PracticeUpdate: Neurology - Winter 2018

EDITOR’S PICKS 8

Restarting Antiplatelet Therapy After Spontaneous

α-Linolenic Acid is Associated With MRI Activity in Multiple

Intracerebral Hemorrhage Neurology

Sclerosis Multiple Sclerosis

Take-home message • The authors of this randomized, placebo-controlled study of omega-3 fatty acids in multiple sclerosis report on the relationship between serum levels of the plant-based omega-3 fatty acid α-linolenic acid (ALA) and MRI and clinical outcome measures over 2 years. For the first 6 months, the patients were randomized to use omega-3 fatty acids in monotherapy or placebo. None of the patients used any disease-modifying drugs during this period. After 6 months, all patients started with subcuta- neous injections of 44 μg of interferon beta-1a three times weekly. ALA was measured in serum phospholipids at baseline and at 6, 12, and 24 months of follow-up. Higher levels of ALA were associated with lower odds of new T2 lesions and T1 gadolinium-enhancing lesions, disability progression, and new relapses during follow-up, but these effect estimates were not statistically significant. • This study is most notable for the introduction of the idea and suggestion for further investigation of the role of ALA and plant-based fatty acids (vs marine sources) in multiple sclerosis pathways. Shila Azodi MD Abstract BACKGROUND The plant-based ω-3 fatty acid α-linolenic acid (ALA) has been associated with lower MS risk. It is currently unknown whether ALA affects disease activity. OBJECTIVE To investigate the association between ALA levels and dis- ease activity. METHODS We conducted a cohort study including 87 multiple sclerosis (MS)-patients who originally participated in a randomized trial of ω-3 fatty acids (the OFAMS study). We measured serum levels of ALA dur- ing follow-up and used random intercept logistic regression to estimate odds ratios (OR) and 95% confidence intervals (CIs) for the association between ALA levels, new magnetic resonance imaging (MRI) lesions, Expanded Disability Status Scale (EDSS) progression and new relapses adjusting for age at inclusion, sex, and use of interferon beta-1a. RESULTS In continuous (per 1-SD increase) multivariable-adjusted analy- ses, higher ALA levels were significantly associated with lower odds of new T2-lesions (OR: 0.59, 95% CI: 0.37-0.95) during follow-up. The effect estimates were similar for new T1Gd+ lesions (OR: 0.73, 95% CI: 0.48- 1.11), EDSS-progression (OR: 0.62, 95% CI: 0.34-1.16) and new relapses (OR: 0.49, 95% CI: 0.22-1.10), but these estimates did not reach statisti- cal significance. Further adjustment for vitamin D and tobacco use did not materially change the results. CONCLUSION We found that higher levels of ALA were associated with lower disease activity in MS-patients. α -Linolenic Acid Is Associated With MRI Activity in a Prospective Cohort of Multiple Sclerosis Patients. Mult Scler 2018 May 01;[EPub Ahead of Print], K Bjornevik, KM Myhr, A Beiske, et al. www.practiceupdate.com/c/69742

Take-home message • The decision to restart antiplatelet therapy (APT) after an intracranial hemorrhage (ICH) and balancing the risks of ischemic vascular events with those of ICH recurrence are difficult and frequent dilemmas for the neurologist. This multicenter, retrospective, matched cohort study compared functional outcomes and health-related quality of life (HRQoL) associated with restarting vs not restarting APT in patients with ICH. After propensity matching, a modified Rankin Scale score (mRS) of 0–2 was achieved in 35.5% of patients resuming APT and 43.9% of patients not resuming APT, not reaching statistical significance. The other outcomemeasures were also non-significantly different between the groups. • The results suggest that, in patients already on APT before presenting with spontaneous ICH, restarting the APT after the acute hospitalization is not associated with worse func- tional outcomes. Codrin Lungu MD Abstract OBJECTIVE To compare the functional outcomes and health-related qual- ity of life metrics of restarting vs not restarting antiplatelet therapy (APT) in patients presenting with intracerebral hemorrhage (ICH) in the ERICH (Ethnic/Racial Variations of Intracerebral Hemorrhage) study. METHODS Adult patients aged 18 years and older who were on APT before ICH and were alive at hospital discharge were included. Patients were dichotomized based on whether or not APT was restarted after hospital discharge. The primary outcome was a modified Rankin Scale score of 0-2 at 90 days. Secondary outcomes were excellent outcome (modified Rankin Scale score 0-1), mortality, Barthel Index, and health status (EuroQol-5 dimensions [EQ-5D] and EQ-5D visual analog scale scores) at 90 days. RESULTS The APT and no APT cohorts comprised 127 and 732 patients, respectively. Restarting APT was associated with lower rates of good func- tional outcome (36.5% vs 40.8%; p = 0.021) and lower Barthel Index scores at 90 days (p = 0.041). The 2 cohorts were then matched in a 1:1 ratio, and the matched cohorts each comprised 107 patients. No difference in pri- mary outcome was observed between restarting vs not restarting APT (35.5% vs 43.9%; p = 0.105). There were also no differences between the secondary outcomes of the 2 cohorts. CONCLUSION Restarting APT in patients with ICH of mild to moderate severity after acute hospitalization is not associated with worse func- tional outcomes or health-related quality of life at 90 days. In patients with significant cardiovascular risk factors who experience an ICH, restarting APT remains the decision of the treating practitioner. Restarting Antiplatelet Therapy After Spontaneous Intracerebral Hem- orrhage: Functional Outcomes. Neurology 2018 Jul 03;91(1)e26-e36, CJ

Chen, D Ding, TJ Buell, et al. www.practiceupdate.com/c/70538

PRACTICEUPDATE NEUROLOGY