Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
Would a surgical decompression be indicated in a patient with amyloidosis and severe median neuropathy at the wrist?
Yes, of course, if the median neuropathy is symptomatic. I am not aware of any literature suggesting lower rates of success with carpal tunnel release surgery in patients with various amyloidosis subtypes compared to non-amyloid CTS.
Would you recommend anti-platelet or anticoagulation in a patient with recurrent strokes, CADASIL, and Antiphospholipid Syndrome?
It depends on the circumstances (e.g. co-morbidities). Would use neither for CAA alone.
Is there practical utility from obtaining CSF autoantibodies in patients with suspected neuropsychiatric systemic lupus erythematosus?
I typically obtain serum and CSF autoimmune encephalopathy panels based on a patient's APE2 score. A score of 4 or more is predictive of having positive serum or CSF antibodies and can be applied to patients with neuropsychiatric lupus and help stratify who to test. I would start the workup with MRI...
What would you recommend for a patient with MS on dimethyl fumarate with recent exacerbations including optic neuritis and new enhancing brain lesions who wishes to go on more intensive therapy such as a B-cell depletion but recently required treatment for shingles?
While live vaccines are still generally discouraged for patients with MS, there is ample evidence that most vaccines are unlikely to trigger new MS lesions. One option then would be to vaccinate with Shingrix, a recombinant vaccine, before starting B-cell therapy. Generally, I would wait at least 2...
Is there a time interval after which you would not offer adjuvant radiotherapy for a malignant, grade 3 meningioma?
Adjuvant radiation for grade 3 meningioma is based on prior observational studies that generally reflect recurrence rates approaching 90% for grade III disease, and the insufficiency of salvage treatment approaches.Given the small numbers of grade 3 tumors, and the heavy bias towards upfront postop ...
How would you treat a patient with necrotizing myopathy with positive anti-HMHCoR Ab unresponsive to standard therapies?
There are several questions raised by this scenario. I have personally never seen a patient with true HMGCR-antibody + necrotizing autoimmune myopathy fail a combination of 3 immunotherapies (high dose prednisone, IVIG, and either Rituximab or oral immunosuppression like Cellcept/azathioprine, etc),...
When do you recommend genetic testing in patients with parkinsonism?
I generally recommend considering genetic testing for parkinsonism in cases of early onset symptoms (before age 50), a history of similar symptoms in first-degree relatives, or when an atypical course is suspected alongside a family history of similar symptoms or ALS, etc.
Is there a point at which further reduction in amyloid burden is no longer clinically meaningful or should the goal always be as much reduction as possible?
I suspect the treatment effect is seen primarily in patients who achieve substantial reduction in amyloid, but I have not seen adequate data showing definitive correlations. How long to treat and how to monitor treatment response are open questions in the field. Amyloid burden was measured in the tr...
If a patient with relapsing remitting MS has comorbid Sjogren's syndrome and is on hydroxychloroquine (Plaquenil), how does that impact choice of DMT for MS?
A patient's pre-existing use of hydroxychloroquine (HCQ) has not impacted my decision on MS DMT. HCQ should not overlap with other DMT mechanisms of action, so the implication on more infections/malignancies is thought to be low. However, the need for additional immunomodulating agents for Sjogren's...
How would you counsel about DMT options for disease-modifying therapy for a patient with multiple sclerosis and positive Hepatitis B surface antigen with negative HBV DNA PCR?
This is mainly an issue when considering B-cell-depleting medicines, alemtuzumab, and cladribine. For this situation (sAg positive), I would refer to Infectious Disease for their input and co-manage. The patient may need to be on chronic antivirals during immunotherapy, at least for the above medica...