Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
Do you start Riluzole on all patients diagnosed with ALS?
No. I discuss riluzole with all patients and explain that it prolongs survival in ALS by a variable amount of time, usually around 3-4 months- therefore, if the patient wants to use anything available to prolong their life, they should take it. I also explain, however, that riluzole will not stop di...
What is your steroid-sparing agent of choice to treat GCA given the current tocilizumab shortage?
If at all possible, I continue to use tocilizumab as a glucocorticoid sparing agent for patients with giant cell arteritis. Given the results of the GIACTA trial, the Villiger trial, and lots of observational data, it is clear that tocilizumab provides efficacy in terms of reducing risk of relapse a...
How do you manage Botox injections in patients with cervical dystonia after getting implanted with DBS?
Patients have a remote; ask them to bring it to the appointment and they can turn off and on before and after the procedure to avoid EMG artifact. Importantly, you need to know where the DBS leads are on the back side of head/neck and make sure you don't damage the leads with the injection. Patient...
What is your strategy to help prevent paclitaxel-related neuropathy?
There are no proven strategies for prevention of CIPN and the use of these supplements is not recommended. Some supplements such as acetyl carnitine can actually worsen neuropathy outcomes and some supplements such as B12, vitamin C, and others may negatively interact with chemotherapy and worsen di...
How do you manage a symptomatic meningioma and associated vasogenic edema in a poor performance status patient?
Superficially, this resembles a straightforward question, but in reality, it is very nuanced, with numerous variables driving decision-making. My sequential "thought-experiment" in a situation like this would proceed as follows:1. Why does the patient have poor KPS? Are there underlying comorbiditie...
How do you counsel young adults with antibody-negative necrotizing myopathy on prognosis and long-term monitoring/treatment?
The first step is to rule out other conditions that are associated with necrotizing myopathy, that can affect treatment and prognosis, like malignancy, thyroid disease, or genetic muscle diseases. History, physical exam, basic laboratory work-up, family history, age-appropriate malignancy screening,...
How do you prescribe Perampanel for use in patients with refractory status epilepticus?
LD: 6-12 mg MD: 12 mg/day Use not recommended in severe renal impairment (CrCl <30 ml/min). Consider dose reduction in mild to moderate hepatic impairment. Use is not recommended in severe hepatic impairment.
How do you approach the management of acute attacks of MOGAD-associated optic neuritis?
If vision loss is severe and has not improved after corticosteroids/IVIG, I would consider plasma exchange (PLEX). Although we do not have controlled studies of PLEX in MOGAD, it is often used for cases of fulminant demyelination in other neuroinflammatory disorders.
For patients with a new diagnosis of active secondary progressive multiple sclerosis (SPMS) without prior trials of disease-modifying therapy, do you treat with siponimod or do you start with a different DMT?
Active SPMS is considered a form of relapsing MS, thus any disease modifying therapy approved for relapsing forms of MS, including siponimod, is appropriate.
When do you consider deep brain stimulation in patients with Huntington's disease?
DBS targeted at either the globus pallidus interna or subthalamic nucleus has been used to treat many forms of dystonia. Occasionally, dystonia can predominate in Huntington's disease, rising to the level to consider DBS. However, the response is generally fairly limited, and side effects can be sub...