Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
How do you determine which patients with ICAS are the best candidates for balloon angioplasty versus those who should continue with aggressive medical management alone?
A recent study on JAMA network found angioplasty superior to medical therapy (dual antiplatelet and statin), whereas previous studies have found angioplasty combined with stenting more risky. I am not sure that appropriate guidelines have yet been developed, but I would think that the stenosis must ...
If a patient who has previously been taking lamotrigine stops taking it for between two weeks and a month, do you have to uptitrate it all over again or do you have another way to resume it?
I'm not aware of good data to answer this question. To be safest, I would probably titrate again at the usual schedule as though starting from scratch. In the epilepsy monitoring unit, we're typically comfortable with restarting at-home doses without retitrating up to 14 days off meds (the lower lim...
Do you treat tumefactive multiple sclerosis differently than other forms of MS both in the acute and maintenance phase?
In general, I opt for early use of high-efficacy therapy like B-cell depletion. This is especially true if the patient has high levels of disease activity (recent relapses, enhancing lesions on MRI, and tumefactive lesions). A single lesion measuring >2cm is considered tumefactive.
How do you determine candidacy for selective dorsal rhizotomy in spastic cerebral palsy?
The answer to this question is simultaneously straightforward and yet hotly debated! I take a fairly practical and simple approach. Here is my take from a neurologist’s perspective: Any child with cerebral palsy with predominant spasticity (minimal to no dystonia) who has some ambulation that is imp...
What is your approach to light sedation in pediatric EMG?
How do you counsel patients with ALS on the benefits of enteral nutrition?
I agree with Drs. @Dr. First Last and @Dr. First Last but what I find frequently is that patients are reluctant to have PEG because of a number of psychological factors; fear of the surgery, fear of having a tube, fear of disease progression, fear that it will keep them alive indefinitely as in the ...
When do you recommend genetic testing in patients with neuropathy?
I would do genetic testing in any chronic progressive polyneuropathy that defies explanation after routine lab testing and is associated with at least one of the following features: positive family history early onset (<35-40) abnormal foot appearance-pes cavus, hammertoes motor predominant symptom...
What abortive and preventative treatments have you found to be helpful for a vestibular migraine?
I still treat using the same medication guidelines as for any migraine presentation. I am more likely to try venlafaxine in these patients. For off-label/guidelines, I am also more likely to try gabapentin and acetazolamide. In addition to pharmacologist management, I have a low threshold to refer f...
What workup do you recommend on patients with suspected ischemic cranial nerve six palsy?
The conventional wisdom is that 90% of isolated ischemic (or "vasculopathic") 6th nerve palsies recover in 6 months or less. Diagnostic certainty of this etiology is increased if the patient is hypertensive, diabetic, or maybe has hyperlipidemia or tobacco use. The real problem for the non-ophthalmi...
How would you manage cognitive changes in a patient with memory impairment and significant brain atrophy with no diagnostic testing consistent with Alzheimer's disease?
It would depend on the clinical history, pattern of atrophy, and diagnostic biomarkers. If I had a patient with a typical clinical history of AD with progressive episodic memory loss substantiated by neuropsychological testing, IADL impairment, and hippocampal atrophy on imaging, I probably would no...