Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
How do you approach the timing of COVID-19 vaccination for patients with multiple sclerosis on B-cell depleting therapies?
B-cell depleting agents can interfere with a patient's ability to develop an adequate humoral response. With regards to the infusions such as rituximab and ocrelizumab, I recommend holding off on getting SARS-CoV2 vaccinations until at least 3 months and up to, at minimum, 2 weeks prior to the next ...
When do you initiate immunosuppressant drugs for patients with a diagnosis of myasthenia gravis?
I assume the question refers to non-steroid immunosuppressant drugs such as azathioprine, mycophenolate, methotrexate, etc. I use those drugs predominantly in generalized MG (although a few patients with ocular MG may also require them), a) in any patient that requires prednisone doses of >20 mg dai...
How does evidence of cerebral amyloid angiopathy/microbleeds affect choices for secondary stroke prevention in patients with a history of ischemic stroke and atrial fibrillation?
This is a discussion I have with the patient, mentioning that the positive predictive value of cortically based cerebral microhemorrhages is not absolute, especially when there is a small number of them and there are no other signs of small vessel disease (such as FLAIR changes or enlarged peri-vasc...
How do you manage random-OFF periods in patients with Parkinson's disease who are otherwise having good control of their motor symptoms?
That's a great question. This clinical scenario is perfect for the use of Parkinson's "rescue therapies." Rescue therapies are those that have a quick-onset of action to provide quick relief, without a significant duration of effect and limited side effects. There are two relatively new drugs on th...
When do you consider a levodopa trial in patients with new-onset dystonia?
Levodopa trials are recommended in all children with any type of dystonia and also adults whose phenotype could be consistent with dopa-responsive dystonia (DRD). An observed levodopa trial (generally up to 300–400 mg of levodopa daily in adults or 4–5 mg/kg/day in children) for at least a month is ...
What is your approach to a patient who has an ischemic stroke while on clopidogrel despite strict compliance and normal results on clopidogrel response assay?
Not all recurrent infarcts are from a failure of anti-thrombotics, some patients with large artery atherosclerosis are not taking their statin (as evidenced by no change in LDL-C) or are not exercising (based on subanalysis of SAMMPRIS), other lacunar subtype patients have uncontrolled hypertension,...
In patients with clinically probable ALS, what other mimicking pathology do you rule out before establishing the diagnosis?
By and large, I agree with the comments. The most important thing is not to give an incorrect diagnosis of ALS, with its dire prognosis, if there is a different cause for the patient's condition, such as MMN, neuropathy, or a spinal cord lesion. I am not in a hurry to give a diagnosis of ALS, in vie...
How do you approach the diagnosis of MS subtypes like Balo's concentric sclerosis?
Balo's concentric sclerosis (BCS) is a demyelinating condition considered a variant of MS characterized by concentric rings of alternating demyelinating and partially myelinated fibers, visible on imaging and on autopsy. Classically described as acute onset with rapid progressive decline, there are ...
In patients with Duchenne Muscular Dystrophy who have an exon 51 mutation, do you treat with both prednisone and Eteplirsen?
How do you approach the management of patients with one clinical demyelinating event and MOG+ antibody status?
I do not always treat a MOG+ single event (isolated optic neuritis, isolated transverse myelitis, or ADEM-like presentation) as it is possible that it might be a one-time-only event (as might occur after a viral illness or vaccination). If there has been "dissemination in time", then I would conside...