receiving IV phenytoin. By reporting our case and discussing the literature on this specific topic, we have essentially two goals. First, we intend to remind clinicians that isolated persistent cough can be an adverse reaction to phenytoin. Second, we hope to encourage further studies that will be able to elucidate the association presented herein.

OnabotulinumtoxinA for trigeminal neuralgia: a review of the available data

Trigeminal neuralgia (TN) patients may develop side effects from centrally acting drugs, have contraindications for neurosurgical procedures, or experience relapse during conventional therapies. OnabotulinumtoxinA (BoNT/A) has been reported to be effective for TN, although this finding has been challenged. An overview of the available evidence based on a narrative/qualitative analysis of the literature is presented. About 90% of patients who receive BoNT/A show an improvement, a higher figure than that reported for the placebo effect of BoNT/A for other headaches. Tolerability of BoNT/A is good, and its few side-effects are transient. The articles reviewed were mainly case reports, case series and open-label trials; however, randomized controlled trials have endorsed the efficacy of BoNT/A for TN. This evidence, together with a better understanding of the analgesic mechanisms of BoNT/A and its proven efficacy in treating other pain syndromes, supports the use of this toxin as a therapeutic option for TN.

The visual system in migraine: from the bench side to the office

BACKGROUND

Throughout history, migraine-associated visual symptoms have puzzled patients, doctors, and neuroscientists. The visual aspects of migraine extend far beyond the aura phenomena, and have several clinical implications.

METHODS

A narrative review was conducted, beginning with migraine mechanisms, then followed by pertinent aspects of the anatomy of visual pathways, clinical features, implications of the visual system on therapy, migraine on visually impaired populations, treatment of visual auras and ocular (retinal) migraine, effect of prophylactic migraine treatments on visual aura, visual symptoms induced by anti-migraine or anti-headache drugs, and differential diagnosis.

RESULTS

A comprehensive narrative review from both basic and clinical standpoints on the visual aspects of migraine was attained; however, the results were biased to provide any useful information for the clinician.

CONCLUSION

This paper achieved its goals of addressing and condensing information on the pathophysiology of the visual aspects of migraine and its clinical aspects, especially with regards to therapy, making it useful not only for those unfamiliar to the theme but to experienced physicians as well.

Eslicarbazepine acetate as adjunctive therapy in patients with uncontrolled partial-onset seizures: Results of a phase III, double-blind, randomized, placebo-controlled trial

Objective

To evaluate the efficacy and safety of adjunctive eslicarbazepine acetate (ESL) in patients with refractory partial-onset seizures.

Methods

This randomized, placebo-controlled, double-blind, parallel-group, phase III study was conducted at 173 centers in 19 countries, including the United States and Canada. Eligible patients were aged ≥16 years and had uncontrolled partial-onset seizures despite treatment with 1–2 antiepileptic drugs (AEDs). After an 8-week baseline period, patients were randomized to once-daily placebo (n = 226), ESL 800 mg (n = 216), or ESL 1,200 mg (n = 211). Following a 2-week titration period, patients received ESL 800 or 1,200 mg once-daily for 12 weeks. Seizure data were captured and documented using event-entry or daily entry diaries.

Results

Standardized seizure frequency (SSF) during the maintenance period (primary end point) was reduced with ESL 1,200 mg (p = 0.004), and there was a trend toward improvement with ESL 800 mg (p = 0.06), compared with placebo. When data for titration and maintenance periods were combined, ESL 800 mg (p = 0.001) and 1,200 mg (p < 0.001) both reduced SSF. There were no statistically significant interactions between treatment response and geographical region (p = 0.38) or diary version (p = 0.76). Responder rate (≥50% reduction in SSF) was significantly higher with ESL 1,200 mg (42.6%, p < 0.001) but not ESL 800 mg (30.5%, p = 0.07) than placebo (23.1%). Incidence of treatment-emergent adverse events (TEAEs) and TEAEs leading to discontinuation increased with ESL dose. The most common TEAEs were dizziness, somnolence, nausea, headache, and diplopia.

Significance

Adjunctive ESL 1,200 mg once-daily was more efficacious than placebo in adult patients with refractory partial-onset seizures. The once-daily 800 mg dose showed a marginal effect on SSF, but did not reach statistical significance. Both doses were well tolerated. Efficacy assessment was not affected by diary format used.

Vagus nerve stimulation may be a sound therapeutic option in the treatment of refractory epilepsy

INTRODUCTION: Refractory epilepsy accounts for 20 to 30% of epilepsy cases and remains a challenge for neurologists. Vagus nerve stimulation (VNS) is an option for palliative treatment. OBJECTIVE: It was to study the efficacy and tolerability of VNS in patients implanted with a stimulator at the Curitiba Institute of Neurology (INC). METHODS: A case study of six patients with refractory epilepsy submitted to a VNS procedure at the INC in the last four years was described and discussed. RESULTS: Mean age at time of implantation was 29 years. Mean follow-up was 26.6 months. Seizure frequency decreased in all patients (40-50% (n=2) and >80% (n=4)). Three patients no longer required frequent hospitalizations. Two patients previously restricted to wheelchairs started to walk, probably because of improved mood. CONCLUSION: In this population, VNS proved to be a sound therapeutic option for treating refractory epilepsy.

Cerebellar ataxia in non-paraneoplastic Lambert-Eaton myasthenic syndrome

Lambert-Eaton myasthenic syndrome (LEMS) is an immune-mediated disorder of the neuromuscular junction that rarely is associated with cerebellar ataxia (CA). We describe two patients with non-paraneoplastic LEMS associated with CA who showed high levels of anti-P/Q-type voltage-gated calcium channels antibodies in the serum and cerebrospinal fluid, and reduced CMAP with increment after brief maximum voluntary contraction in electrophysiological studies. We suggest that LEMS should be considered in the differential diagnosis of patients with CA.

Botulinum-A toxin in the treatment of painful post-stroke nocturnal paroxysmal dystonia triggered by periodic limb movements of sleep: case report

INTRODUCTION: Sleep disorders presenting involuntary movements may be very annoying to patients, apart from their negative influence on sleep. OBJECTIVE: To report the use of botulinum type-A toxin (BoNT-A) to manage the case of a patient whose sleep was severely disrupted by episodes of dystonic posturing of the right lower limb triggered by periodic limb movements of sleep (PLMS). METHOD: A 79-year-old woman with mild post-stroke right hemiparesis presented with recurrent painful episodes of dystonia of the right lower limb, which disrupted her sleep. The dystonic episodes could also be voluntarily triggered by extension of the right hallux. Polysomnography confirmed that the dystonic episodes were triggered by PLMS. Twenty units of BoNT-A (20U/500U vial) were injected into her right extensor hallucis longus. RESULTS: Shortly after BoNT-A was injected, the dystonic symptoms abated, and the patient achieved better sleep efficiency. CONCLUSION: The PLMS-related involuntary extension of the hallux was probably triggering the nocturnal post-stroke lower limb dystonic paroxysms. BoNT-A injection into the right extensor hallucis longus was effective in managing this condition and thus resolved the associated disruption of sleep.

Epilepsia e desordens de malformação do desenvolvimento cortical

OBJETIVOS: As desordens do desenvolvimento cortical (DDC) constituem a segunda causa de epilepsia refratária. Diversas patologias estão incluídas nas DDC. Seu diagnóstico foi facilitado com o desenvolvimento na neuroimagem. MÉTODOS: No presente artigo, apresentamos sete casos divididos em três grupos, de acordo com o mecanismo de produção das DDC: 1) anormalidades da proliferação e diferenciação de neurônios da glia; 2) anormalidades de migração neuronal; 3) anormalidades na organização neuronal. A investigação consistiu em história mais exame neurológico, avaliação neuropsicológica, ressonância magnética e eletrencefalograma. RESULTADOS E CONCLUSÕES: Três pacientes apresentaram displasia cortical focal, dois apresentaram heterotopia em banda, um paciente apresentava lisencefalia e uma apresentava esquizencefalia. Todos os pacientes apresentavam epilepsia de difícil controle. Malformações corticais constituem um grupo heterogêneo de causas de epilepsia de difícil controle. É importante para o manejo médico que as diversas formas de malformações corticais sejam conhecidas e diagnosticadas, o que foi facilitado pelo advento da ressonância magnética.

An open study of botulinum-A toxin treatment of trigeminal neuralgia

Thirteen subjects with trigeminal neuralgia were treated with botulinum-A neurotoxin (BoNT/A) in an open-label pilot study. After BoNT/A, visual analog scale score, surface area of pain, and therapeutic coefficient were reduced in all patients and for all branch trigeminal nerves studied. Therefore, BoNT/A is an efficient treatment. There were no major side effects. A placebo-controlled clinical trial is needed to confirm these findings.

Leão's cortical spreading depression

Cortical spreading depression was described in 1943 by Aristides Leão, a Brazilian neurophysiologist. Initially considered to be a mysterious event as it was discovered serendipitously, its nature has become progressively better known. Cortical spreading depression is now accepted as the mechanism underlying migraine aura and has became known as either Leão's spreading depression or cortical spreading depression. Recent studies have suggested a role for Leão's cortical spreading depression in the pathogenesis and symptomatology of neurologic disorders such as transient global amnesia, head injury, and cerebrovascular diseases.

Tratamento cirúrgico da epilepsia do lobo temporal: análise de 43 casos consecutivos

Quarenta e três pacientes com epilepsia refratária ao tratamento medicamentoso foram submetidos à cirurgia de epilepsia do lobo temporal no Instituto de Neurologia de Curitiba, entre os anos de 1998 a 2003. Trinta e nove (90,6%) pacientes apresentavam esclerose mesial temporal, e quatro (9,4%), tumores cerebrais. Dos trinta e sete pacientes que possuíam avaliação pós-operatória completa, 83,7% apresentaram classificação I, segundo Engel (livres de crises incapacitantes). Complicações pós-operatórias ocorreram em 18,6%: uma infecção da ferida operatória, um caso de hidrocefalia, um de fístula liquórica, dois casos de paralisia transitória do IV nervo craniano e um de hemiparesia transitória. Não houve nenhum óbito relacionado à cirurgia de epilepsia no presente estudo.

Warfarin as a therapeutic option in the control of chronic cluster headache: a report of three cases

Chronic cluster headache remains refractory to medical therapy in at least 30% of those who suffer from this condition. The lack of alternative medical therapies that are as effective as, or more effective than, lithium carbonate makes new therapies necessary for this highly disabling condition. Based on a previous report, we gave oral anticoagulants to three patients with chronic cluster headache. Two of them remained cluster headachefree while taking warfarin. In the third patient, the use of warfarin for three weeks initially increased the frequency and intensity of cluster headache attacks but subsequently induced a prolonged remission. In spite of the paucity of data available, oral anticoagulation appears to be a promising therapy for chronic cluster headache.

"Hot-water epilepsy ", "warm-water epilepsy", or bathing epilepsy? Report of three cases and considerations regarding an old theme

Partial and generalized tonic-clonic reflex seizures related to hot water bathing have been described as temperature-related. We describe three cases of bathing epilepsy: a 28 year-old white male and a 30 year-old white female with spells triggered either by warm or hot water, and a 32 year-old female with spells triggered by hot water. The later two of the three cases presented localized epilepsy and a familial history of epilepsy. A complex tactile stimuli might play the most relevant role on seizure triggering, as well as water temperature with an additive effect over cutaneous stimulation.