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...
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 clinical management in this clinical setting. Notably, LP may be performed immediately, which may be clinically relevant, if the drug levels are under the cut-off chosen to rule out any anticoagulant effect. However, consensus is still lacking and different advisory bodies (French expert opinion, [2] Swiss operating procedures [3]) set the lower threshold limit for the anticoagulant effect of DOACs at a range between 20-50 ng/mL for other urgent procedures, like intravenous thrombolysis.
Therefore, if there were an international, or at least European consensus on the recommended DOAC drug level cut-off to rule out any anticoagulant effect, the management of patients requiring urgent or emergent procedure, like LP or surgery, would be facilitated. Obviously, if the DOACs levels are within the therapeutical range, a delay before the LP is required, according to the recommendations.
However, a remarkably different management may be prospected if an LP is indicated in patients is on dabigatran, where emergency reversal may be achieved by idarucizumab, as Dodd et al. [1] report, recommending previous consultation with a hematologist. This is another crucial point and a clinical novelty, where an urgent/emergent LP may be allowed in dabigatran-treated patients in only a few minutes after idarucizumab administration. Although literature evidence is still scarce and only a few cases (three, considering ours) have been reported to date, in our experience an LP after dabigatran emergency reversal by idarucizumab is a safe procedure, as was demonstrated by our two personal cases, one published, [4] one in press. Therefore, we are of the opinion that idarucizumab could be safely administered to patients requiring LP, also in the absence of a haematologist, to save the time inevitably required by the consultation.
Another reversal agent, andexanet-alpha, was recently approved by the FDA and seems to be appealing for patients on direct factor Xa inhibitors (rivaroxaban, apixaban and edoxaban), as Dodd et al. [1] report. However, the time required to reverse the DOAC effect and the putative pro-thrombotic effect of andexanet-alpha make it an unlikely candidate for an emergency reversal of direct factor Xa inhibitors before an LP.
Lastly, Dodd et al. [1] recommend the DOAC first dose 6 hours after an atraumatic LP. We suggest the following algorhythm: in the presence of a CHADSVADSC score of >=3 administer the DOAC after 6 hours and after 12 hours with a CHADSVASC score of <3.
It is, however, encouraging that a novel clinical scenario is emerging for the management of patients on DOACs, where outstanding opportunities are provided by the availability of specific DOAC levels dosages, even if international consensus would be welcome to set a clear cut-offs for the anticoagulant effect and, above all, by the reversal agent idarucizumab, which seems to be a safe and effective tool for urgent/emergent LP in dabigatran-treated patients.
References
1. Dodd KC, Emsley HCA, Desborough MJR, Chhetri SK. Periprocedural antithrombotic management for lumbar puncture: Association of British Neurologists clinical guideline. Pract Neurol. 2018 Aug 28. pii: practneurol-2017-001820. doi: 10.1136/practneurol-2017-001820. [Epub ahead of print]
2. Touzé E, Gruel Y, Gouin-Thibault I, De Maistre E, et al. Intravenous thrombolysis for acute ischaemic stroke in patients on direct oral anticoagulants. Expert opinion of the SocieteFrancaise de NeurologieVasculaire (SFNV) and the GroupeFrancaisd'etudes sur l'Hemostase et la Thrombose (GFHT). Eur J Neurol 2018 Jan 23. doi: 10.1111/ene.13582.
3. Seiffge DJ, Traenka C, Polymeris AA, et al. Intravenous Thrombolysis in Patients with Stroke Taking Rivaroxaban Using Drug Specific Plasma Levels: Experience with a Standard Operation Procedure in Clinical Practice. J Stroke 2017; 19(3): 347-355.
4. Agosti S, Casalino L, Daffonchio A, Arena L, Celli L and Rota E. Emergency Lumbar Puncture for Suspected Meningitis after Dabigatran Reversal with Idarucizumab: A Case Report. J Clin Case Rep 2018, 8:4.
We are very grateful to Dr Rota and colleagues for their interest in our guideline.
In essence, we agree that international consensus on DOAC level measurement and cut-off levels would be welcome.
The experience reported by Dr Rota and colleagues of their use of idarucizumab for emergency reversal of dabigatran prior to lumbar puncture is reassuring. Our guideline refers to the need to consult a haematologist prior to administration; however, a guideline is for guidance and we recognise that locally agreed protocols may vary. Likewise, the timings mentioned in the guideline relating to the safe reinitiation of DOACs are by necessity pragmatic. Further evidence in this area will of course be very welcome to further inform practice.
With respect to the article entitled ‘Montezuma’s revenge’: neurological disorders in the returning traveller, the authors make an important point about the treatment of malaria: hopefully GPs and potential travellers in the UK are always extra-ordinarily careful about malaria prophylaxis.
However, I believe it worth pointing out that the list of illnesses which may be acquired in certain countries is, unfortunately, simply wrong (Figure 1). The following infectious diseases are not found in South Africa:
1. Relapsing fever (except described in penguins![1]).
2. Plague.
3. African sleeping sickness.
Following successful treatment of the outbreak in Madagascar perhaps one should also note that the Western half of the United States is historically a region where plague is found (not mentioned by the authors)[2]. I appreciate that the list provided in the article is derived from another source, but I am sure the authors will agree on the importance of avoiding the promulgation of inaccurate information.
Finally, despite what the authors may maintain, the correct treatment, if any, of cerebral neurocysticercosis does indeed continue to remain controversial, and adequate RCTs have not been performed[3][4]. Decisions on treatment may well need to be made on a case by case basis, and it is important that neurologists should be aware of the dearth of hard evidence concerning the treatment of neurocysticercosis.
With respect to the article entitled ‘Montezuma’s revenge’: neurological disorders in the returning traveller, the authors make an important point about the treatment of malaria: hopefully GPs and potential travellers in the UK are always extra-ordinarily careful about malaria prophylaxis.
However, I believe it worth pointing out that the list of illnesses which may be acquired in certain countries is, unfortunately, simply wrong (Figure 1). The following infectious diseases are not found in South Africa:
1. Relapsing fever (except described in penguins![1]).
2. Plague.
3. African sleeping sickness.
Following successful treatment of the outbreak in Madagascar perhaps one should also note that the Western half of the United States is historically a region where plague is found (not mentioned by the authors)[2]. I appreciate that the list provided in the article is derived from another source, but I am sure the authors will agree on the importance of avoiding the promulgation of inaccurate information.
Finally, despite what the authors may maintain, the correct treatment, if any, of cerebral neurocysticercosis does indeed continue to remain controversial, and adequate RCTs have not been performed[3][4]. Decisions on treatment may well need to be made on a case by case basis, and it is important that neurologists should be aware of the dearth of hard evidence concerning the treatment of neurocysticercosis.
1 Yabsley MJ, Parsons NJ, Horne EC, et al. Novel relapsing fever Borrelia detected in African penguins (Spheniscus demersus) admitted to two rehabilitation centers in South Africa. Parasitol Res 2012;110:1125–30. doi:10.1007/s00436-011-2602-2
2 Global distribution of natural plague foci. WHO. 2016.http://www.who.int/csr/disease/plague/Plague-map-2016.pdf?ua=1
3 Carpio A, Fleury A, Romo ML, et al. Neurocysticercosis: the good, the bad, and the missing. Expert Rev Neurother 2018;18:289–301. doi:10.1080/14737175.2018.1451328
4 Singh G, Sharma R. Controversies in the treatment of seizures associated with neurocysticercosis. Epilepsy Behav 2017;76:163–7. doi:10.1016/j.yebeh.2017.05.033
Sir,
I thoroughly enjoyed reading Dr. Allen’s excellent paper on the right way to do the ankle jerk. He is quite right in saying that ‘tendon reflexes’ are not tendon reflexes. Tapping a tendon leads to stimulation of the Golgi tendon organs, which are actually inhibitory to the alpha neurones, so no response should occur. The muscle contraction probably results from the vibrations transmitted to the intrafusal muscle fibres, leading to activation of the anterior horn cells and thus causing muscle contraction in response to the stimulus. The term “deep tendon reflex” is completely inappropriate; which deep tendons can one access? Levator palpebrae superioris? Piriformis? Gluteus medius? The tendons percussed have to be superficial so that we can get at them.
Although Dr. Allen’s method is absolutely appropriate in patients who are confined to bed, those patients who are mobile can, I suggest, be better examined if you ask them first to kneel on the seat of the chair on which they were sitting, grasping its back with their hands. They are thus unconsciously performing a Jendrassik manoeuvre, augmenting any response that their bodies might make. Their ankles, projected out behind the seat, can be tapped easily, and the response noted with equal facility.
Now in my 80s, I cannot remember whether it was Erb or Westphal or Romberg or somebody else who first suggested this method; but after 55 years in Neurology, I still find it the best way to asse...
Sir,
I thoroughly enjoyed reading Dr. Allen’s excellent paper on the right way to do the ankle jerk. He is quite right in saying that ‘tendon reflexes’ are not tendon reflexes. Tapping a tendon leads to stimulation of the Golgi tendon organs, which are actually inhibitory to the alpha neurones, so no response should occur. The muscle contraction probably results from the vibrations transmitted to the intrafusal muscle fibres, leading to activation of the anterior horn cells and thus causing muscle contraction in response to the stimulus. The term “deep tendon reflex” is completely inappropriate; which deep tendons can one access? Levator palpebrae superioris? Piriformis? Gluteus medius? The tendons percussed have to be superficial so that we can get at them.
Although Dr. Allen’s method is absolutely appropriate in patients who are confined to bed, those patients who are mobile can, I suggest, be better examined if you ask them first to kneel on the seat of the chair on which they were sitting, grasping its back with their hands. They are thus unconsciously performing a Jendrassik manoeuvre, augmenting any response that their bodies might make. Their ankles, projected out behind the seat, can be tapped easily, and the response noted with equal facility.
Now in my 80s, I cannot remember whether it was Erb or Westphal or Romberg or somebody else who first suggested this method; but after 55 years in Neurology, I still find it the best way to assess the ankle jerk in mobile patients.
It is interesting that Graham Warner mentions the sound of absent ankle reflexes. I remember discussing the thud of an absent ankle with Michael Harrison, who was my greatest clinical guru, when I was his registrar at the Middlesex Hospital in London. I have also mentioned it to my students but tended to get the l look back that tells me politely that I might not come from the same planet as them. I suspect this is because learning to examine patients involves learning novel complex perceptions. Much of this is honed over many years and like all complex perceptions involves more than one sensory modality. As neurologists, we all know that appreciating a subtle flavour involves lot more than the sensory information from the tongue; it is mostly olfactory but also involves texture and temperature as well as context and expectation. This is why to many of us the discussions of wine buffs about the subtle flavours of different vintages sound like the ramblings of someone from an alien world. Thus when teaching students one has to realise that they are learning complex perceptions in unfamiliar contexts and may not be able to appreciate subtleties such as the sound of reflexes. So their “what planet is he from?” look is appropriate because perceptually they are in a different world to that of an experienced clinician. As teachers, we need to guide them to our world of complex perceptions and not all can follow, just as I would never succeed as a wine-taster (not that I don’t like...Show More
It is interesting that Graham Warner mentions the sound of absent ankle reflexes. I remember discussing the thud of an absent ankle with Michael Harrison, who was my greatest clinical guru, when I was his registrar at the Middlesex Hospital in London. I have also mentioned it to my students but tended to get the l look back that tells me politely that I might not come from the same planet as them. I suspect this is because learning to examine patients involves learning novel complex perceptions. Much of this is honed over many years and like all complex perceptions involves more than one sensory modality. As neurologists, we all know that appreciating a subtle flavour involves lot more than the sensory information from the tongue; it is mostly olfactory but also involves texture and temperature as well as context and expectation. This is why to many of us the discussions of wine buffs about the subtle flavours of different vintages sound like the ramblings of someone from an alien world. Thus when teaching students one has to realise that they are learning complex perceptions in unfamiliar contexts and may not be able to appreciate subtleties such as the sound of reflexes. So their “what planet is he from?” look is appropriate because perceptually they are in a different world to that of an experienced clinician. As teachers, we need to guide them to our world of complex perceptions and not all can follow, just as I would never succeed as a wine-taster (not that I don’t like a nice Malbec). Furthermore, many tendon hammers around these days have such hard rings that hitting one’s hand hard enough to listen for absent reflexes may prove a painful experience. Show Less
Chris Allen’s series on neurological examination offers huge relief to fellow experts who execute it incorrectly, such as the “ankle jerks”. I too use the plantar method although caution Juniors/Students to do it the right way (tendon method) when non-neurologists assess in osce’s/finals. But in teaching them how to tick the boxes I have questioned why I do what I do (self-questioning being one of the reasons I seize the opportunity to train others). I then recall as an SHO Simon Nurick (one of the people who inspired me) tellinging me to listen to the reflexes, in that when absent one hears a dull thud (rather like that of a pleural effusion, so it is interesting to learn that neurological hammers evolved from those used for respiratory examination). And it sounds more resonant when present, all akin to how taught a violin string might be, I tell them. In fact not only do I listen, as well as observe (visual observation is all that generalists teach Medical Students), but also feel. I believe this most useful when the tension in the “strings” are greatest in hypertonic such that there may be no apparent movement nor sound, but one gets tactile feed back. Hence where possible I always strike the hammer against my own hand placed carefully to achieve best transmission of the force. I suspect all “experts” draw the greater data without knowing and can so better analyse the clinical situation.
I’m confident too that they like me may even apply varying non-standard force...
Chris Allen’s series on neurological examination offers huge relief to fellow experts who execute it incorrectly, such as the “ankle jerks”. I too use the plantar method although caution Juniors/Students to do it the right way (tendon method) when non-neurologists assess in osce’s/finals. But in teaching them how to tick the boxes I have questioned why I do what I do (self-questioning being one of the reasons I seize the opportunity to train others). I then recall as an SHO Simon Nurick (one of the people who inspired me) tellinging me to listen to the reflexes, in that when absent one hears a dull thud (rather like that of a pleural effusion, so it is interesting to learn that neurological hammers evolved from those used for respiratory examination). And it sounds more resonant when present, all akin to how taught a violin string might be, I tell them. In fact not only do I listen, as well as observe (visual observation is all that generalists teach Medical Students), but also feel. I believe this most useful when the tension in the “strings” are greatest in hypertonic such that there may be no apparent movement nor sound, but one gets tactile feed back. Hence where possible I always strike the hammer against my own hand placed carefully to achieve best transmission of the force. I suspect all “experts” draw the greater data without knowing and can so better analyse the clinical situation.
I’m confident too that they like me may even apply varying non-standard forces to gain more data points and look for the degree of spread I do to judge the UMN flavour of things.
Eponymous names are not allowed, and I don’t know if SN’s teaching was something handed down, so tendon jerk sounds cannot be labelled Nurick’s sign, but in the world of evidenced practice we can still recognise experience, wisdom and “eminence”??
Graham Warner
Dear Editor,
Show MoreWe 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...
We are very grateful to Dr Rota and colleagues for their interest in our guideline.
In essence, we agree that international consensus on DOAC level measurement and cut-off levels would be welcome.
The experience reported by Dr Rota and colleagues of their use of idarucizumab for emergency reversal of dabigatran prior to lumbar puncture is reassuring. Our guideline refers to the need to consult a haematologist prior to administration; however, a guideline is for guidance and we recognise that locally agreed protocols may vary. Likewise, the timings mentioned in the guideline relating to the safe reinitiation of DOACs are by necessity pragmatic. Further evidence in this area will of course be very welcome to further inform practice.
To the Editor
With respect to the article entitled ‘Montezuma’s revenge’: neurological disorders in the returning traveller, the authors make an important point about the treatment of malaria: hopefully GPs and potential travellers in the UK are always extra-ordinarily careful about malaria prophylaxis.
However, I believe it worth pointing out that the list of illnesses which may be acquired in certain countries is, unfortunately, simply wrong (Figure 1). The following infectious diseases are not found in South Africa:
1. Relapsing fever (except described in penguins![1]).
2. Plague.
3. African sleeping sickness.
Following successful treatment of the outbreak in Madagascar perhaps one should also note that the Western half of the United States is historically a region where plague is found (not mentioned by the authors)[2]. I appreciate that the list provided in the article is derived from another source, but I am sure the authors will agree on the importance of avoiding the promulgation of inaccurate information.
Finally, despite what the authors may maintain, the correct treatment, if any, of cerebral neurocysticercosis does indeed continue to remain controversial, and adequate RCTs have not been performed[3][4]. Decisions on treatment may well need to be made on a case by case basis, and it is important that neurologists should be aware of the dearth of hard evidence concerning the treatment of neurocysticercosis.
1 Yab...
Show MoreSir,
I thoroughly enjoyed reading Dr. Allen’s excellent paper on the right way to do the ankle jerk. He is quite right in saying that ‘tendon reflexes’ are not tendon reflexes. Tapping a tendon leads to stimulation of the Golgi tendon organs, which are actually inhibitory to the alpha neurones, so no response should occur. The muscle contraction probably results from the vibrations transmitted to the intrafusal muscle fibres, leading to activation of the anterior horn cells and thus causing muscle contraction in response to the stimulus. The term “deep tendon reflex” is completely inappropriate; which deep tendons can one access? Levator palpebrae superioris? Piriformis? Gluteus medius? The tendons percussed have to be superficial so that we can get at them.
Although Dr. Allen’s method is absolutely appropriate in patients who are confined to bed, those patients who are mobile can, I suggest, be better examined if you ask them first to kneel on the seat of the chair on which they were sitting, grasping its back with their hands. They are thus unconsciously performing a Jendrassik manoeuvre, augmenting any response that their bodies might make. Their ankles, projected out behind the seat, can be tapped easily, and the response noted with equal facility.
Now in my 80s, I cannot remember whether it was Erb or Westphal or Romberg or somebody else who first suggested this method; but after 55 years in Neurology, I still find it the best way to asse...
Show MoreChris Allen’s series on neurological examination offers huge relief to fellow experts who execute it incorrectly, such as the “ankle jerks”. I too use the plantar method although caution Juniors/Students to do it the right way (tendon method) when non-neurologists assess in osce’s/finals. But in teaching them how to tick the boxes I have questioned why I do what I do (self-questioning being one of the reasons I seize the opportunity to train others). I then recall as an SHO Simon Nurick (one of the people who inspired me) tellinging me to listen to the reflexes, in that when absent one hears a dull thud (rather like that of a pleural effusion, so it is interesting to learn that neurological hammers evolved from those used for respiratory examination). And it sounds more resonant when present, all akin to how taught a violin string might be, I tell them. In fact not only do I listen, as well as observe (visual observation is all that generalists teach Medical Students), but also feel. I believe this most useful when the tension in the “strings” are greatest in hypertonic such that there may be no apparent movement nor sound, but one gets tactile feed back. Hence where possible I always strike the hammer against my own hand placed carefully to achieve best transmission of the force. I suspect all “experts” draw the greater data without knowing and can so better analyse the clinical situation.
Show MoreI’m confident too that they like me may even apply varying non-standard force...
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