Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
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...
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...