Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
What is the significance of isolated increase of Asialo-GM1 antibodies with nerve conduction suggestive of sensory motor axonal polyneuropathy?
These autoantibodies need to be interpreted with clinical context. Generally, GM1 IgM antibodies are associated with multifocal motor neuropathy with conduction block (MMN), which is a pure motor syndrome with acquired demyelinating features on nerve conductions/EMG. GM1 IgG antibodies are typically...
Do you typically recommend a wash-out period when switching patients with myasthenia gravis from Soliris to Vyvgart?
Both eculizumab and efgartigimod are extremely expensive drugs with the annual cost being 6 digit $ (ok, efgartigimod is cheaper). Therefore, practically all patients taking eculizumab have gone through the pre-authorization and insurance approval process, and typically their insurance will absorb ...
Does COVID-19 infection (and use of Paxlovid or other antivirals) affect your decision on timing of maintenance anti-CD20 mAb therapy (eg Rituxan, Ocrevus) in patients with multiple sclerosis?
There have been several publications addressing B-cell therapies in general and severity of COVID infection, see Simpson-Yap et al., PMID 34610987 for a recent analysis from a large international dataset.Overall, while there is an increased risk for hospitalization and ICU admission with Ocrevus com...
How do you approach treatment of a grade 4 IDH-mutant astrocytoma, a diagnosis now distinct from glioblastoma according to the 2021 WHO Classification for CNS Tumors?
This is an excellent question. The short answer is that until we have more data on this new entity, I would treat an IDH mutant (mt) grade 4 astrocytoma as I would have prior to the 2021 WHO revision, that is to say, with concurrent chemoradiation therapy and adjuvant Temodar for 6 cycles (or a clin...
When do you consider cenobamate for focal epilepsy?
I consider cenobamate in treatment-resistant focal epilepsy. Typically, I will suggest it when I have a patient who has failed at least 2 other medications, and who may not be a good surgical candidate or may not be interested in surgery. I utilize the titration packs provided by the company to titr...
In patients chronically treated for Wilson's disease with trientine hydrochloride (Syprine®), would you expect development of neurologic symptoms?
On trientine, patients with asymptomatic WD should remain asymptomatic. The onset of neurological symptoms in someone with only hepatic disease on maintenance therapy represents treatment failure. Precise rates and etiologies of treatment failure are lacking, though one cohort review documented 19% ...
Do you screen for any environmental exposures in patients with newly diagnosed ALS?
I would at least ask the questions when obtaining history-specifically regarding occupational exposure to heavy metals like mercury, lead or arsenic. There is also a theory about BMAA a toxic aminoacid made by Cyanobacteria that may explain clusters of ALS-like or Parkinsonian syndrome that occurred...
Do you typically encounter phrenic involvement in patients with CIDP?
No. Respiratory involvement is very unusual in CIDP, unlike GBS (AIDP) where it is common. In CIDP frequency of phrenic nerve involvement is <10%, probably below 5. Of course, there are always exceptions to the rule. If the phrenic nerve is involved and the mechanism is predominantly demyelinating (...
Do you use isosorbide dinitrate spray for the treatment of neuropathic pain?
I don’t and I think it’s mostly due to lack of availability- I don’t think you can get the spray form in the US to use for neuropathic pain. It’s more popular in the UK and other countries following a publication about its efficacy in diabetic neuropathy in 2002: Yuen et al., PMID 12351464.
How do you approach the management of purposeless groaning/involuntary humming in PSP?
Involuntary and purposeless vocalizations, such as groaning, are commonly observed in Progressive Supranuclear Palsy. They can be intermittent or more continuous in nature, typically not associated with pain, and more bothersome to the caregiver than the patient. SSRIs, such as escitalopram, have be...