High-volume anesthetic suboccipital nerve blocks show potential as a treatment option for patients suffering from refractory chronic cluster headaches, according to an observational case series study published in Headache.

For this retrospective 7-year study, researchers followed 10 patients (9 men and 1 woman) who were refractory to treatment for their chronic cluster headaches. Over this time period, the patients were injected at least twice with a solution of 9 mL of 1% lidocaine and 1 mL of triamcinolone 40 mg at the suboccipital fossa. Complete response to treatments was defined as no cluster headaches, and a partial response was defined as either fewer attacks, lower intensity attacks, or shorter lasting attacks.

A complete response occurred in 9 patients, with their relief occurring in less than 24 hours. One patient did not show any response. For responders, the mean response duration was 10.3 weeks (mean range=1.5 to 31 weeks), with 2 patients having pain relief for 44 weeks. Patient’s response time was very consistent after each injection, only varying up to 7 days. Serial injections improved quality of life for many patients. The woman in the study had a long remission time, and over the course of the study, her headaches transitioned to episodic cluster headaches.  One participant, who received the greatest number of injections, developed avascular necrosis and the causal relationship with the suboccipital injections was not determined.  The remainder of participants noted no major adverse events and clinicians noted only mild bone loss at the injection site.


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Future studies need a standard protocol for pain descriptions and to evaluate if corticosteroids are necessary for relief in addition to the block or if the anesthetic block is effective on its own.


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In conclusion, patients with refectory chronic cluster headaches were shown to find reliable pain relief from high-volume anesthetic suboccipital nerve blocks over a long-term follow-up.

The author noted no conflicts of interest.

Reference

Rozen, TD. High-volume anesthetic suboccipital nerve blocks for treatment refractory chronic cluster headache with long-term efficacy data: an observational case series study. [published online August 24, 2018]. Headache. doi: 10.1111/head.13394

Patients with geographic atrophy secondary to age-related macular degeneration (AMD) may potentially benefit from monthly or every-other-month intravitreal pegcetacoplan, an investigational targeted C3 inhibitor, to control lesion growth, according to a paper presented at the American Academy of Ophthalmology 2021 Annual Meeting, held November 12-15, 2021 in New Orleans.

Lesion growth is irreversible in geographic atrophy. Researchers believe pegcetacoplan, an investigational therapy designed to target the complement overactivation that generates geographic atrophy progression, can prevent lesion growth and reduce the likelihood of severe disease.

The objective of the research was to evaluate the efficacy and safety of intravitreal pegacetacoplan in geographic atrophy from the DERBY (ClinicalTrials.gov Identifier: NCT03525613) and OAKS (ClinicalTrials.gov Identifier: NCT03525600) 24-month phase 3 clinical trials.

DERBY and OAKS were 2 randomized, double-masked, sham-controlled clinical trials that compared the efficacy and safety of monthly or every-other-month intravitreal pegacetacoplan to sham in this patient population. Enrollment was completed for DERBY in June 2020 and in July 2020 for OAKS. The trials included patients (DERBY, N=621; OAKS, N=638) who were at least 60 years old, had best corrected visual acuity 24 letters or better, and geographic atrophy area between 2.5 and 17.5 mm² or 1 focal point lesion 1.25 mm² if multifocal geographic atrophy at baseline. 

A change in lesion size in geographic atrophy through fundus autofluorescence from baseline to month 12 was the primary endpoint for both trials. Secondary endpoints included change in visual function from baseline. Safety was measured based on the number of incidences of ocular and systemic adverse events.

The researchers shared their findings of 12-month efficacy and safety data in both Phase 3 studies at the American Academy of Ophthalmology 2021 Annual Meeting on Monday, November 15. 

“Pegcetacoplan is the only targeted C3 inhibitor being evaluated in patients to control lesion growth in GA [geographic trophy],” presenters reported. 

Autoimmune encephalitis develops in approximately one-third of patients with herpes simplex encephalitis within a 3-month period of completing antiviral treatment, according to study results published in Lancet Neurology. Age appears to be associated with neurologic symptoms, immunotherapy response, and long-term outcome in these patients, with older patients experiencing worse outcomes compared with younger patients.

Researchers enrolled patients with clinically confirmed herpes simplex encephalitis who were receiving care at 19 secondary and tertiary centers in Spain (n=54). Patients were followed up to 2 months, 6 months, and 12 months from disease onset. In another cohort, investigators retrospectively enrolled patients who developed post-herpes autoimmune encephalitis (n=51). Clinical and demographic features were compared between patients who developed autoimmune encephalitis vs patients who did not. Comparisons were also stratified by age, with patients age ≤4 compared with patients age >4. Post-herpes autoimmune encephalitis risk factors were also assessed in the retrospective cohort.

In the retrospective cohort, a total of 14 patients (27%) developed autoimmune encephalitis after herpes simplex encephalitis, with 100% of these patients featuring neuronal antibodies at or prior to symptom onset. Of the remaining 37 patients who did not develop autoimmune encephalitis, a total of 11 (30%) patients had antibodies to NMDAR (n=3) or unknown antigens (n=8) (P <.001).

A significant risk factor for autoimmune encephalitis was antibody detection within a 3-week period of herpes simplex encephalitis (odds ratio [OR] 11.5; 95% CI, 2.7-48.8; P <.001). Patients age ≤4 were significantly more likely to experience a shorter median of days between herpes onset and autoimmune encephalitis onset when compared with patients age >4 (26 days [interquartile range 24-32] vs 43 days [interquartile range 25-54], respectively; P =.0073). In addition, individuals age ≤4 were more likely to have choreoathetosis (27 [100%] of 27 vs 0 of 31, respectively; P <.001), decreased level of consciousness (96% vs 23%, respectively; P <.001), NMDAR antibodies (89% vs 61%, respectively; P =.033), and significantly worse 1-year outcome (median modified Rankin Scale 4 [IQR 4-4] vs 2 [2-3], respectively; P <.0010; seizures 63% vs 13%, respectively; P =.001) compared with patients age <4.


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Limitations of the analysis include the relatively small number of patients in each cohort and the use of a clinician-based questionnaire to obtain retrospective data for one of the cohorts.

“Autoimmune encephalitis should be strongly considered in patients who, within this timeframe, develop new neurological or psychiatric symptoms, characterized in younger children by choreoathetosis,” the researchers wrote, “and in older children and adults by cognitive and behavioral impairment or psychosis.”

Reference

Armangue T, Spatola M, Vlagea A, et al. Frequency, symptoms, risk factors, and outcomes of autoimmune encephalitis after herpes simplex encephalitis: a prospective observational study and retrospective analysis [published online July 23, 2018]. Lancet Neurol. doi:10.1016/S1474-4422(18)30244-8

Reference

Singh RP, Steinle NC, Boyer DS, et al. Efficacy and safety of intravitreal pegcetacoplan in GA: results from the phase 3 DERBY and OAKS trials. Paper presented at: The American Academy of Ophthalmology 2021 Annual Meeting; November 12-15, 2021; New Orleans. Abstract PA064.

This article originally appeared on Ophthalmology Advisor