Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
Do you continue to use Botox to treat chronic migraine in a patient who becomes pregnant?
First of all, my use of botulinum toxin for the preventive treatment of chronic migraine has dramatically decreased since I started working with the CGRP antibodies in the context of clinical trial research in 2012. I find them to be much more effective than botulinum toxin, equally well if not bett...
Do you avoid SSRIs in patients with a history of RCVS?
SSRIs are on a long list of medications associated with RCVS. The condition is relatively rare, and a very low percentage of patients have recurrences. If there is a strong indication for antidepressants, I would treat them with appropriate warnings.
How do you evaluate patients with suspected pseudo-dementia?
I am very careful about diagnosing a functional cause for cognitive impairment. I typically get vitamin B12 and TSH levels, and also get a neuropsychological evaluation. They are usually able to pick up underlying behavioral disorders or poor effort. If unrevealing, and there are no obvious risk fac...
Is it possible to develop worsening motor features of Parkinson's disease (PD) when using clozapine (for treatment of PD psychosis) above a certain dose?
Clozapine does not appear to worsen Parkinson's disease at most doses used for patients with PD. Other side effects are dose limiting such as orthostatic hypotension and sedation. The challenge of blood monitoring has limited the use of this drug in the US.There is a wonderful podcast on movementdis...
How would you manage a patient with secondary progressive multiple sclerosis manifesting with increased neuropsychiatric manifestations (ex. psychosis) with no recent changes on brain MRI?
Exclude the usual suspects such as infections, electrolyte abnormalities, and polypharmacy. If nothing pans out and nutritional causes or deficiencies have been excluded I would direct such patients to psychiatric care. I will also make sure that the patient is not suicidal by doing a Beck Depressio...
How do you approach the workup and management of patients with suspected functional neurologic disorders?
This is not really an answerable question. I would re-frame the question, because it really depends on the kinds of symptoms they have and the neurologic exam that is performed. I disagree with neurologists who say that "functional neurologic disorders" are a diagnosis of exclusion. That is absolute...
Do you use pimavanserin to treat psychotic symptoms in Lewy body dementia?
Yes, if insurance allows. However, it is my medication of last resort after trying cholinesterase inhibitor and SSRI. It can be used in the place of quetiepine. Note that this is an off-label use of the medication.
Would you avoid the use of keppra in patients with TBI due to concerns for worsening agitation?
I suspect that this practice of prophylactic antiepileptic medications for TBI patients will go away over time. History has shown us time and time again that we over-medicate patients.
For patients with significant side effects to a cholinesterase inhibitor, do you try another medication in the class or avoid it altogether?
Firstly, I titrate up the medication so that if there is a side effect, I can retreat to my last tolerated dose. If the side effect is dizziness or faintness, then I will stop trying to escalate the dose. If the side effect is vivid dreaming, then one might try to take the medication in the morning....
When do you recommend driving tests in patients who have memory loss?
I recommend a driving test when: there is any concern by the family, the clinical dementia rating is greater than 0.5, there are visuospatial defects on cognitive testing, there are problems with Trails A or B, and also whenever I cannot be sure.