Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
Do you send only serum paraneoplastic panels or also include CSF evaluation in patients with concern for paraneoplastic neuropathy?
Ideally, you should send both serum and CSF. There are several cases where the antibodies are positive only in CSF and not in serum.References: Graus et al., PMID 34006622 McKeon et al., PMID 21422462
When do you order SSEPs for evaluation of multiple sclerosis?
Occasionally, I order Visual EPs. SSEPs are largely worthless and Auditory VEPs, though occasionally helpful are rarely worth the trouble. A good thorough history, a detailed neurologic examination, a 3T MRI, and if necessary spinal fluid with good analysis for bands, IgG index, and kappa light chai...
In a patient with neurosarcoidosis who required infliximab for initially refractory symptoms but is now stable, how do you decide on the optimal time to de-escalate therapy?
I typically base this decision on several factors: Severity of initial symptoms, tolerability or side effects of treatment, degree/timeline of radiographic improvement, and patient preferences. I begin to consider tapering off or de-escalating infliximab after around 12-24 months of clinical and rad...
What are the main reasons that exercise trials have collectively failed to demonstrate sufficient evidence for disease modification in Parkinson's disease?
This paper by Ruiz et al discusses your question: On Disease Modifying and Neuroprotective Treatments for Parkinson's Disease: Physical Exercise. A big problem with studying exercise in any disease is that patients who can exercise are generally healthier than patients who cannot, so studies compari...
Would you start anticoagulation in a patient with a history of CVA 1 year ago and high risk APL profile who was never started on anticoagulation, but is now presenting for follow up and without recurrent thrombotic events?
This is a difficult question. The details here are important. Therapeutically, you can go either way in my opinion. Were the positive antiphospholipid antibodies checked again later? Did the patient have an infection when the APS labs were first done? Does the patient have diabetes or other CV risk ...
What additional testing besides LAC/APLS, factor V Leiden, prothrombin gene mutation, JAK 2 do you draw for unprovoked cerebral venous sinus thrombosis?
Cerebral venous sinus thromboses (CVST) are often put into the category of "thromboses of unusual sites,"--as opposed to the more common lower extremity thromboses or pulmonary emboli.Provoked causes of CVST include pregnancy or exogenous estrogen use, infection of the head/neck or CNS, head trauma,...
How long can you treat dermatomyositis with IVIG?
Typically, in best-case scenarios, you can treat dermatomyositis with IVIG for 1 year, but some patients require it for 18-24 months, and the minority of patients continue to require it over several years. Some patients may only need it until you achieve improvement, especially in some countries whe...
Do you routinely screen for sleep apnea in patients with acute ischemic stroke?
We at least ask the patient and family about sleep apnea symptoms. In patients who answer positively, or in those who deny symptoms but have obvious risk factors such as obesity, we do make the referral to our sleep clinic.
Which IV medications do you offer for outpatient headache infusions?
Eptinezumab (Vyepti) in a dose of 100 or 300 mg. It is a CGRP antibody marketed for the preventive treatment of episodic or chronic migraine. However, in a randomized, double-blinded, placebo-controlled trial treating patients with 100 mg IV for moderate or severe migraine headache, it met the FDA-d...
Do you utilize muscle MRI to track disease progression in myopathies?
Muscle MRI can be helpful in assessing for active disease/inflammatory myopathy and can help sampling in a more targeted manner when considering a muscle biopsy. Fatty replacement is seen in more advanced cases of myopathy and has been used as a marker of disease progression in non-inflammatory/slow...