Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
How do you dose steroids in neurosarcoidosis patients with a worsening clinical symptoms or MRI findings?
The route of dosing of glucocorticoids for neurosarcoidosis typically depends on the severity of illness and symptoms. For example, significant CNS involvement on imaging or patients presenting with AMS, weakness, vision changes/loss, or seizures would benefit from IV methylprednisolone followed by ...
When would you consider neuro-stimulants in post-stroke patients?
To my knowledge, there are no large, randomized trials supporting the use of neurostimulants in stroke rehabilitation. When patients are too sleepy to participate in therapy, I have been known to use very low-dose methylphenidate or modafinil. Levodopa has also been tried with mixed results.
What is the practical application of serological MS disease activity testing (offered by Octave Bio) for patients with MS?
I have been using the MSDA in my clinic for about a year now. I have found it to be a reliable indicator of suspected, known, and in a few cases, impending, disease activity. When to order it and why is where I think we need to do some work. Some examples where I think it has been useful for my pati...
What was the rationale behind using RANO-HGG criteria instead of RAPNO criteria for the primary endpoint in the FIREFLY-1 trial for pLGG?
I think this was a mistake, but I understand that this was requested by the FDA. We all know that MEK and BRAF inhibitors change the pattern of enhancement within days/weeks after the beginning of the treatment. As RANO-HGG is essentially based on the assessment of enhancing measurable and nonmeasur...
In those with a history of anti-NMDA encephalitis with identified teratoma s/p resection and clinical symptom improvement, is there a role for monitoring anti-NMDA antibody titer as a marker of disease recurrence?
This has been extensively answered in the literature. The paper of Gresa-Arribas et al., PMID 24360484 in Lancet Neurol 2014 answers the question. "In the current study, the importance of CSF antibody titers is demonstrated in patients with clinical relapses in whom the fluctuation of CSF titers cor...
Are CGRP antagonists effective at aborting intractable headaches in hospitalized patients when traditional “migraine cocktails” have failed?
The time has come for us to limit ourselves in our treatment of migraine patients to migraine-specific medications. These are the triptans and gepants for abortive treatment and the CGRP antibodies and gepants for preventive treatment. The "migraine cocktails" that we employ in emergency room and ho...
Do you recommend any diagnostic testing for patients with blepharospasm?
I don't think there is a single best algorithm to work up patients with blepharospasm. I think it is important to distinguish blepharospasm from excessive eye blinking as a reaction to eye irritation or as a manifestation of behavioral or psychiatric issues. An eye exam an be helpful in this case. I...
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.