Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
How do you approach handling the many-page disability paperwork of neurological disease such as Parkinson's disease?
It can be daunting when one is handed a long form to fill out for disability in advanced PD patients. Admittedly, it is not my favorite thing to do but it will make all the difference in the life of the patient, so it is extremely important to handle it carefully. In the past, I used to have them re...
In antiphospholipid syndrome with recurrent strokes, would you consider adding antiplatelets to warfarin?
I agree with Dr. @Dr. First Last. I have had patients with APS and recurrent thromboembolic events although not necessarily strokes to whom I have added aspirin and HCQ to the treatment regimen. I did this because she continued to have recurrent events. However, there is at least one article that ne...
What is the recommended management approach in regard to diagnostic evaluation and treatment for patients with homocystinuria and cerebral thrombosis?
I think it’s reasonable to start anticoagulants for 3 to 6 months after getting complete blood test panels for hypercoagulation states. Be careful while interpreting abnormal hypercoagulation test results since many times you may see abnormalities. I would also repeat them within 3 months when the p...
Are triptans contraindicated in patients with Moya Moya syndrome who have never had an ischemic stroke?
I am not aware of specific evidence regarding triptans and Moyamoya. The contraindication in stroke is not based on data, just from concern about vasoconstriction, for which there is no clear evidence in the intracranial circulation. Hence I would be willing to prescribe a triptan, with appropriate ...
Would you give checkpoint inhibitor therapy to a cancer patient with known dermatomyositis given the association of checkpoint inhibitor associated myocarditis, myasthenia gravis, and myositis?
I think the dermatomyositis could be more paraneoplastic that would actually benefit from controlling the cancer with ICI. I would give the treatment but I would carefully follow-up the patient for any irAEs. I will also document the rheumatological assessment, CPK, and myositis panel before startin...
What is your approach to initiating and titrating midodrine for both inpatient and ambulatory settings?
It depends on the indication: Orthostatic Hypotension: 2.5 mg TID CC Inpatient - Check orthostatics SEATED 5', then Standing 1' 3' 5' about one hour after dosing. Increase by 2.5 mg every other dose until patient clinically not orthostatic or 10mg TID CC is achieved or seated hypertension or other s...
How do you manage anti-seizure medications at follow-up in patients who had acute symptomatic seizures due to PRES?
Repeat MRI in 6 months to see if there is a resolution of PRES changes. If resolved and no clinical history concerning for sz then repeat EEG. If EEG and MRI are negative, with no clinical symptoms then slowly taper of AED. Also educate the patient while tapering of meds there is risk of sz, (thi...
When do you consider intrathecal baclofen pump in patients with acquired spasticity?
I am a neurologist in Minneapolis and have directed a spasticity clinic for over 20 years. We typically have at least 100 intrathecal baclofen patients. It is an excellent therapy for selected patients but requires dose adjustments and refills of the Medtronic synchromed pumps. Problems may occur wi...
What is your treatment approach for multiple sclerosis related fatigue?
I generally recommend optimizing any non-pharmacologic interventions first. Exercise, making sure there is no sleep issue, treating comorbid depression. A recent trial suggests a lack of benefit for amantadine, methylphenidate, and modafinil. I find that in general, they don’t make much of an impact...
What is your preferred antiepileptic medication for a patient with treatment refractory epilepsy who also has alcohol use disorder?
If the patient has alcohol use disorder, it is best to avoid any medications that could cause elevated liver enzymes, because that could be misconstrued as alcohol-related liver issues. This would eliminate the first-generation anti-seizure medications such as phenytoin, phenobarbital, and valproate...