Welcome to the Neurology Updates section of our Hospital Medicine Cheat Sheets blog! We summarize recent practice-changing research in neurological disorders from peer-reviewed journals. Each entry is concise, clinically focused, and includes a journal link, statistical robustness, study strengths and pitfalls, clinical implications, and a practical example of application. Stay informed about new guidelines, therapies, and diagnostic approaches.
The TIMELESS trial in New England Journal of Medicine evaluates tenecteplase (0.25 mg/kg) for acute ischemic stroke, reporting comparable functional outcomes to standard care across key endpoints.
Statistical Robustness
RCT with predefined margins; narrow CIs for major outcomes. Power for superiority analyses is limited by sample size.
Limited data in certain subgroups (e.g., late-window thrombolysis with LVO).
Clinical Implication
Tenecteplase offers a streamlined alternative to alteplase and may improve door-to-needle logistics.
Practical Example
A 65-year-old with acute stroke (NIHSS 8) presents within 3 hours. Administer tenecteplase 0.25 mg/kg after CT rules out hemorrhage; coordinate post-thrombolysis monitoring.
Reference: Albers GW, et al. Tenecteplase for Stroke at 4.5–24 Hours with Perfusion-Imaging Selection. N Engl J Med. 2024;390:701–711.
5. Updated AHA/ASA Guidelines for Intracerebral Hemorrhage
Contemporary AHA/ASA guidance emphasizes early BP control (e.g., targeting SBP <140 mmHg when appropriate), rapid triage, and multidisciplinary care to improve outcomes in ICH.
Statistical Robustness
Recommendations draw on RCTs including INTERACT2 and ATACH-II, with meta-analytic support for BP targets.
Ultra-early windows and frail patients require individualized targets; resource variability impacts implementation.
Clinical Implication
Initiate aggressive but safe BP control, coordinate neurosurgical evaluation, and follow protocolized supportive care.
Practical Example
A 55-year-old with ICH (SBP 180 mmHg): start nicardipine infusion to target SBP <140 mmHg within 2 hours; consult neurosurgery for hematoma assessment.
Reference: Greenberg SM, et al. Guidelines for Spontaneous ICH. Stroke. 2022 (AHA/ASA).
6. Noninvasive Vagus Nerve Stimulation for Cluster Headache
Sham-controlled trials of noninvasive vagus nerve stimulation (nVNS) in episodic cluster headache show reductions in attack frequency and rescue medication needs.
Statistical Robustness
Randomized, sham-controlled designs with significant primary outcomes; some secondary endpoints have wider CIs due to smaller samples.
Strengths
Non-pharmacologic, patient-administered therapy.
Pitfalls
Evidence strongest in episodic (vs chronic) cluster; device cost/access considerations.
Clinical Implication
nVNS can reduce reliance on acute medications for eligible episodic cluster patients.
Practical Example
A 45-year-old with episodic cluster headache: prescribe nVNS and teach use at attack onset; monitor frequency and rescue use.
Reference: Goadsby PJ, et al. nVNS for cluster headache—ACT study. Headache. 2024/earlier trials.
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