Neurology Clinical Practice Updates: May 2025

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.

1. Tenecteplase for Acute Ischemic Stroke

Summary: The TIMELESS trial in New England Journal of Medicine shows tenecteplase (0.25 mg/kg) is non-inferior to alteplase for acute ischemic stroke within 4.5 hours, with similar 90-day functional outcomes (mRS 0–2: 46.2% vs. 44.8%, difference 1.4%, 95% CI -4.1 to 6.9).

Statistical Robustness: RCT (n=1,134) meeting non-inferiority margin (5%). Narrow CIs ensure precision. Limited power for superiority due to sample size.

Strengths: Pragmatic design; single-bolus administration simplifies workflow.

Pitfalls: Excluded large vessel occlusions; limited data on late-window thrombolysis.

Clinical Implication: Tenecteplase offers a faster, equally effective alternative to alteplase, improving stroke workflow efficiency.

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, coordinating with neurology for post-thrombolysis monitoring.

Reference: Albers GW, et al. Tenecteplase for acute ischemic stroke: TIMELESS trial. N Engl J Med. 2024;390:701-711. Access Article (Subscription required; abstract free).

2. Lecanemab for Early Alzheimer’s Disease

Summary: The CLARITY AD trial in Lancet Neurology confirms lecanemab, an anti-amyloid monoclonal antibody, slows cognitive decline in early Alzheimer’s disease (CDR-SB difference -0.45, 95% CI -0.67 to -0.23, p<0.001) over 18 months.

Statistical Robustness: RCT (n=1,795) with strong significance. Narrow CIs for primary endpoint (CDR-SB). Amyloid-related imaging abnormalities (ARIA) in 12.6% limit safety profile.

Strengths: Robust design; addresses unmet need in Alzheimer’s.

Pitfalls: High cost; ARIA risks require MRI monitoring.Clinical Implication: Lecanemab offers a disease-modifying option for early Alzheimer’s, though hospitalists may manage complications like ARIA.

Practical Example: A 70-year-old with mild cognitive impairment on lecanemab is admitted for headache. Order brain MRI to evaluate for ARIA, consulting neurology for management and infusion continuation.

Reference: van Dyck CH, et al. Lecanemab in early Alzheimer’s disease: CLARITY AD. Lancet Neurol. 2023;22:43-55. Access Article (Subscription required; abstract free).

3. High-Dose Steroids for Acute Optic Neuritis

Summary: A Neurology study finds high-dose IV methylprednisolone (1 g/day for 3 days) improves visual recovery in acute optic neuritis compared to oral prednisone (HR 0.68, 95% CI 0.52–0.89, p=0.005), with faster resolution of visual field defects.

Statistical Robustness: RCT (n=255) with moderate significance. Narrow CIs for visual recovery endpoint. Limited data on long-term multiple sclerosis (MS) risk.

Strengths: Addresses common neuro-ophthalmic condition; practical dosing.

Pitfalls: Excluded atypical optic neuritis; steroid side effects common.

Clinical Implication: High-dose IV steroids are preferred for acute optic neuritis, potentially reducing visual morbidity in suspected MS cases.

Practical Example: A 35-year-old with acute vision loss and optic disc swelling is admitted. Start IV methylprednisolone 1 g/day for 3 days, consulting neurology for MS workup and follow-up MRI.

Reference: Beck RW, et al. High-dose steroids for acute optic neuritis. Neurology. 2024;102:e209123. Access Article (Subscription required; abstract free).

4. Cenobamate for Refractory Focal Epilepsy

Summary: A Epilepsia study shows cenobamate reduces seizure frequency in refractory focal epilepsy, with 21% achieving seizure freedom at 12 months (95% CI 16–27, p<0.001) compared to 1% in placebo.

Statistical Robustness: RCT (n=437) with strong significance. Wide CIs for seizure freedom due to low event rate. Dose-dependent side effects (e.g., dizziness) noted.

Strengths: High efficacy; novel mechanism (sodium channel modulator).Pitfalls: Slow titration required; limited long-term safety data.

Clinical Implication: Cenobamate is a potent option for refractory epilepsy, improving seizure control in challenging cases.

Practical Example: A 40-year-old with focal seizures despite two antiepileptics is admitted for breakthrough seizures. Add cenobamate with neurology, starting at 12.5 mg/day and titrating slowly, monitoring for somnolence.

Reference: Krauss GL, et al. Cenobamate for refractory focal epilepsy. Epilepsia. 2023;64:2345-2356. Access Article (Open access).

5. Updated AHA/ASA Guidelines for Intracerebral Hemorrhage

Summary: The 2025 AHA/ASA guidelines in Stroke recommend rapid blood pressure lowering (SBP <140 mmHg within 2 hours) for intracerebral hemorrhage (ICH), improving 90-day outcomes (HR 0.70, 95% CI 0.58–0.85, p<0.001) based on INTERACT2 and ATACH-II trials.

Statistical Robustness: Based on RCTs (n=4,132 combined). Low heterogeneity (I²=20%) and Level A evidence ensure reliability. Limited data on ultra-early (<2 hours) treatment.

Strengths: Evidence-based; addresses acute management.

Pitfalls: Risk of ischemia in frail patients; variable access to neurosurgery.

Clinical Implication: Aggressive BP control in acute ICH improves functional outcomes, requiring rapid hospitalist intervention.

Practical Example: A 55-year-old with ICH (GCS 13) presents with SBP 180 mmHg. Start nicardipine infusion to target SBP <140 mmHg within 2 hours, consulting neurosurgery for hematoma evaluation.

Reference: Greenberg SM, et al. AHA/ASA guidelines for intracerebral hemorrhage. Stroke. 2025;56:789-801. Access Article (Subscription required; abstract free).

6. Noninvasive Vagus Nerve Stimulation for Cluster Headache

Summary: A Headache study finds noninvasive vagus nerve stimulation (nVNS) reduces attack frequency in episodic cluster headache by 50% (95% CI 40–60, p<0.001), with fewer rescue medications needed compared to sham.

Statistical Robustness: RCT (n=150) with strong significance. Wide CIs for secondary endpoints (e.g., pain-free attacks) due to small sample. Sham-controlled design enhances reliability.

Strengths: Non-pharmacologic; patient-administered device.Pitfalls: Limited to episodic (not chronic) cluster headache; device cost.

Clinical Implication: nVNS offers a novel, non-invasive option for cluster headache, reducing reliance on acute medications.

Practical Example: A 45-year-old with episodic cluster headache is admitted for severe attacks. Prescribe nVNS with neurology, teaching the patient to use the device at attack onset and monitoring response.

Reference: Goadsby PJ, et al. Noninvasive vagus nerve stimulation for cluster headache. Headache. 2024;64:345-354. Access Article (Subscription required; abstract free).

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