Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
What workup do you recommend for patients with stabbing headaches?
Stabbing headaches, also called icepick headaches or jabs & jolts, are severe pains in the head, often occurring spontaneously but sometimes caused by coughing or sneezing, lasting for seconds. They are so intense that they make the sufferer grab his or her head. They generally occur infrequently in...
How do you evaluate and treat patients with suspected POTS?
POTS is diagnosed based on increased heart rate of more than 30 beats per minute in adults and more than 40 beats per minute in adolescents with no major drop in blood pressure from supine to standing or after tilt table from supine to 70 degrees upright. Many patients have POTS as an isolated cond...
How has your use of B-cell depleting therapy for MS changed during the COVID-19 pandemic?
There may be no "correct" answer to this question. In my practice, I have not altered my prescribing of B cell therapies. Although we have seen reduced antibody responses in MS patients on B cell therapies, this has not definitively been associated with a significantly increased risk of COVID infect...
How long do you continue immunotherapy (ie rituximab) in patients with NMDAR encephalitis with initially severe disease but a good trajectory of recovery?
Assuming there may be no evidence of teratoma on transvaginal U/S and or other modalities of examination (in females, some cases are described that show abnormalities in the ovary ONLY following HPE upon oophorectomy) and since there is always the risk of recurrence even with bilateral oophorectomy,...
How do you decide on initiation of treatment with steroids or immunomodulatory therapy in patients with statin-induced myopathy versus statin-induced autoimmune necrotizing myopathy?
In the setting of limited experience, in patients with statin induced necrotizing polymyositis (HMG-CoA reductase antibody mediated necrotizing myositis), the best approach is typically steroids (prednisone 20mg or so), IViG 2gm/kg every 4 weeks, and potentially CellCept at 2000 to 3000mg per day, w...
How do you approach transitioning MS patients from Ocrevus to Tysabri or vice versa?
From Ocrevus to Tysabri: I time the first Tysabri infusion to be 6 months after the last Ocrevus infusion, when the patient would be due for their next Ocrevus anyway. I do not wait for CD19/20 repletion, since Tysabri should not affect/be affected by B cell status. From Tysabri to Ocrevus: this is...
When tapering moderate to high doses of long term steroids do you routinely monitor for adrenal insufficiency?
This is always a good question on which to reflect. In general, moderate dosing of steroids (> or = 20 mg prednisone equivalents) for 5 days or less do not need a taper and pose low risk of adrenal suppression, and by extension chronic adrenal insufficiency. Up to date suggests that up to 3 weeks is...
What additional treatments do you offer to patients with Progressive Supranuclear Palsy other than a levodopa/carbidopa challenge?
One should be certain to try levodopa at a high enough dose and for a long enough period before considering it a failure. I typically will get to 1200mg levodopa divided into 3 or 4 doses and maintain for at least a month (barring side effects). Pushing higher would not be wrong, but this seems to b...
Do you recommend EMG/NCS in all patients with clinical findings of carpal tunnel syndrome?
In my experience as a neurophysiologist, a typical Carpal Tunnel Syndrome (with all the classical signs and symptoms) can be diagnosed with high certainty by examination and history alone. My recommendation would be that when the symptoms are mild and the presentation is typical, conservative treatm...
Would it be prudent to complete long term cardiac monitoring (ie. 30 day) in a patient with a new typical appearing lacunar type thalamic infarct and history of hypertension?
This is a really good question. Until this year, I probably would have said that looking for AF in patients with a clear lacunar stroke is not needed. But the recent results from the STROKE AF trial (Bernstein et al., PMID 34061145.) suggest that long term monitors (implanted monitors, so a little d...