Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
How would you treat a patient with small fiber neuropathy and elevated FGFR3 titers of 6000?
Assuming no other cause of neuropathy has been found, the short answer is symptomatic treatment with meds for neuropathic pain like gabapentin, pregabalin, tricyclics, other antidepressants, etc. I will explain why immunotherapy with IVIG is probably NOT the way to go. FGFR3 antibodies were describe...
How would you manage anti-platelet therapy in patients presenting with ischemic stroke and have a history of von Willebrand disease?
I follow the ASH ISTH NHF WFH 2021 guidelines, recommendation 3: "In patients with VWD and cardiovascular disease who require treatment with antiplatelet agents or anticoagulant therapy, the panel suggests giving the necessary antiplatelet or anticoagulant therapy over no treatment (conditional reco...
Are there any risk factors for IO induced rhabdomyolysis and how do you approach and manage it?
IO can affect the muscle in many ways. There is a myasthenia gravis and myositis overlap. I am not sure we know whether it is rhabdomyolysis versus a CK leak vs steroid myopathy vs muscle necrosis due to something else. Did the patient have EMG or muscle biopsy? There is a lot we do not understand a...
Based on its mechanism of action, do you think sodium phenylbutyrate and taurursodiol could have benefit in other neurodegenerative disorders?
Yes, in fact, this drug combination is also being evaluated for other neurodegenerative diseases including Alzheimer's disease (AD). The PEGASUS trial was a biomarker-driven phase 2 trial in AD; in the trial, treatment with AMX0035 resulted in significant changes in several biomarkers that have rele...
How do you manage a diabetic patient with generalized myasthenia gravis post thymectomy previously treated with Imuran?
There is some additional information required to answer this question, specifically: a) did the patient have thymoma on pathological exam? and perhaps the most important b) What was the clinical status of the patient's MG prior to thymectomy (severity, MG ADL/QMG scores)? and c) Was azathioprine the...
What is your treatment approach for a recurrent brainstem glioma?
Recurrent brainstem glioma is a very challenging situation. One could consider participating in a clinical trial if available, especially one that targets some of the known mutations in the tumor (such as histone h3, TP53, ATRX, ACVR1, and others). We have previously re-irradiated a few patients at ...
How does failure to recover clinically after >2 years in a patient with suspected diabetic amytrophy shift diagnostic and therpeutic approach?
The natural history of diabetic amyotrophy is to improve after deficits have reached a nadir; the improvement can be incomplete, but usually occurs within 12-18 months from the onset of symptoms. Therefore, if there are persistent but stable deficits 2 years after the onset of symptoms this may repr...
Do you screen for paraneoplastic antibodies in patients with suspected ALS?
I do not screen ALS patients routinely for PNP antibodies because I do not believe true paraneoplastic ALS exists as a disease entity. The few rare paraneoplastic motor neuron syndromes I am aware of are very different from typical ALS- either a purely UMN syndrome resembling PLS which has been desc...
Do you typically assess plasma levels of the phosphorylated axonal neurofilament H subunit (pNF-H) in patients with ALS?
I do not. While I am a fan of using neurofilament levels in trials, I am not yet convinced that these help me care for patients. Several more studies are ongoing which may eventually change my mind.
Would the concerns about respiratory side effects from sodium phenylbutyrate and taurusodiol change your management of patients with predominantly bulbar ALS?
When you say "respiratory side effects" I assume you are referring to the rate of upper respiratory tract infections being higher in the Relyvrio-treated patients compared to the placebo-treated ones. I cannot think of a reason this product would make patients more susceptible to respiratory infecti...