Safety of anti-CGRP monoclonal antibodies in patients with migraine during the COVID-19 pandemic: Present and future implications.

BACKGROUND AND OBJECTIVE: CGRP, a neuropeptide involved in migraine pathophysiology, is also known to play a role in the respiratory system and in immunological conditions such as sepsis. We analyzed the impact of the use of CGRP antagonists in patients with migraine during the COVID-19 pandemic, caused by the SARS-CoV-2 coronavirus. METHODS: This is a multicentre cross-sectional study. From May to November 2020, through a national survey distributed by the Spanish Society of Neurology, we collected data about the presence of COVID-19 symptoms including headache and their characteristics and severity in patients with migraine treated with anti-CGRP monoclonal antibodies (mAb), and compared them with patients with migraine not receiving this treatment. We also conducted a subanalysis of patients with COVID-19 symptoms. RESULTS: We recruited 300 patients with migraine: 51.7% (155/300) were taking anti-CGRP mAbs; 87.3% were women (262/300). Mean age (standard deviation) was 47.1 years (11.6). Forty-one patients (13.7%) met diagnostic criteria for COVID-19, with no statistically significant difference between patients with and without anti-CGRP mAb treatment (16.1% vs 11.0%, respectively; P=.320). Of the patients with COVID-19, 48.8% (20/41) visited the emergency department and 12.2% (5/41) were hospitalised. Likewise, no clinical differences were found between the groups of patients with and without anti-CGRP mAb treatment. CONCLUSION: Anti-CGRP mAbs may be safe in clinical practice, presenting no association with increased risk of COVID-19.

Safety of anti-CGRP monoclonal antibodies in patients with migraine during the COVID-19 pandemic: Present and future implications / Seguridad de los anticuerpos monoclonales anti-CGRP en pacientes con migraña durante la pandemia de COVID-19: implicaciones actuales y futuras

Background and objective: CGRP, a neuropeptide involved in migraine pathophysiology, is also known to play a role in the respiratory system and in immunological conditions such as sepsis. We analyzed the impact of the use of CGRP antagonists in patients with migraine during the COVID-19 pandemic, caused by the SARS-CoV-2 coronavirus.MethodsThis is a multicentre cross-sectional study. From May to November 2020, through a national survey distributed by the Spanish Society of Neurology, we collected data about the presence of COVID-19 symptoms including headache and their characteristics and severity in patients with migraine treated with anti-CGRP monoclonal antibodies (mAb), and compared them with patients with migraine not receiving this treatment. We also conducted a subanalysis of patients with COVID-19 symptoms.ResultsWe recruited 300 patients with migraine: 51.7% (155/300) were taking anti-CGRP mAbs; 87.3% were women (262/300). Mean age (standard deviation) was 47.1 years (11.6). Forty-one patients (13.7%) met diagnostic criteria for COVID-19, with no statistically significant difference between patients with and without anti-CGRP mAb treatment (16.1% vs 11.0%, respectively; P = .320). Of the patients with COVID-19, 48.8% (20/41) visited the emergency department and 12.2% (5/41) were hospitalised. Likewise, no clinical differences were found between the groups of patients with and without anti-CGRP mAb treatment.ConclusionAnti-CGRP mAbs may be safe in clinical practice, presenting no association with increased risk of COVID-19. (AU)

Antecedentes y objetivo: El péptido relacionado con el gen de la calcitonina (CGRP, por sus siglas en inglés), es un neuropéptido involucrado en la fisiopatología de la migraña, que también es conocido por participar en la regulación del sistema respiratorio y en algunas enfermedades inmunológicas como la sepsis. Hemos analizado el impacto del uso de los antagonistas de CGRP en pacientes con migraña durante la pandemia de COVID-19, causada por el coronavirus SARS-CoV-2.MétodosEstudio transversal multicéntrico desarrollado entre mayo y noviembre de 2020, en el que la Sociedad Española de Neurología distribuyó a nivel nacional una encuesta de la que recogimos datos sobre la presencia, las características y la gravedad de síntomas de COVID-19, entre los que se encontraba la cefalea, en pacientes con migraña tratados con anticuerpos monoclonales (AcM) anti-CGRP, y los comparamos con los de pacientes con migraña que no recibían dicho tratamiento. También realizamos un subanálisis de los pacientes con síntomas de COVID-19.ResultadosIdentificamos 300 pacientes con migraña: 51,7% (155/300) recibían AcM anti-CGRP; el 87,3% eran mujeres (262/300) y la edad media (desviación estándar) de la muestra fue de 47,1 (11,6) años. Un total de 41 pacientes (13,7%) cumplían los criterios diagnósticos de COVID-19, sin diferencias estadísticamente significativas entre los pacientes que recibían tratamiento con AcM anti-CGRP y los que no (16,1% y 11,0%, respectivamente; p = 0,320). De los pacientes con COVID-19, el 48,8% (20/41) acudieron a urgencias y el 12,2% (5/41) fueron hospitalizados. Igualmente, no se detectaron diferencias clínicas entre los pacientes que recibían dicho tratamiento y los que no.ConclusiónEl tratamiento con AcM anti-CGRP parece un recurso seguro en la práctica clínica, y no se asocia a un mayor riesgo de COVID-19. (AU)

Safety of anti-CGRP monoclonal antibodies in patients with migraine during the COVID-19 pandemic: Present and future implications.

BACKGROUND AND OBJECTIVE: CGRP, a neuropeptide involved in migraine pathophysiology, is also known to play a role in the respiratory system and in immunological conditions such as sepsis. We analyzed the impact of the use of CGRP antagonists in patients with migraine during the COVID-19 pandemic, caused by the SARS-CoV-2 coronavirus. METHODS: This is a multicentre cross-sectional study. From May to November 2020, through a national survey distributed by the Spanish Society of Neurology, we collected data about the presence of COVID-19 symptoms including headache and their characteristics and severity in patients with migraine treated with anti-CGRP monoclonal antibodies (mAb), and compared them with patients with migraine not receiving this treatment. We also conducted a subanalysis of patients with COVID-19 symptoms. RESULTS: We recruited 300 patients with migraine: 51.7% (155/300) were taking anti-CGRP mAbs; 87.3% were women (262/300). Mean age (standard deviation) was 47.1 years (11.6). Forty-one patients (13.7%) met diagnostic criteria for COVID-19, with no statistically significant difference between patients with and without anti-CGRP mAb treatment (16.1% vs 11.0%, respectively; P=.320). Of the patients with COVID-19, 48.8% (20/41) visited the emergency department and 12.2% (5/41) were hospitalised. Likewise, no clinical differences were found between the groups of patients with and without anti-CGRP mAb treatment. CONCLUSION: Anti-CGRP mAbs may be safe in clinical practice, presenting no association with increased risk of COVID-19.

Microhemorragias cerebrales múltiples asociadas con el desarrollo de coagulación intravascular diseminada / Multiple cerebral microbleeds associated with disseminated intravascular coagulation

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[The cost of neurological disease]. / El coste de las enfermedades neurológicas.

INTRODUCTION: Cost studies are an indispensable tool for the clinician to know the financial consequences of neurological diseases in the health care system and to establish the efficacy of the different therapeutic measures used in the daily practice. DEVELOPMENT: The financial burden of neurological diseases on health care and stroke costs is analyzed. The cost of neurological diseases, specifically stroke, depends mainly on their high incidence and related disability. In the case of stroke, the establishment of strategies aimed at decreasing hospital stay and disability on discharge is required to reduce the disease related cost. CONCLUSIONS: One of the main determinants for the cost of neurological diseases is disability. Therapeutic measures that are capable of reducing the patient's disability will also decrease the disease-associated cost.

El coste de las enfermedades neurológicas / The cost of neurological disease

Introducción. Los estudios de coste son las herramientas de las que dispone el clínico para conocer las consecuencias económicas de las enfermedades sobre el sistema sanitario y establecer la eficacia de las diferentes medidas terapéuticas utilizadas en la práctica diaria. Desarrollo. Se analiza el impacto de las enfermedades neurológicas sobre el gasto sanitario y los costes del ictus. El coste de las enfermedades neurológicas y concretamente en el ictus se explica por su elevada prevalencia e incidencia y sobre todo la discapacidad y dependencia que producen. En el caso del ictus la reducción del coste de la enfermedad requiere la implantación de estrategias dirigidas para disminuir la estancia hospitalaria y la discapacidad al alta. Conclusiones. Uno de los condicionantes más importantes del gasto sanitario en las enfermedades neurológicas es la discapacidad que producen. Las medidas terapéuticas que consigan reducir la discapacidad de los pacientes disminuirán a la vez el coste asociado a la enfermedad

Introduction. Cost studies are an indispensable tool for the clinician to know the financial consequences of neurological diseases in the health care system and to establish the efficacy of the different therapeutic measures used in the daily practice. Development. The financial burden of neurological diseases on health care and stroke costs is analyzed. The cost of neurological diseases, specifically stroke, depends mainly on their high incidence and related disability. In the case of stroke, the establishment of strategies aimed at decreasing hospital stay and disability on discharge is required to reduce the disease related cost. Conclusions. One of the main determinants for the cost of neurological diseases is disability. Therapeutic measures that are capable of reducing the patient’s disability will also decrease the disease-associated cost

[Ilioinguinal neuropathy: usefulness of conduction studies]. / Neuropatía ilioinguinal: utilidad de los estudios de conducción.

Ilioinguinal neuropathy is an under-recognized etiology of pelvic pain, that is frequently misdiagnosed with alternative etiologies of pelvic pain. This is partially due to the limited usefulness of neurophysiological studies. Indeed, electromyography of the lower abdominal musculature identifies slightly more than half of the cases. In spite of an available conduction technique described in normal subjects, the usefulness of nerve conduction studies in ilioinguinal neuropathy is uncertain because their use has not been validated with patients. We describe the case of a patient with left inguinal pain following left inguinal herniorraphy. He underwent repeated surgeries and several analgesic treatments, without amelioration of pain. Conduction studies were consistent with ilioinguinal neuropathy. Anesthetic block relieved symptoms temporarily, and the symptoms disappeared upon section of the ilioinguinal nerve. This case describes the usefulness of conduction studies in the diagnosis of ilioinguinal neuropathy.

[Medical treatment of intracranial arterial stenosis. Are primary and secondary prevention the same thing?]. / Tratamiento médico de la estenosis arterial intracraneal. Es el mismo en prevención primaria que en secundaria?

AIMS: In this study we review the risk factors associated with the formation and progression of an atheroma plaque, the mechanism involved in cerebral ischemia secondary to intracranial atheromatosis and possible medical treatment in primary and secondary prevention. DEVELOPMENT: Medical treatment of intracranial stenoses (ICS) is aimed at stopping the progression of the atheroma plaque and at preventing recurrences in the case of symptomatic stenoses. It is based on the control of vascular risk factors, the use of statins and antithrombotic therapy (antiplatelet or anticoagulation drugs). Although antiplatelet agents have not proved to be beneficial in the primary prevention of stroke, they are recommended in patients with ICS in order to lower the risk of heart attack associated with this pathology. The use of antiplatelet drugs in the secondary prevention of ischemic stroke secondary to an ICS is based on clinical trials which have shown that antiaggregation prevents non-cardioembolic strokes. Nevertheless, several retrospective studies have observed that oral anticoagulation is better than antiaggregation with aspirin. Two prospective clinical trials are currently being conducted which will, in the next few years, help to determine what the first choice medical treatment is for this group of patients. CONCLUSIONS: Medical treatment of ICS patients must include the control of vascular risk factors and the use of statins. New studies are needed to be able to establish the first choice antithrombotic drug in secondary prevention.

Tratamiento médico de la estenosis arterial intracraneal. ¿Es el mismo en prevención primaria que en secundaria? / Medical treatment of intracranial arterial stenosis. Are primary and secondary prevention the same thing?

Objetivo. En este trabajo se revisan los factores de riesgo asociados a la formación y progresión de la placa de ateroma, el mecanismo de la isquemia cerebral secundaria a la ateromatosis intracraneal y las posibilidades de tratamiento médico en prevención primaria y secundaria. Desarrollo. El tratamiento médico de las estenosis intracraneales (EIC) tiene como objetivos impedir la progresión de la placa de ateroma y evitar las recurrencias en el caso de las estenosis sintomáticas. Se basa en el control de los factores de riesgo vascular, el empleo de estatinas y la terapia antitrombótica (antiagregación o anticoagulación). Aunque los antiagregantes no han demostrado ningún beneficio en la prevención primaria del ictus, en los pacientes con EIC se recomiendan para reducir el riesgo de infarto de miocardio asociado a esta patología. La utilización de antiagregantes plaquetarios en la prevención secundaria del ictus isquémico secundario a una EIC se sustenta en los ensayos clínicos que han demostrado que la antiagregación previene el ictus no cardioembólico. Sin embargo, varios estudios retrospectivos han observado que la anticoagulación oral es superior a la antiagregación con aspirina. Actualmente, están en marcha dos ensayos clínicos prospectivos, que en los próximos años contribuirán a definir cuál es el tratamiento médico de elección de este grupo de pacientes. Conclusión. El tratamiento médico de los pacientes con EIC debe incluir el control de los factores de riesgo vascular y la utilización de estatinas. Se necesitan nuevos estudios para definir cuál es el antitrombótico de elección en la prevención secundaria (AU)

Aims. In this study we review the risk factors associated with the formation and progression of an atheroma plaque, the mechanism involved in cerebral ischemia secondary to intracranial atheromatosis and possible medical treatment in primary and secondary prevention. Development. Medical treatment of intracranial stenoses (ICS) is aimed at stopping the progression of the atheroma plaque and at preventing recurrences in the case of symptomatic stenoses. It is based on the control of vascular risk factors, the use of statins and antithrombotic therapy (antiplatelet or anticoagulation drugs). Although antiplatelet agents have not proved to be beneficial in the primary prevention of stoke, they are recommended in patients with ICS in order to lower the risk of heart attack associated with this pathology. The use of antiplatelet drugs in the secondary prevention of ischemic stroke secondary to an ICS is based on clinical trials which have shown that antiaggregation prevents non-cardioembolic strokes. Nevertheless, several retrospective studies have observed that oral anticoagulation is better than antiaggregation with aspirin. Two prospective clinical trials are currently being conducted which will, in the next few years, help to determine what the first choice medical treatment is for this group of patients. Conclusions. Medical treatment of ICS patients must include the control of vascular risk factors and the use of statins. New studies are needed to be able to establish the first choice antithrombotic drug in secondary prevention (AU)

[Neuropsychiatric disorders in Parkinson's disease]. / Trastornos neuropsiquiátricos en la enfermedad de Parkinson.

OBJECTIVE: This paper reviews the main neuropsychiatric disorders associated with Parkinson's disease (PD) and describes the neuropathological hypothesis proposed to explain these symptoms. DEVELOPMENT: This disease is usually associated with neuropsychiatric complications such as depression, anxiety and apathy. Besides, psychiatric symptoms are one of the most common side effects of antiparkinsonian drug-therapy. CONCLUSIONS: Depression is the most frequent emotional disorder reported in patients with PD. Up to 20% of parkinsonian patients meet DSM-IV criteria for major depressive episode and another 20% for dysthymia, while the prevalence of depression in normal aged population is about 2-8%. The relationship between PD and depression has not been fully established. Some investigators have suggested that depressive symptoms in PD are causally related to the underlying neuropathological process, affecting predominantly serotoninergic and dopaminergic pathways. Alternatively, depression in PD may represent a normal reaction to the progressive physical impairment induced by the disease. Otherwise, up to 20% of parkinsonian patients present levodopa-induced psychiatric complications. Visual hallucinations are the commonest, but delusions, confusional states, sexual disorders and sleep disorders have also been described. Serotonin and dopamine have been implicated in the neuropathological basis of these disorders.

[Clinical aspects and prognostic factors of intracerebral hemorrhage]. / Aspectos clínicos y factores pronósticos en la hemorragia intracerebral.

INTRODUCTION: Intracerebral hemorrhage represents approximately 20% of all strokes. In spontaneous intracerebral hemorrhage the essential etiological factor is arterial hypertension, and the most frequent site the putamen and lobes of the cerebrum (lobar hematoma). The mortality is higher than in cerebral infarct, although the long-term prognosis is similar. DEVELOPMENT: We review the most relevant forms of presentation and clinical findings of intracerebral hemorrhage in adults, which show a combination of symptoms common to all types of hematoma and those symptoms which depend on their site. We also analyse the factors and studies which have sought to recognize variables predicting morbimortality.

Aspectos clínicos y factores pronósticos en la hemorragia intracerebral / Clinical aspects and prognostic factors of intracerebral hemorrhage

Introducción. La hemorragia intracerebral representa aproximadamente el 20 por ciento de todos los ictus. En la hemorragia intracerebral espontánea el factor etiológico esencial es la hipertensión arterial, y su localización preferente es el putamen y los lóbulos cerebrales (hematoma lobular). Presenta una mortalidad más elevada que el infarto cerebral, mientras que el pronóstico funcional a largo plazo es similar. Desarrollo. Se revisan las formas de presentación y las manifestaciones clínicas más relevantes de la hemorragia intracerebral en el adulto, que combina una serie de síntomas comunes a cualquier tipo de hematoma, y aquellos que dependen de su localización. Asimismo, se analizan los factores y estudios que han tratado de reconocer variables predictivas de morbimortalidad (AU)

[Current situation of neuroprotection in stroke]. / Situación actual de la neuroprotección en el ictus.

Focal and global brain ischemic injury represents one of the most important causes of human neurological disability and mortality in developed countries. It has been long recognized that the two major therapeutic approaches to ischemic stroke involve improving blood flow and the reduction or blockade of the cellular and subcellular consequences of ischemic injury. The important advances experienced during the last decade on the knowledge of pathophysiological mechanisms of brain ischemia and the development of new drugs give us a glimmer of hope in the treatment and they allow us to reject the nihilistic attitudes. We review the new pharmacological approaches to cytoprotective therapy for acute ischemic stroke and the results of reported clinical trials.