From 23rd to 26th May 2020 the European Academy of Neurology (EAN) held its 6th congress, for the first time fully streamed online. Originally planned to take place in Paris, the planning committee chose to go virtual rather than cancelling the congress in light of the ongoing COVID-19 pandemic – a decision they can only be congratulated for. With over 2500 presentations and posters and a record-breaking 42,500 participants from around the world, this had been a huge organisational and technical effort that was mastered exceptionally well.
Symposia were held in combination with pre-recorded lectures and live “question and answer” sections. As in previous years there was a large number of workshops and teaching courses as well which had to be re-conceptualised to fit the virtual congress format, but nevertheless have been a great source of education throughout this congress despite no direct hands-on-experience. We saw excellent courses on caring for pregnant women with neurological diseases, examination of vertigo, acute neurology and many others. Participants were able to further test their knowledge in the Brain challenge quiz, socialise through the virtual hub or try out the yoga classes.
Throughout the conference the unifying spirit of the neurology community during lockdown has been one of inspiration, flexibility, optimism and collaboration, and all presenters took the challenge of preparing their talks at high standards and mastered the technical hurdles.
The overarching theme this year “Time for Action. Predict – Prevent – Repair” was reflected in a huge number of brilliant talks covering all areas of neurology. Given the enormous amount of presentations and topics covered during the congress we can only give a brief and incomplete summary. But for interested EAN members webcasts can still be viewed on demand on the EAN webpage.
“Predict”
Right at the start of the conference, Yann LeCun – computer scientist by background – gave an inspiring overview during his opening lecture on how artificial intelligence and in particular deep learning has revolutionised the way machines can learn and could be used hopefully more widely in the future to support clinicians making early diagnoses and predictions, for example by more accurate imaging reporting augmented by artificial intelligence.
A further hot topic of this year’s congress focused on predicting outcomes of patients in a prolonged disorder of consciousness. Steven Laureys presented results by his research group in the Brown-Séquard lecture showing that the use of fMRI, EMG and ERP in patients with disorders of consciousness was able to help distinguish minimally conscious states from vegetative state and that their use can facilitate basic communication and interaction with aphasic, non-communicating minimally conscious patients. He further emphasised that professionals should no longer use the term vegetative state due to its negative perceptions and associations with the public, and rather speak of a state of unresponsive wakefulness. The EAN also issued updated guidelines which reflect these recommendations (Kondziella et al 2020).
In the field of neurodegenerative disorders, many presentations focused on new diagnostic approaches and use of biomarkers to facilitate early diagnosis and risk stratification. This includes skin biopsies investigating for α-synuclein depositions in small nerve fibres in early stages of suspected Parkinson’s Disease, more wide usage of CSF amyloid and tau analysis as well as neuroimaging biomarkers in the early diagnosis of Alzheimer Dementia, which in the long term will also require healthcare systems to adapt to facilitate those diagnostic pathways.
Focus was also placed on the need for trandiagnostic research in neurodegeneration; many patients with dementia have more than one pathology on brain biopsy (for example vascular or Lewy body pathology frequently occurs in patients with sporadic Alzheimer’s disease). This multi-pathology comorbidity in dementia along with newly defined syndromes such as Primary Age Related Tauopathy and Limbic predominant age-related TDP-43 encephalopathy, pose an additional challenge in the accurate diagnosis of dementia. More accurate, multi-source biomarkers and deep clinical phenotyping as well as research into differential diagnosis of different dementia syndromes is needed to address this and facilitate the development of effective disease-specific treatments.
A very interesting teaching course on “Neurology by night” highlighted the importance of adequate diagnosis of idiopathic REM sleep behavioural disorders (iRBD) as they have a highly predictive value of affected individuals developing synucleinopathy in the future, up to 90% after 14 years, making iRBD a possibly better and more specific prodromal symptom than depression, hyposmia or constipation.
“Prevent”
Prevention, very often in the form of secondary prevention, plays a major role in caring for patients with neurological conditions. So not surprisingly many of this year’s talks focused on better prevention of stroke and dementia, but also preventing progressive disabilities for patients suffering from long-term conditions such as epilepsy and migraine.
The EAN issued a statement this year which addresses the need to identify and treat Obstructive Sleep Apnoea early as it comes with an increased risk for stroke, and concludes that CPAP might offer some benefit in primary and secondary prevention in those patients. Furthermore, stroke survivors are at higher risk of developing sleep disorder breathing and sleep-wake-disorders in general, which if not diagnosed can cause increased disability and future stroke risk (Bassetti et al 2020).
The congress also saw multiple presentations addressing the positive effects of sleep-activity regulation in preventing and ameliorating symptom progression of dementia, ranging from presentations explaining the presumed molecular mechanism behind that effect, e.g. the role of the glymphatic pathway clearing the interstitial space from amyloid, to presentations providing evidence that improved sleep-wake-cycles and increased daytime activities can result in better cognitive performance in standard neuro-psychometric testing just by using specific lighting systems in care homes for example.
Besides sleep disorders we have known for many years that multiple modifiable risk factors, such as weight, hypertension and smoking contribute largely to a person’s stroke risk. Reviewing multiple large studies such as the INTERTSROKE study and Framingham study, David Tanne concluded that up to 90% of strokes are preventable by targeting those modifiable risk factors early, and since stroke is a major risk factor for subsequent development of dementia, up to a third of dementia cases could be likewise prevented.
On a more experimental, still pre-clinical note, Hugues Chabriat presented results from other research groups who made some promising advances in the field of immunisation to prevent small vessel damage in transgenic mice expressing mutant Notch3, which could in future be of relevance in preventing brain damage and disability in patients with CADASIL. Chabriat received the Brain Prize this year for his and his team’s efforts in researching the genetic causes of CADASIL.
Multiple studies thematising adequate and timely epilepsy management were presented. Some of the take-home-messages were that in status epilepticus early treatment is crucial, benzodiazepines at adequate doses should be used first-line followed by anti-epileptic drugs (AED) such as Levetiracetam, Sodium Valproate or Phenytoin, which have been found to be equally effective in status treatment (Concept, EcLIPSE, ESETT-trial 2019); seizures related to auto-immune encephalitis respond poorly to AED but warrant early immunosuppressant treatment; and in treatment refractory epilepsy, surgical treatment should be considered as early as 5 to 7 years after first diagnosis as this is associated with better outcomes in terms of seizure-freedom and less complication rates from surgery.
Two studies have investigated the positive effect of the complement inhibitor Ecilizumab in treatment of generalised Myasthenia Gravis (REGAIN study) and on relapse rate in Neuromyelitis optica spectrum disorders (PREVENT study).
“Repair”
Frustratingly, in the third category of the overarching theme – repair – not many advances have been made and neurological disorders remain widely untreatable and neuronal damage irreversible.
There have been some studies addressing advances in neuro-rehabilitation including one remarkable study by Mhanna and colleagues on Primary Progressive Aphasia and contralateral cathodal transcranial magnetic stimulation achieved remarkable improvement in verbal semantic association and fluency.
Further congress highlights
This year’s congress also addressed the challenges in caring for patients with severe neurological disorder and long-term disability and stressed the importance of implementing collaborations with associated specialties of psychiatry and palliative care medicine to allow our patients best possible care where we cannot cure them.
Preliminary data of the European registries collating prevalence of neurological complications in patients with COVID-19: Main neurological manifestations that have been reported are anosmia, headaches and delirium, but also increased stroke risk due to hyperthrombotic state, and some rarer cases of encephalitis and neuropathy.
The conference closed with congress highlights, announcement of tournament winners and handing over the EAN presidency officially to Claudio Bassetti, who has been acting President since 2019, following Franz Fazekas, who has been EAN President since 2018.
The next EAN congress will be held from 19th to 22nd June 2021 in Vienna.
References
Bassetti, C.L.A., Randerath, W., Vignatelli, L., Ferini‐Strambi, L., Brill, A.‐K., Bonsignore, M.R., Grote, L., Jennum, P., Leys, D., Minnerup, J., Nobili, L., Tonia, T., Morgan, R., Kerry, J., Riha, R., McNicholas, W.T. and Papavasileiou, V. (2020), EAN/ERS/ESO/ESRS statement on the impact of sleep disorders on risk and outcome of stroke. Eur J Neurol. doi:10.1111/ene.14201
Kondziella, D., Bender, A., Diserens, K., van Erp, W., Estraneo, A., Formisano, R., Laureys, S., Naccache, L., Ozturk, S., Rohaut, B., Sitt, J.D., Stender, J., Tiainen, M., Rossetti, A.O., Gosseries, O., Chatelle, C. and (2020), European Academy of Neurology guideline on the diagnosis of coma and other disorders of consciousness. Eur J Neurol, 27: 741-756. doi:10.1111/ene.14151
