Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
If a patient develops itching with their first dose of Tysabri despite pre-treatment, does this indicate that further cycles of Tysabri are contraindicated or do you continue Tysabri at the next cycle?
I generally stop natalizumab in patients with hypersensitivity. In this case, it may be a little more nuanced depending on how bad the symptoms were. I have had cases with very mild itching that have successfully been re-challenged with minimal steroid pre-treatment for a dose or two, then back to t...
How has the recent FDA approval of tovorafenib impacted your treatment decisions for pediatric patients with relapsed/refractory low-grade glioma?
With the FDA approval, and given the tolerability of therapy and the pediatric friendly once weekly dosing and formulations, I will prescribe tovorafenib regularly for my patients with relapsed refractory low grade glioma. I do think it will become a standard choice in this setting. That said, given...
How will you sequence therapies in dermatomyositis given the results of the ProDERM trial?
I will try oral immunosuppressants first, either methotrexate, azathioprine, or mycophenolate first; and then add IVIG if there is no response or even minimal response.
How do you approach patients with recurrent TGA in the emergency room?
I generally observe the patient in the hospital if the symptoms are still present or have resolved within 24 hours. I obtain an MRI to look for hippocampal lesions or evidence of stroke, CTA head and neck. If I see a patient days, weeks, or months after the event, I do an outpatient workup or an MRI...
How do you counsel patients on the side effects of sodium phenylbutyrate and taurursodiol?
The most common side effects were gastrointestinal (nausea, diarrhea, abdominal pain) and, when they occurred, they generally did so during the first 3 weeks of treatment. For most patients, these were mild and manageable.
How do you interpret the results of oligoclonal bands ordered to evaluate for demyelinating disease in patients with brain MRI lesions of unclear etiology?
While the presence of oligoclonal bands (OCBs) has been incorporated in the updated diagnostic criteria as a surrogate for dissemination in time, OCBs should not be used in isolation to make the diagnosis of multiple sclerosis. There are several systemic and peripheral immune diseases, including inf...
What is your approach to dosing rituximab in patients with multiple sclerosis?
I was trained to administer rituximab (for MS) using a protocol of 1000 mg on D1 and D15, followed by 1000 mg every 6 months. However, there is the realization that this particular dosing strategy may not be optimal for all patients. An insightful neurology article (and podcast) delves into the link...
How do you manage patients with a prior intracerebral hemorrhage from probable cerebral amyloid angiopathy who develop new small vessel ischemic infarcts?
In this situation, I would consider using cilostazol since it has both antihypertensive and antiplatelet properties. However, the safety profile is unclear in patients with amyloid angiopathy.
When do you consider immunosuppression in patients with Sjogren's neuropathy?
Only when disease activity is moderate-severe, impairing QoL, or rapidly progressive, ie mononeuritis multiplex/vasculitis, with significant risk of end-organ/tissue damage. Occasionally, autonomic neuropathy in SjD can be so debilitating to patient, and all other supportive treatments have failed, ...
How long do you wait for a patient to be seizure-free before you clear them with regard to operating heavy machinery (i.e., for work)?
I would use the driving laws in the state where the patient resides as the guide for this. After all, if the patient can drive a car, it would be hard to tell them they can’t operate other heavy machinery. In my state, this would mean 6-12 months (we have a variable restriction on driving privileges...