Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
Which IV medications do you offer for outpatient headache infusions?
Eptinezumab (Vyepti) in a dose of 100 or 300 mg. It is a CGRP antibody marketed for the preventive treatment of episodic or chronic migraine. However, in a randomized, double-blinded, placebo-controlled trial treating patients with 100 mg IV for moderate or severe migraine headache, it met the FDA-d...
Do you utilize muscle MRI to track disease progression in myopathies?
Muscle MRI can be helpful in assessing for active disease/inflammatory myopathy and can help sampling in a more targeted manner when considering a muscle biopsy. Fatty replacement is seen in more advanced cases of myopathy and has been used as a marker of disease progression in non-inflammatory/slow...
How do you manage cranial radiotherapy in the setting of an acute CVA?
Location of the infarct is important to consider, like brainstem or cerebellum or MCA areas apart from functional status. Lesion (infarct) volume (measured on DW-MRI) is an objective surrogate marker for infarct resolution [Gaudinski et al., PMID 18635854]. Either a SPECT or PET/CT scans can be used...
Do you ever use bevacizumab in combination with standard radiation and temozolomide in the first-line setting for patients with glioblastoma?
Two clinical trials (AVAGLIO and RTOG 0825) used bevacizumab (Avastin) along with standard temozolomide and radiation therapy for newly diagnosed glioblastoma. While they did not see improved OS, they did see improved PFS. In an evaluation of AVAGLIO, for those patients who did not go on to receive ...
How do you choose between adjuvant PCV vs temozolomide in high risk oligodendroglioma with IDH mutation and 1p/19q co deletion?
In our practice, we typically offer procarbazine/lomustine (with or without vincristine) to all patients with high risk oligodendroglioma, IDH mutated, 1p/19q codeleted. Temozolomide based on the Stupp regimen is used as an alternative when there are specific concerns for PCV related toxicity or str...
How do you manage oxaliplatin-induced acute peripheral nerve hyperexcitability?
This can be very frustrating for both the patient and the treating physician, as there is little that we can do to prevent this from happening. I have found that assurance is the most important thing that we can do for patients. For example, some patients can develop pharyngolaryngeal dysesthesias (...
What steroid-sparing agent would you use for treatment of neurosarcoidosis with leptomeningeal and parenchymal involvement?
I am a strong proponent of infliximab for many cases of CNS neurosarcoidosis, particularly in more urgent cases. My experience is that response can sometimes be quite prompt, certainly in comparison to more conventional agents, and I have seen clinical and radiological improvement even during the in...
Is placing a VP shunt a major risk to spread medulloblastoma or other malignant brain tumors into the gut?
While most malignant primary brain tumors will NOT spread to the gut via VPS, case reports of pediatric brain tumors dominate the literature regarding this risk. Germ cell tumors are probably most commonly reported, followed by PNETs and medulloblastomas [Piatt and Garton, PMID 18431216, Kay et al.,...
Is antiplatelet or anticoagulant therapy preferred for the secondary prophylaxis of cryptogenic stroke in a patient with underlying malignancy?
Will look at the stroke radiographically. If appears embolic and the patient is low risk for bleeding, with respect to their cancer regimen, co-morbidities, and labs, I will discuss off-label anticoagulation with eliquis. If there are additional, chronic embolic appearing strokes - that will also sw...
How do you counsel patients on control of glioma-related seizures following radiation?
About a third of malignant glioma patients present with a seizure, another third of patients will eventually develop seizures, and the last third never have seizures. Curiously, seizures as a presenting complaint carry a BETTER prognosis than those with focal neurologic deficits at diagnosis. The im...