Abstract
Controversies in Neurology (CONy) is an international congress dedicated to debates in several areas of neurology. Its second annual meeting was held in Athens, Greece, in October 2008, with an attendance of over 1200 participants. Several debates were held between opposing leaders in the fields of multiple sclerosis, stroke, Parkinson’s disease, dementia, epilepsy and headache.
The idea behind this meeting was that instead of frontal talks, listening to debates is a much better instruction method, since it presents the pros and cons of each argument as forcefully as possible, thus highlighting weaknesses in long-held opinions and in new results. Although to a large extent medical practice is regulated by clinical guidelines, there is much that is beyond the data that are needed for evidence-based medicine.
In fact, this approach seemed highly successful, as witnessed by the impressive turnout exceeding 1200 participants from around the world who listened to outstanding speakers, each of whom promoted their respective points of view.
The opening talks included plenary lectures, the first by GS Alexopoulos (Cornell University, NY, USA), who was asked the intriguing question, “Is late-life depression a cerebrovascular disease?”. He provided impressive data on the relationship of white matter lesions with depression (and with dementia). Following this talk, James Toole (USA) discussed the issue of mental incompetence developing among political leaders, and mentioned the famous examples of FD Roosevelt and D Eisenhower who developed a stroke while in office, and others, posing the question of the role of their physicians in such situations. Even more provocative was the interesting talk by G Vithoulkas (Greece), who asked whether homeopathy is a science.
There was a full-day stroke session, debating several issues, such as the role of antihypertensive drugs in stroke prevention, where D Russell (Norway) vehemently defended the view that angiotensin AT1 antagonists are the best choice for hypertensive patients, since its protective effects go beyond their antihypertentive properties. On the other hand, L Csiba (Hungary) persuasively claimed the angiotensin converting enzyme inhibitors are just as good and may be slightly better.
Other debates in the ‘prevention of stroke’ field included the use of antidyslipidemic agents. Dyslipidemia is a known risk factor for stroke and treatment with statins is believed to reduce stroke incidence. However, there are no established targets for serum lipid levels. P Amarenco (France) promoted the approach ‘the lower the better’, while D Spence (Canada) was more conservative, warning about the adverse events associated with statins and claiming that there are no data that support excessive lowering of cholesterol for the prevention of stroke.
Another debate centered on the question of whether patent foramen ovale should be closed to prevent stroke, who are the best candidates, and how early the procedure should be performed. In this debate, H Mattle (Switzerland) held the more aggressive view while JL Mas (France) was more restrained.
The approach to acute ischemic stroke was discussed from two angles. One was whether thrombolysis should be attempted even beyond the established 3-h window (N Wahlgren; Sweden) or whether an endovascular approach should be preferred (M Mazighi; France).
The other debate was whether blood pressure should be reduced in a hypertensive patient following an acute stroke (J Wojczal; Poland) or, conversely, increased (N Bornstein; Israel).
Asymptomatic carotid artery stenosis is diagnosed frequently (e.g., in the evaluation prior to coronary artery bypass surgery), and there is disagreement of whether it should be treated medically (supported by D Spence) or by endarterectomy or perhaps stenting (O Bajenaru; Romania). The issue of carotid stenting in older patients (aged over 50 years) was also raised (GS Chrysanthakopoulos; Greece), as well as the decision regarding the approach in a patient with symptomatic carotid artery disease.
In the multiple sclerosis (MS) field, several prominent neuroimmunologists debated various conceptual issues, such as whether neuromyelitis optica is a separate clinical entity or part of the MS spectrum (B Weinshenker; USA vs A Compston; UK), whether the accumulated data in genetics have really advanced our understanding of MS (A Compston vs J Chapman; Israel) and whether trauma can precipitate MS (V Brinar; Croatia vs A Siva; Turkey).
In the therapeutic field, several interesting issues were discussed, for example, how to treat patients now that new drugs become available, such as natalizumab. PK Coyle (USA) promoted adherence to drugs with a proven safety and efficacy record while HP Hartung (Germany) claimed that new oral therapies offer better options and should, therefore, be preferred.
While therapy for relapsing–remitting has been established as being able to reduce relapse rate, the approach to slow conversion to chronic disability is still under debate, with new methods being explored. A heated debate on the value of interferons in delaying conversion to chronic–progressive stage of the disease emerged between G Comi (Italy) and CG Ebers (UK).
Another debate focused on the use of stem cells in MS, where the proponent, D Karussis (Israel) was opposed by L Kappos (Switzerland).
At another session, the ‘new players on the block’ in the MS field were briefly presented. These included cladribine, daclizumab, laquinimod, alemtuzumab, rituximab, BG00012, fingolimod, autologous hematopoietic stem cells and natalizumab. This session attracted a large crowd who listened attentively. This session was followed by a satellite symposium arranged by BayerHealthcare, which stressed the benefit of early treatment in addition to presenting the results of several studies with IFN-β.
Parkinson's disease (PD) was another major topic, with debates on how early should treatment be initiated (E Wolters; The Netherlands: in the premotor phase; K Sethi; USA: only later).
A similar debate emerged regarding the use of deep brain stimulation in PD, where M Hariz (UK) promoted implantation of electrodes before motor complications occur, whereas P Limousin (UK) contradicted him rather forcefully.
Drug therapy for PD concentrated on two trendy issues. One was based on the new results, which demonstrated that rasagiline was able to slow the progression of PD if started early. The question discussed was whether rasagiline is superior to selegiline, since the two drugs are very similar in structure and function. While A Schapira (UK) claimed that rasagiline has unique pharmacological properties, M Horstink (The Netherlands) presented the results of a Dutch study from which he concluded that the two drugs are essentially identical in their clinical efforts. The ultimate way to prove one of these claims is through a new study in which the two drugs (and placebo) are given in parallel, in a blinded, randomized design. Unfortunately it does not seem that such a study is being planned.
Dementia was another prominent topic, which included debates concerning the relevance of microvascular brain disease, the usefulness and cost–effectiveness of cholinesterase inhibitors in Alzheimer’s disease, and whether these drugs should be discontinued in advanced dementia, and the role of cholinergic deficits and of vascular lesions in the pathogenesis of the dementia of PD.
There were several other exciting debates, on headache, myasthenia gravis, neuropathies, amyotrophic lateral sclerosis, and more. However, not all topics were covered and the organizers promised to expand in their next congress (Prague, Czech Republic, 8–11 October 2009).
Financial & competing interests disclosure
Amos Korczyn is the Chairman of CONy. The author has no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.
No writing assistance was utilized in the production of this manuscript.