Emerging evidence on interventions for small artery blockage, the development of imaging devices to improve care for remote patients and boosting the dementia neurology workforce are all tipped to be major focuses of the specialty in 2024.
The limbic asked three leading neurologists for their takes on what has recently changed practice and what is about to alter the landscape.
Professor Bernard Yan, neurologist and endovascular neurointerventionist at Royal Melbourne Hospital and University of Melbourne
What’s something that changed practice in neurology in 2023?
The principles underlying all this is that to change medical practice, you need randomised controlled studies and not one, but several, to actually move the needle.
We knew in 2015 that by performing endovascular thrombectomy with intravenous thrombolytics that patients with an acute stroke do better than doing nothing but intravenous thrombolytics come with its own risks of brain haemorrhage.
So we started some studies a few years ago (which have just been completed) to ask the question whether we could remove intravenous thrombolytics or keep them.
The findings from our study called DIRECT-SAFE were similar to five other studies around the world and they showed that intravenous thrombolytics was essential.
That changed guidelines in 2023, including the European and American stroke guidelines.
Secondly, all of these studies have only focused on patients with a small ischaemic core but there’s a greater group of patients with larger, irreversibly damaged brain tissue. That question of whether these patients will benefit hadn’t been answered.
Two more studies came out in 2023 published in the New England Medical Journal, together with two studies announced at major meetings, showing beyond any doubt that endovascular thrombectomy also benefits patients with larger ischaemic core.
This has already translated to guidelines for Australia.
What’s something likely to shape neurology in 2024?
From a stroke point of view, we haven’t had any evidence about intervening in patients with small artery blockage.
Small vessel blockage is a bit of a Cinderella because nobody really knows what to do with these patients and they constitute about 25% of all strokes, which is not a small proportion. These patients really haven’t benefited from any effective therapy.
So we started a study to look at offering thrombectomy for distal artery occlusion.
We will probably get the results at the end of 2025 or beginning of 2026. There are now five ongoing studies to answer this question so this would be exciting.
Dr Rowena Mobbs, Sydney neurologist at Macquarie University and director of the Australian CTE Biobank
What’s something that changed practice in neurology in 2023?
Awareness of the neurological sequelae of repeated brain injuries has been a controversial topic in 2023.
Whether or not one believes in the clinical manifestation of Chronic Traumatic Encephalopathy (CTE), the neuropathological causal association with brain injury is clear and there is need to invest in greater research whilst we remain a contact sport loving nation.
At worst case, there could be tens of thousands of patients living with this insidious dementia.
What’s something likely to shape neurology in 2024?
Dementia neurology will continue to rise as a key workforce area of need in 2024.
Many are aware of the tsunami of patients living with dementia but fewer are aware that so many are of younger onset (under 65) or young biologically when over 65.
Hence, whilst geriatricians have traditionally played a role, it is the cognitive neurologist who will also become part of care teams.
Australia already has under servicing and delays in neurology consultations nationally through to 2034 predictions, so investment will be needed by governments now to train more neurologists to address this issue.
Dr Angela Dos Santos, neurologist at the Alfred and Royal Melbourne Hospital, UNSW and research fellow at the Australian Stroke Alliance
What’s something that changed practice in neurology in 2023?
Since 2021 we have seen the evolution of the Australian Stroke Alliance with their partner organisations Titan, Micro-X and EMVision on a journey to transform pre-hospital stroke care.
In 2023 we have seen the development of Zeus, a telehealth platform that has enabled communication between frontline paramedics and stroke neurologists.
What’s something likely to shape neurology in 2024?
In 2024 we will see the ongoing development of imaging devices from Micro X and EMVision to differentiate ischaemic from haemorrhagic stroke which will hopefully enable treatment with thrombolysis in the field, by paramedics, with the assistance of a stroke neurologist via Zeus.
This is a game changer and will see more patients thrombolysed in the “golden hour” after symptom onset, which translates to drastically reduced morbidity and mortality.