Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
How would you advise a younger patient with residual/recurrent optic nerve meningioma, proceeding with radiotherapy, about the risks of malignant transformation or induction of other brain malignancies because of radiation?
The risk of malignant transformation of an optic nerve sheath meningioma (ONSM) after RT appears to be remarkably low, much lower than the risk of blindness from an untreated, progressive ONSM. In a younger patient, I would lean toward RT for patients with imaging progression or early visual loss, ...
What early clinical findings help in differentiating CIDP vs. POEMS?
I would like to share that I had a very challenging experience last year with a patient ultimately diagnosed with POEMS by myself, after more than one year of treatment as CIDP. There were multiple reasons it was challenging:1.) The patient presented initially with NO systemic features - just the ne...
How do you counsel elderly patients who demonstrate mild cognitive impairment but do not meet the criteria for a neurocognitive disorder?
I would let them know that mild cognitive impairment (MCI) is an umbrella diagnosis with many different contributing factors as well as risk factors for progression to dementia. Control what you can control. Limit contributing factors such as pain, mood, and sleep optimization, as well as limiting a...
How do you adjust the management of epilepsy in patients who are planning to fast?
Great question! During Ramadan, Muslims fast from dawn to sunset. They can take their medications before dawn and after sunset. In most cases, they can continue their current bid regimen without having to change to extended-release. Remind them of the importance of maintaining a good sleep schedule ...
How do you sequence pharmacologic treatments for primary insomnia?
First, be sure you have already addressed deficiencies in sleep hygiene: Room at 65 degrees F Wearing earplugs Complete darkness (no visible hand in front of face) No clock Golden hour before bed ETOH, nicotine, and caffeine reduction with cessation of 4 hours before bed Writing a list of worries B...
How do you treat nocturnal leg cramps?
Nocturnal leg cramps are similar to daytime leg cramps, but stretching may be less convenient to use as a remedy, as sleep can be further disrupted. Treating and preventing leg cramps typically utilizes some combination of hydration and electrolytes but sometimes, medications can help. Consider the ...
What is your threshold for pursuing a lumbar puncture in an older hospitalized patient with acute altered mental status when the initial workup — including labs, imaging, and urinalysis — is unrevealing?
My threshold for lumbar puncture in an older hospitalized patient with acute altered mental status is high. In my practice, I will not pursue an LP in a patient over 65 solely because an otherwise routine evaluation for delirium is unrevealing. A negative workup alone does not sufficiently increase ...
Do you find the UPDRS useful for the care of Parkinson's disease patients outside of research?
The UPDRS and MDS-UPDRS are both useful research tools for Parkinson’s. Parts one, two, and four are interview-based with some rater guidance. Part three is an objective assessment by the clinical rater. Performing part three of either UPDRS test in non-research settings is helpful to improve your u...
Would you consider adding gabapentin off label for use in the treatment of glioblastoma at this time?
As an author on the paper, let me emphasize the findings and speculate on the implications. Recently, a number of laboratories have unraveled stunning preclinical and mechanistic findings demonstrating the ability of a subset of malignant glioma cells to usurp neuronal circuitry to promote tumor gro...
How does premorbid dementia affect your decision to offer acute stroke intervention?
I would try to engage the family, along with the patient, about goals of care, quality of life before the stroke, whether APOE status is known (E4E4 is a contraindication for tenecteplase), etc. This would lead to a decision about aggressive therapy, tenecteplase and/or endovascular therapy. Previou...