21 e-Letters

published between 2017 and 2020

  • Response to: Beyond the hummingbird - Deer Drs...

    Dear Editor,

    We read with great interest the recent article by Drs Page & Gaillard describing neuroradiology signs and their variable utility [1].

    We recently attempted to bring science to the art of descriptive radiological signs by conducting a randomized controlled trial to assess the utility of these signs for medical student radiology education [2]. We found that ‘Metaphoric Signs’ (linking radiology resemblance to an object or concept which is not actually present in an image) increased descriptive and diagnostic ability as well as students’ lesson enjoyment, when compared to teaching with normal anatomy comparators.

    The importance of diagnostic accuracy of commonly used signs was similarly emphasised in our discussion. In addition to being diagnostically accurate, the success of a metaphoric sign also relies on how well it resonates with each individual learner, based on their perception of the real-world similarity alluded to in the radiology image and their prior experiences[3,4]. This is aptly exemplified by Author FG’s stronger association of the pontine appearance in osmotic demyelination with a blockbuster sci-fi trilogy than classical mythology.

    An interesting observation in our study was that several students used incorrect wording for the name of the signs yet identified the correct diagnosis. Students who correctly diagnosed agenesis of the corpus callosum from a coronal MRI image containing the ‘Moose head sign’ [5] varia...

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  • Cannabinoids for spasticity in primary lateral sclerosis (PLS)

    To the editor

    We greatly enjoyed the excellent recent review on the diagnosis and management of primary lateral sclerosis (PLS). Turner and Talbot emphasize the importance of controlling spasticity as the most troublesome symptom, which is often associated with pain, discomfort and physical disability [1].
    As the authors point out, the current standard of care (baclofen, tizanidine, benzodiazepines and botulinum toxin) is frequently complicated by side effects, difficulties in titration and a lack of well controlled clinical studies [2]. We were thus surprised that the authors omitted the option of medicinal cannabis from the discussion of this very important topic.
    A study by Riva and colleagues offers clear evidence on the efficacy of the cannabinoid preparation Nabiximol for the control of spasticity in ALS and PLS patients [3], which is further supported by Meyer and colleagues providing compelling real world evidence of this effect [4].
    The THC:CBD oromucosal spray (nabioximols, brand name Sativex) became approved in European Union countries in 2010. Although only approved for people with moderate to severe spasticity in multiple sclerosis, who have not responded adequately to other anti-spasticity regimes, THC:CBD is increasingly being used off-label for spasticity in patients with motor neuron diseases. In addition, the patients themselves have self-medicated with recreational cannabis for many years [5].
    The multicenter, double-blind,...

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  • Response to Weydt et al

    We thank Dr Weydt and colleagues for their interest in our review. We are aware of the subjective benefit of cannabinoids reported by some living with multiple sclerosis, and a trial of THC:CDB spray is also approved by the UK’s National Institute for Health & Care Excellence (NICE). The CANALS study mentioned, in which PLS patients were well represented (28% of treatment arm and 20% of placebo arm), was a Phase 2 study powered to consider safety and tolerability. Adverse events were reported in 76% of the treatment group versus 27% in the placebo group. A reduction in the clinician’s Modified Ashworth Spasticity scale score was noted, and in the patient’s numeric rating scale score for pain, but not their scores for spasm or spasticity. In the discussion, the authors note that muscle cramping was not alleviated in a prior randomised trial of THC in ALS (1). We agree with their call for further evaluation, through a Phase 3 study of the benefit of cannabinoids over the licensed therapies for spasticity outlined in our review.


    1. Weber M, Goldman B, Truniger S. Tetrahydrocannabinol (THC) for cramps in amyotrophic lateral sclerosis: a randomised, double-blind crossover trial. J Neurol Neurosurg Psychiatry. 2010 Oct;81(10):1135-40. doi: 10.1136/jnnp.2009.200642. PMID: 20498181.

  • Oh No, Not DaT Again

    It gives more discomfort than pleasure to comment on DaT scanning again but your editorial [1] prompted me to find out that the number of DaTscans carried out in England is increasing yearly, from 4550 in 2012/3 to 8840 in 2018/9. A trip to the dentist might have been wiser, my long-expressed opinion (based on the fundamental principles that let down 18FDopa PET) being that the DaTscan is a waste of time, radiation and money [2]. In brief it is a low resolution, inadequately sensitive, inadequately reproducible test with too many false negatives and little knowledge of confounding influences. The acronym SWEDD has, mercifully, been consigned to the dustbin[3] but we don’t have the neuropathological studies or large and long-term blinded follow-up studies, in patients and healthy individuals, despite the many tests and years since its commercial introduction, that would tell the true false positive and negative rate of the test. We can’t then confidently say how strongly a normal result argues against a clinical diagnosis of PD. Neurology is not the only specialty that uses DaTscan and indication-creep (good for the shareholder, bad for the taxpayer) means that it is also being used to distinguish Lewy Body Dementia from Alzheimer’s Dementia despite limited supportive data (4). It must also be remembered that the test measures biochemistry, not pathology; the statement in the case presentation [5] “a DaTscan was normal, with no evidence of degenerative Parkinsonism” is...

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  • Personalising secondary prevention for stroke: the importance of considering multiple aetiologies

    With great interest, we read the review by Markus on personalising the secondary prevention approach to patients with stroke ¹, published in the most recent issue of Practical Neurology. Where we are presented with clinically useful and evidence-based advice for the etiological assessment of patients with acute ischemic stroke (AIS), focusing on lacunar stroke syndromes of a non-lacunar cause, and its appropriate therapeutic management. We consider the article of great importance: a must-read for all physicians who care for patients with AIS since etiological assessment is paramount to dictate the appropriate secondary prevention measures.

    The author proposes using the TOAST classification (Trial of Organon 10172 in Acute Stroke Treatment), arguing that classification systems that prime clinical syndromes over pathophysiological mechanisms are less useful. Nevertheless, the author omitted one classification which–partially–resolves the issue: the ASCOD (Atherosclerosis, Small-vessel, Cardiac embolism, Other, Dissection) system ². A comprehensive classification, which allows for more than one aetiology, while giving a degree of a causal relationship to the presence of each category of disease (1 potential, 2 uncertain, 3 unlikely, 0 disease not detected) including incomplete assessment (9 insufficient work-up), while considering some clinical features.

    The ASCOD approach permits the identification of patients with diseases that would have been left as indeterm...

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  • UK Consensus on pregnancy in multiple sclerosis: an update

    Dear Editors,

    Following the publication of the “UK consensus on pregnancy in multiple sclerosis: ABN guidelines” in January 2019, new data has become available and an update is required. Whilst these updates do not change the overall recommendations in the guidelines, they add information, which we feel all neurologists should be aware of in order to provide the highest quality of information to all women with MS considering pregnancy.

    (1) Interferon beta preparations in pregnancy

    In September 2019, the EMA Committee for Medicinal Products for Human Use (CHMP) recommended a label change for interferon beta-1a, peginterferon beta-1a and interferon beta-1b, i.e. Avonex, Betaferon, Extavia, Plegridy and Rebif, stating that they may be considered during pregnancy if clinically indicated, and can be used during breastfeeding [1]. This decision was based on data from interferon beta registries, national registries and post-marketing experience. However, data from exposure during second and third trimesters remains limited. The duration of exposure during the first trimester is uncertain, because data were collected when interferon beta use was contraindicated during pregnancy, and it is likely that treatment was interrupted in many women when the pregnancy was detected and/or confirmed.

    This supports the recommendation in the “UK consensus on pregnancy in multiple sclerosis: ABN guidelines” that these products are safe to be continued at least until...

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  • Clinic letters revisited-clinic letters demystified.

    We read the article “neuromythololgy” by Martin Turner and Phillip Smith ,” clinic letters revisited”1. We completely agree that the 2002 Department of Health directive that patients should be sent a copy of their clinic letters was ,” a major force in improving clinic letters”.
    The article however makes no mention of the 2018 advice2 from the Academy of Medical Royal Colleges entitled ,” please write to me”. It strongly recommends that most letters be addressed directly to the patient with a copy to the GP and that English fully comprehensible to patients is used and any technical language is explained. This approach avoids much of the discussion in the article of terms like ,”this pleasant gentleman”.

    We have both adopted this recommended approach since 2018. One of us starts letters,” thank you for coming this morning and explaining that you are a 43 year old garage mechanic and that you have suffered tingling in the right hand for 6 months”. The other starts,” your GP wrote to me that you have had tingling in your right hand for 6 months”.

    We have carried out a preliminary audit of patients, GPs, and hospital consultants attitude to this suggested change by showing them 2 similar letters one addressed to the GP and the other to the patient. GPs quite strongly favoured letters addressed to the patient saying they received far fewer requests to clarify what the hospital doctor meant. Patients were roughly evenly divided, whilst hospital consultants st...

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  • Outside The Waiting Room

    As I make my way to the outpatient clinic, late as usual after the morning rounds to start another busy day, an unusual walk in front of me seizes my attention: an elderly lady, with a narrow-based and short-stepped gait, decreased left-arm swing and stooped posture; unable to see her face, I assume she’s heading for the neurology outpatient clinic. Yet she passes by and I lose sight of her on the ophthalmology service. Not a patient of ours, I think to myself. That same night, while having supper at a restaurant with my soon-to-be-wife, I notice a few tables away a man on his seventies celebrating his birthday, surrounded by family. In front of the candle-sparkling birthday cake, I get a glimpse of an unusual face: elevated eyebrows, like on a permanent surprise, unable to direct his gaze to the cake—Procerus sign and vertical gaze paresis—I think to myself, while I notice the stooped posture and global slowness of movements while everyone on the table compliments him—parkinsonism also, definitely progressive supranucl…—“You’re doing that again, leave the man alone.” My train of thought gets wrecked by my fiancee, not being the first time, she knows I tend to distinguish and observe people with abnormal movements. I leave the man alone and finish my supper. -SACT.

    It was with exceptional interest that we read “The Waiting Room”, by Araújo et al. recently published online on Practical Neurolo...

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  • Response to Torres et al

    We thank Dr Torres and colleagues for drawing the readers’ attention to the additional value of observing patients with parkinsonian syndromes even before they enter the hospital premises. They focus specifically on the question how neurologists should act when one incidentally spots clear signs of a neurological disease among total strangers in social situations, and they emphasize just how exceptionally difficult this may be for experts in movement disorders, as these conditions can be very visible even to bystanders. Many readers will recognize how compelled one can feel to make a heartfelt recommendation to strangers to seek a neurological consultation, for example when they demonstrate clear-cut signs of Parkinson’s disease or some other neurological condition. However, we have neither acted on the impulse as this would be a serious breach of this person’s privacy. In addition, we need to realize that we are fully ignorant of the person’s context, barriers and motives that have prevented this person – who might already be aware of the signs - from seeking medical attention. We agree that one can only observe, but interfering would be out of line. Indeed, we previously observed a remarkable Parkinson-like gait disorder in Russian president Vladimir Putin and several other highly ranked Russian officials,1 just because we could not suppress our almost innate tendency to analyze movements, in this case when observing the publicly available v...

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  • Lumbar puncture on Direct Oral Anticoagulants (DOACs): a novel, emerging perspective

    Dear Editor,
    We read the article by Dodd et al. (2018) [1] with great interest. The authors provide evidence-based recommendations for the periprocedural management of antithrombotic and anticoagulant treatment in patients who require a lumbar puncture (LP). Indeed, this is a very relevant practical point for neurologists, above all when an urgent diagnostic LP is mandatory to rule out an infectious disease of the central nervous system, or a subarachnoid hemorrhage. The recommendations on adjustment/reversal of warfarin for patients on oral anticoagulants, who require LP, are well known, i.e. long-term LP allowed if INR is < 1.4. Whilst the question of how to manage patients on Direct Oral Anticoagulants (DOACS), a relatively novel pharmacological class, is also to be answered. Dodd et al’s article [1] reports that if a non-urgent LP has to be carried out he these patients, current recommendations vary among different advisory bodies about the time lapse necessary for DOAC withdrawal before the LP, depending on the renal function. The interesting possibility of measuring the drug-specific levels, so as to estimate the anticoagulant effect of a DOAC, is also mentioned, although the authors are of the opinion that routine testing before the LP is not necessary. [1]
    We believe that this is a crucial point, above all in the case of an urgent or emergent LP. Indeed, in our experience, when available, drug-specific levels can be obtained quickly and guide the cl...

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