Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
For patients with post-stroke headaches, what treatment do you typically recommend?
First off, I usually recommend treating the headache based on phenotype. So if the headache meets ICHD-3 criteria for migraine, then treat as migraine.Great resource for current treatment recommendation in general for migraine: Ailani et al., PMID 34160823.In terms of considerations specific for str...
What workup do you start in patients with evidence of demyelination on EMG/NCS?
Workup of a demyelinating neuropathy depends on the most likely diagnosis based on history and examination of the patient. Some electrophysiological features may also help differentiate an acquired from a hereditary demyelinating neuropathy- for example, multifocal conduction blocks, non-uniform con...
How do you differentiate motor neuron disease from limb girdle muscular dystrophy on electrodiagnostic testing?
I would primarily differentiate these diseases based on history and clinical examination. Motor neuron disease looks like a neuropathic disease, and you are looking for that mix of upper and lower motor neuron signs (hyperreflexia paradoxically found with fasciculations and atrophy). This evolves ov...
What is your approach to checking serum vWF antigen levels in adult patients with CNS vasculitis for monitoring disease activity?
I never have checked them but I am aware of interest in this by the Hamburg group. (Ref) Following disease activity in CNS-V is challenging but reduction/clearing of pleocytosis is important to us. Also now being able to look at serial direct vascular wall imaging is of interest and appears to corre...
How do you determine if a patient is safe to drive after having a PCA infarct?
In many patients with PCA infarction, the answer is clear, that they cannot safely drive. In my state, the law requires 140 degrees of lateral vision for driving privileges, not met by patients with homonymous hemianopsias. These patients need to be told that they cannot legally drive, and this need...
How do you manage ADHD in patients with Tourette syndrome?
Most people start with guanfacine, clonidine, or atomoxetine but you can still try stimulants first.
How do you manage tinnitus in patients with intracranial hypotension?
Tinnitus or hearing loss is "a common complaint" (1) with intracranial hypotension (I do not know if anyone has documented an exact percentage).The etiology of tinnitus or muffled hearing in intracranial hypotension is unknown. Traction or irritation of the acoustic nerve due to "sagging" of the bra...
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...