Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
When would you consider continuing valproic acid (Depakote) for seizure prophylaxis preconception or during pregnancy?
Frequent seizures with attempted wean. Nocturnal events increase the risk of SUDEP. Prior change in ASMs attempted twice pre-pregnancy with acute breakthroughs.
What is your approach to counseling older patients and their families regarding expected recovery of aphasia following a large hemispheric stroke?
There is no precise answer for this question. Every patient follows their own course after a stroke. The size of the infarct and the age of the patient will affect the prognosis. Older patients and those with larger infarcts tend not to have as much recovery. The improvement of aphasia can proceed o...
Do you prescribe respiratory muscle training (RMT) devices to patients with dysphagia?
We encounter dysphagia frequently in our patients with Parkinson's disease and other movement disorders. If there are any concerns about swallowing or aspiration, my first step is to refer to Speech Therapy for evaluation, and I defer to their expertise for specific treatments from there. That said,...
How have you refined your approach to disclosing a new diagnosis of dementia to a patient and their family?
I tend to think about this disclosure as layers of an onion. My general layers are: Explain what dementia is (and is not) and how we got to that diagnosis. Something like "You and your family have noticed memory problems, and the testing we just did confirms that. The memory problem appears signifi...
How do you counsel patients who do you not experience early relief of hemifacial spasm after microvascular decompression surgery?
From a neurology standpoint, I counsel patients (preferably ahead of time) that surgery has a reasonable chance of improving hemifacial spasm but is not always effective. There can also be both early and late (reemergent) persisting spasm. I have treated some patients after MVD with botulinum toxin,...
How do you approach sequentially tapering combination therapy (i.e., IVIG, mycophenolate, rituximab) for dermatomyositis that is in remission?
This process involves trial and error and requires collaboration between the physician and the patient to determine the most appropriate tapering strategy. My personal preference is to begin tapering medications with the highest risk of side effects. Among IVIG, mycophenolate, and rituximab, I would...
How do you approach evaluation of a patient referred for mononeuritis multiplex and +SSB?
Step 1: A clinical syndrome of mononeuropathy multiplex always requires an EMG study. Is the primary mechanism of the MnM axonal or demyelinating? If it is demyelinating, there are only two possible diagnoses: multifocal CIDP (Lewis Sumner syndrome, which can occur in the context of Sjogren's syndro...
Can needle EMG or nerve conduction studies cause transient MRI abnormalities, such as apparent inflammation, edema, or enhancement of a nerve, that could be mistaken for neuritis on subsequent imaging?
Yes—needle EMG can create small, transient post-procedure MRI/MR-neurography abnormalities at needle insertion sites, including focal T2/STIR hyperintensity interpreted as edema and occasional small hematoma, which can potentially be mistaken for local pathology if the timing is not recognized. In a...
Have any of the findings from the 2026 AAN/AHS review of migraine prevention changed your practice?
Neither this nor other reviews or guidelines determine what I do in practice. I base what I do in practice on my knowledge and experience as well as on common sense, of course, always with the best interest of the patient in mind. As I mentioned earlier in posts and also emphasize in my book, HEADAC...
How do you manage problematic disinhibited behaviors in patients with neurocognitive disorders?
This requires a problem-centered approach. I suggest the following thought process. Analyse the root cause: Is it disinhibition? Unmet needs? Under/Overstimulating environment? Medication side effect? For disinhibition (frontal lobe dysfunction): I have had success with gabapentin and low-dose Depa...