Abstract:The introduction of immune checkpoint inhibitors (ICIs) has dramatically changed the landscape of treatment for a variety of cancers. However, there is increasing recognition of neurotoxicity related to ICI use. In this review, we will discuss the peripheral nervous system neurologic immune related adverse events (PNS-nirAEs) of anti-CTLA4, anti-PD1, and anti-PDL1 ICIs, including nerve, neuromuscular junction, muscle, and overlap syndromes. We will discuss the relevant epidemiology, pathophysiology, clinical syndromes, diagnostic approaches, treatment, and prognosis of PNS-nirAEs. We will discuss the safety and efficacy of ICIs when utilized in patients with pre-existing neurologic autoimmune disorders (NAIDs). Lastly, we will discuss relevant treatment options and when to consider rechallenging with ICI after an initial de novo PNS-nirAE or exacerbation of a pre-existing NAID.
Abstract:Immunotherapies such as chimeric antigen receptor T cell (CAR-T) therapy and immune checkpoint inhibitors have improved cancer survival but are associated with potentially severe neurotoxicities that can impair neurologic function, quality of life, and survival. Despite their growing use, substantial disparities persist in the recognition, diagnosis, and management of cancer therapy-related neurotoxicities, disproportionately affecting underserved populations. In this review, we apply the social-ecological model (SEM) to examine how factors across individual, interpersonal, organizational, community, and policy levels contribute to inequities in neurotoxicology care. We synthesize evidence on barriers to early detection and access to neurologic expertise and highlight emerging strategies to promote equity, including early symptom recognition, improved specialty access, and supportive institutional infrastructure. We also explore the potential of behavioral economics-informed approaches and artificial intelligence-enabled tools, including telemedicine and remote monitoring, as scalable strategies to reduce inequities in neurotoxicity care.
Abstract:Approximately half of the brain subsumes visual function, so neurologic toxicities of immunotherapy medications may frequently manifest with visual symptoms. As the use of immunotherapeutic medicines proliferates for a broader array of indications, neuro-ophthalmologists in clinical practice may increasingly be referred patients with visual symptoms that result. In this review, we discuss the spectrum of neuro-ophthalmic manifestations of immunotherapy toxicity with a broad review of the literature. Both immune checkpoint inhibitors and chimeric antigen receptor T cell therapies are discussed.
Abstract Carotid tumors are rare, hyper-vascular structures arising from the chemoreceptors of the carotid body. In this study, we will discuss the classification and diagnosis of carotid body tumors, as well as surgical resection, which is the definitive treatment for these lesions. We will highlight important preoperative considerations to minimize the risk of bleeding, cranial nerve injury, and stroke with surgical resection.
Abstract:Isolated cranial tremors (face tremor, jaw tremor, vocal tremor, and embouchure tremor) are unusual examples of focal tremor disorders. The etiology and treatment of these troublesome and occasionally disabling conditions deserve more attention. In this review, we summarize current knowledge about these disorders and consider their etiologies and treatment approaches. We suggest changes to the current classification system of isolated cranial tremors based on shared phenomenology and treatment response.
Abstract:Dystonia and tremor are common movement disorders with heterogenous presentations. Their overlap, termed "tremor in dystonia" for this review, is a common phenomenon that is classified inconsistently in practice and the literature. While the two-axis structure of the dystonia and tremor classifications clarified some aspects of tremor in dystonia, confusion and contention remain amongst clinicians. This is due not only to the varied definitions proposed over time and clinical heterogeneity, but the current lack of consensus on the underlying pathophysiology. This paper outlines the existing and proposed definitions for tremor in dystonia, clinical assessment, adjunct objective measures, and current understandings of the pathophysiology of dystonia.
Abstract:Acquired pendular nystagmus consists of quasi-sinusoidal oscillations of the eyes that significantly impair gaze stability and visual clarity. It most commonly occurs in demyelinating disorders such as multiple sclerosis and in acquired degenerative conditions like oculopalatal tremor. Other etiologies-including drug toxicity, metabolic and genetic disorders, and granulomatous diseases-can also produce syndromes featuring pendular nystagmus. Analysis of its kinematic properties has provided clues to the underlying mechanisms of this otherwise enigmatic disorder. In this review, we examine the clinical features of neurological conditions associated with pendular nystagmus, with emphasis on its acquired forms, and summarize recent advances in diagnostic strategies and therapeutic development. Pendular nystagmus is defined by quasi-sinusoidal oscillations of the eyes that impair visual acuity and produce oscillopsia.1 Despite its designation as "nystagmus," this disorder lacks the hallmark waveform of classical nystagmus-slow drifts followed by rapid corrective saccades. Instead, pendular nystagmus consists of consecutive slow phases of eye movement, giving it a pendular appearance. These oscillations typically exhibit a dominant frequency of 4 to 6 Hz, although certain conditions, such as oculopalatal tremor (OPT; see below), present with lower frequencies around 2 Hz, while demyelinating disorders may reach frequencies up to 8 Hz. The phenomenology of pendular nystagmus reflects diverse underlying pathophysiological mechanisms associated with neurodegenerative, toxic-metabolic, immune-mediated, and genetic disorders. This review aims to provide a comprehensive resource on the pathophysiology, phenomenology, etiology, and therapy of pendular nystagmus.
Abstract Carotid endarterectomy (CEA) has been considered the standard of care for symptomatic carotid stenosis (sCS). Carotid artery stenting (CAS) warrants reevaluation for equivalence to CEA given advances in embolic protection and stent technology. Our patients with sCS undergo computed tomography angiography and perfusion, magnetic resonance imaging, and carotid duplex ultrasonography to guide selection for CEA, CAS, or transcarotid artery revascularization (TCAR). Preoperative management includes dual antiplatelet therapy and maximal-dose statin therapy, comorbidity optimization, smoking cessation counseling, cardiac risk assessment for stroke, systemic anticoagulation for an intraluminal thrombus, and perfusion-based risk stratification. For CAS, we routinely use dual embolic protection with proximal balloon occlusion and distal filters, second-generation micromesh stents, and poststenting aspiration. Intravascular lithotripsy and integrated embolic protection have broadened the indications for CAS. We present our algorithm for managing sCS, demonstrating CEA, CAS, and TCAR as equivalent in safety and effectiveness for most patients, while recognizing select factors conferring higher risk with each approach.
Abstract:The evaluation, diagnosis, and treatment of functional neurological disorder (FND) requires a specific skillset, an individualized approach to care, and resilience to navigate clinical challenges. Elements of care have evolved alongside a maturing understanding of the disease in a manner that has improved diagnostic accuracy, patient experience, patient outcomes, and health care utilization. This article reviews current evidence-based approaches to the evaluation of patients with FND, the delivery of the FND diagnosis, and the selection of an appropriate treatment plan.
Abstract Carotid atherosclerosis is a major cause of ischemic stroke, historically managed according to luminal stenosis severity. However, stenosis alone fails to capture plaque biology, as features such as intraplaque hemorrhage (IPH), lipid-rich necrotic core, fibrous cap rupture, ulceration, and perivascular inflammation strongly influence vulnerability and clinical outcomes. Advances in imaging have shifted the focus from lumen quantification to multimodal plaque phenotyping. Ultrasound, computed tomography angiography (CTA), magnetic resonance imaging (MRI), digital subtraction angiography, photon-counting CT (PCCT), and positron emission tomography (PET) provide complementary morphological and biological information, while contrast-enhanced ultrasound, radiomics, and artificial intelligence (AI) enhance risk stratification beyond conventional parameters. MRI remains the reference for detecting IPH, while CTA and PCCT improve lumen and tissue characterization. PET tracers further interrogate inflammatory and calcification pathways. Emerging frameworks such as Plaque-Reporting and Data System aim to standardize reporting and integrate multimodal biomarkers. The future of carotid imaging lies in precision medicine, combining advanced imaging, AI, and molecular biology to optimize individualized stroke prevention strategies.
Abstract:Developing neurologic educators is vital to the future of neurologic care. This chapter presents a practical framework to recruit, prepare, and sustain educators across the career arc. It outlines a milestones-based pathway from resident-as-educator to clinician-educator tracks with protected time, mentored capstone scholarship, and educator-portfolio development. Five reinforcing priorities: (1) professional development with instructional-design support; (2) communities of practice that normalize peer observation, coaching, and writing collaboratives; (3) recognition systems that convert effort into promotable evidence; (4) promotion pathways anchored in the educator portfolio with transparent criteria; and (5) support and compensation models that treat protected time as currency and education as measurable work. It clarifies distinctions among mentorship, sponsorship, and coaching. Future directions include integrating Health Systems, Neuroequity, and Health Humanities; leveraging AI and immersive technologies for adaptive learning; and linking educator impact to patient-centered outcomes. These strategies position educator development as a core strategy to improve neurologic care.
This manuscript discusses nonpharmacological, nonsurgical interventions for tremor, mostly essential tremor, predominantly arm tremor. We will review botulinum toxin injections (BoNT), transcutaneous electrical stimulation (TES), multiple orthotic/mechanical devices, vibration strategies, cooling, and adaptive utensils. BoNT has copious but inconsistent efficacy data, the optimal tremor phenotypes, muscle selection, and injection techniques remain debated. The TES section discusses mostly peripheral nerve stimulation at the wrist, including commercially available open-loop systems and closed-loop systems (Felix), as well as spinal and cerebellar TNS. Orthotic devices, which physically dampen tremor, include the STIL B.P. orthosis, the Tremulo, GyroGlove, WOTAS exoskeleton, liquid harmonic dampeners, Steadi-3, and Readi-Steady. Vibration devices include the Encora Pulse and Vilim ball. Adaptive devices include weighted spoons, deep cavity spoons, counter-balance utensils, and electrical actuator devices.
