Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
Are there any risk factors for IO induced rhabdomyolysis and how do you approach and manage it?
IO can affect the muscle in many ways. There is a myasthenia gravis and myositis overlap. I am not sure we know whether it is rhabdomyolysis versus a CK leak vs steroid myopathy vs muscle necrosis due to something else. Did the patient have EMG or muscle biopsy? There is a lot we do not understand a...
Based on its mechanism of action, do you think sodium phenylbutyrate and taurursodiol could have benefit in other neurodegenerative disorders?
Yes, in fact, this drug combination is also being evaluated for other neurodegenerative diseases including Alzheimer's disease (AD). The PEGASUS trial was a biomarker-driven phase 2 trial in AD; in the trial, treatment with AMX0035 resulted in significant changes in several biomarkers that have rele...
How do you manage a diabetic patient with generalized myasthenia gravis post thymectomy previously treated with Imuran?
There is some additional information required to answer this question, specifically: a) did the patient have thymoma on pathological exam? and perhaps the most important b) What was the clinical status of the patient's MG prior to thymectomy (severity, MG ADL/QMG scores)? and c) Was azathioprine the...
What is your treatment approach for a recurrent brainstem glioma?
Recurrent brainstem glioma is a very challenging situation. One could consider participating in a clinical trial if available, especially one that targets some of the known mutations in the tumor (such as histone h3, TP53, ATRX, ACVR1, and others). We have previously re-irradiated a few patients at ...
How does failure to recover clinically after >2 years in a patient with suspected diabetic amytrophy shift diagnostic and therpeutic approach?
The natural history of diabetic amyotrophy is to improve after deficits have reached a nadir; the improvement can be incomplete, but usually occurs within 12-18 months from the onset of symptoms. Therefore, if there are persistent but stable deficits 2 years after the onset of symptoms this may repr...
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?
No, I see no gain testing for any serum level. For the diagnosis, potential biomarkers values in ALS patients have overlap with control subjects and those with other diseases, so none stand alone for the diagnosis. Since they could “support” a diagnosis, I rely on the clinical course, neurologic exa...
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 ...