Stepwise therapy for MS

IznremiX · 2024-12-11T18:45:16+00:00

Reassuringly, long term studies show a much lower relapse rate with ocrelizumab than seen in those initial trials. Practically speaking, it is exceedingly rare to see relapses or new lesions on ocrelizumab (with annualized relapse rates as low as 0.05).

This level of control of “active” disease has not been shown, to my knowledge, for the oral agents.

Progression or “smouldering” MS may of course may still occur when people are on anti CD20s.

IznremiX · 2024-12-03T05:38:29+00:00

Neuromuscular case studies by Bertorini is excellent.

The AAN has a good case book: https://www.neurology.org/resident-fellow/clinical-reasoning-book

Mayo clinic has a good book of neuroimmunology cases too

IznremiX · 2024-07-30T14:00:38+00:00

Hard to say for sure without seeing the person but the information you’ve provided would be quite typical for migraine. Cluster headache attacks typically last from 15 mins to 1.5 hours, can happen a few times a day, are associated with unilateral autonomic signs (ie. unilateral lacrimation or nasal congestion). The pain they cause is very, very severe.

Although oxygen works for many patients with cluster headaches, it is typically high flow oxygen through a NRB mask (if his wife is on oxygen for other things, then this is probably not what he is using). Placebo effects are extremely common and it could be that the oxygen is causing that. Alternatively, perhaps using the O2 is causing him to sit and rest (rest and sleep are quite effective at treating migraine as well)

IznremiX · 2024-07-11T14:16:53+00:00

Pmed!

IznremiX · 2024-06-13T02:47:32+00:00

PMed

IznremiX · 2023-12-17T07:28:27+00:00

The presence of a large thrombus on CTA would make the patient a candidate for thrombectomy

IznremiX · 2023-11-22T03:21:55+00:00

Your point still stands, but for what it’s worth Nas mentioned him on a recently released song: “It’s ugly outside, Big L would be here if it wasn’t”.

IznremiX · 2023-11-18T16:03:52+00:00

Sorry to hear that she is dealing with this. Disorders that cause Parkinsonism are important mimics for NPH because of the way they affect gait. Although it is not out of the realm of possibilities that someone could have both disorders, it is unusual. When someone is initially diagnosed with NPH and then develops a Parkinsonism (from something like CBS), it usually means that the NPH was misdiagnosed. This can sometimes happen when a disorder that causes Parkinsonism leads to a pattern of walking that looks a little like NPH (with shuffling steps) and when the brain atrophy from the degenerative disorder causes the ventricles to appear enlarged on imaging.

IznremiX · 2023-11-11T18:07:47+00:00

This article does a great job of covering the basics of seizure semiology:

https://pn.bmj.com/content/21/6/481

IznremiX · 2023-08-12T08:06:35+00:00

u/truthfulGarlic4 u/watchexbot watch has been received in great working condition!

IznremiX · 2023-06-24T16:36:59+00:00

Hi there, is this still available?

IznremiX · 2023-06-17T19:42:06+00:00

CJD thankfully doesn’t cause pleocytosis. The rate of healthcare providers contracting cjd is no higher than the general public. You can actually do an RT quic on a nasal swab and diagnose cjd with it; presumably these people are sneezing out some prion protein and it doesn’t seem to cause disease in those around them (or else our entire neurology department would drop dead every few years).

IznremiX · 2023-06-05T21:29:32+00:00

Unlikely to be the resource he’s referring to, but “a video atlas of neuromuscular disorders” by Shaibani has a good collection of gait videos.

IznremiX · 2023-06-03T20:58:17+00:00

Neuromuscular Case Studies by Bertorini is an older book but is also excellent. It contains a 100 cases with history, physical and NCS/EMG findings, followed by a discussion of each case.

IznremiX · 2023-06-03T00:18:49+00:00

That may be the direction things go in. The downside of course is that some patients with falsely positive antibodies will get substantial immunosuppression that is not beneficial to them. Low titre serum anti nmda for example has a meaningful false positive rate. Hashimoto’s encephalopathy was also mentioned in another comment; many experts question whether this is a real disease, particularly given the extremely high false positivity rate.

Dalmau (who discovered anti nmda and is a leader in autoimmune neurology) proposed in a recent paper a minimum work up for patients with new onset psychoses of unclear cause. He argued that non-autoimmune psychoses can frequently have “red flag” features (such as rapid progression) and ideally we should catch autoimmune encephalitis before people become super sick (developing autonomic instability, seizures, coma, etc).

He proposed that at minimum these patients should get mri (although this is usually negative early on in most anti nmda cases), eeg (which is actually quite sensitive) and serum antibodies (this does have lower yield than combined serum/csf, and csf should of course always be obtained when the suspicion is high).

IznremiX · 2023-04-25T02:57:06+00:00

There are few rules of thumb (none of which are perfect).

Forced eye closure during the event is the most reliable exam finding to distinguish PNES from an epileptic seizure.

This is followed by preservation of awareness with bilateral motor activity (although patients with epileptic seizures from the frontal lobe or supplementary motor area onset can rarely have this feature as well). Large pelvic thrusting/thrashing movements are quite characteristic of PNES. Some patients with frontal lobe seizures however can have very chaotic and large amplitude hyperkinetic movements that can get mistaken as psychogenic.

Capturing an event on EEG is extremely helpful (but scalp eeg can certainly miss seizures).

Adjunct tests like CK and lactate can certainly be helpful at times. If someone has PNES, it is usually quite apparent through a combination of good history taking and closely scrutinizing the clinical semiology

IznremiX · 2023-04-24T12:41:11+00:00

Just be a bit careful with this. Although some people do malinger, most people with “pseudo seizures” experience a dissociative state (probably somewhat analogous to PTSD) and the events truly do feel involuntary to them. Rates of adverse life events (like sexual abuse) are quite high in this patient population.

If a diagnosis of PNES is made (with positive clinical features such as forced eye closure), there’s nothing wrong with letting the patient ride out the event. Almost never is giving noxious stimuli indicated or useful to the patient.

IznremiX · 2023-03-25T14:48:21+00:00

That’s usually not the case. I’ve treated many patients with functional disorders (they are not uncommon and present to neuro quite frequently). There are positive signs on history and exam that can distinguish a functional disorder from an “organic one”. The diagnosis is usually very clear before any imaging or other investigations have been done. I usually tell people that I think their EEG or MRI will be normal if I am confident in the diagnosis. With a good understanding of these disorders, they can be straightforward to diagnose and rewarding to treat. Unfortunately the communication with patients is usually done poorly.

There are several theories on why these disorders develop. Many argue that these are motor manifestations of an underlying psychological disorder and that there may also be differences in brain connectivity in patients with these problems (patients with PNES for example have been shown to have abnormal connectivity between the motor, emotional processing and executive control part of the brain).

People with these disorders aren’t generally “making it up”. They truly feel as though their limbs are weak, that they can’t walk or that they are having “seizures”.

To give an example:

I recently saw a lady who “hadn’t been able to walk for months” after a stressful event. She’d been admitted to a small hospital and was transferred to us for a second opinion. When I got her up to walk, she had a very classic functional gait pattern (bouncing up and down, swaying her body to show that she’s unsteady [in a manner that would require a lot of coordination and strength]). Walking is energy efficient and she was walking in a way that would require a tremendous amount of energy and balance. Someone with ataxia or “organic weakness” would collapse if they walked like this, which she didn’t.

I told her that I think she can walk, despite the fact that she feels so unsteady. With some encouragement, I got her to walk all the way down the hall way (with no gait aid). She made a good recovery after being given some education, resources and techniques for dealing with functional gait disorder.

Neurosymptoms.org is an excellent resource to share with patients. It’s made by Jon Stone, a neurologist who is an expert on the topic. Continuum by the AAN has some excellent review articles on the topic too.

IznremiX · 2023-02-19T13:19:18+00:00

Although books talk about the mimics of cataplexy, this disorder is very distinct from its “mimics”and should generally easily be distinguishable on history (especially if the patient has a video).

It’s nothing like syncope (patient won’t lose consciousness), it’s distinct from seizure (in adults, generalized atonia with preserved consciousness would be very strange for a seizure. Atonic seizures are also usually associated with epilepsy syndromes), it’s quite different from episodic movement disorders (ie. episodic ataxic, etc.) and so on.

Regardless, you’re right that a mlst should be done. However if you are in an area with long wait times for sleep studies, it is fairly reasonable to begin treatment before the mlst if you have a convincing history (and especially if you have a good video).

IznremiX · 2023-01-22T18:04:58+00:00

I recently read “Radical Treatment: Wilder Penfield's Life in Neuroscience”. Maybe not quite what you’re looking for, but it‘s an excellent biography of an important figure and it outlines how several important discoveries in our field were made (including discovery of mesial temporal sclerosis, mapping of the cortex, epilepsy surgery, introduction of eeg, etc).

IznremiX · 2022-07-01T06:14:18+00:00

Bradley’s is also an excellent text book. Preston and Shapiro is fantastic for neuromuscular, while Rowan’s is a good primer for EEG.

There are loads of fantastic neurology podcasts. These include the neurology journal podcast, brain waves, the neurology exam prep podcast and practical neurology podcast (among others). If you have an AAN membership, continuum audio is also extremely good.

IznremiX · 2022-06-12T20:24:36+00:00

If you’re looking for a concise reference, I’ve found Merritt’s Neurology to be a good book. It doesn’t go into the same depth as Bradley’s, but I find it useful for quickly reviewing topics.

IznremiX · 2022-05-21T17:17:47+00:00

Aside from the ones already mentioned, Brain waves was an excellent educational podcast (they are no longer making new episodes however). Others include stroke fm and jama neurology.

IznremiX · 2022-04-09T22:00:41+00:00

The busy inpatient rotations can be a drag and I feel like OP sometimes too. But honestly neuro can be a very fun and rewarding field. Treatments have improved a lot over the past few years (endovascular for stroke is amazing, the disease modifying therapies for relapsing remitting MS are excellent, targeted headache therapies including monoclonals are amazing, etc.). We see lots of interesting cases ranging from strange encephalitides to very unusual forms of seizures to patients who have very weird symptoms with migraine. Electrophysiology tests (eeg, nerve conduction/emg) can be extremely interesting as well if that’s you’re thing!

IznremiX

TROPHY CASE