Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
How do you evaluate asymptomatic patients referred for benign intracranial hypertension?
"Benign intracranial hypertension" is not really the preferred term for pseudotumor cerebri or idiopathic intracranial hypertension (IIH) anymore, as the phenomenon can lead to permanent vision loss and thus cannot be considered truly benign. Having said that, if the patient has no symptoms (no blur...
Do you maintain an age cutoff for the use of triptans in healthy older patients without cardiovascular risk factors?
I do not have an age cutoff for the use of triptans in older patients. I do not perform routine screening for coronary artery disease in aging patients already on triptan therapy. I do recommend 5HT1f agonist or CGRP antagonist over triptans if they have documented CAD, peripheral vascular disease o...
When do you use levocarnitine in patients on Depakote therapy for seizures?
No, unless they have elevated ammonia or LFt levels related to VPA. Hope this helps!
Do you treat patients with riluzole who have ALS and a valosin-containing protein mutation?
Yes. Riluzole is a glutamate antagonist; motor neuron damage due to glutamate-related excitotoxicity is a theme in ALS pathophysiology regardless of the genetic mutation that may cause ALS. Based on this, and the lack of any available VCP-specific treatments, I see no reason not to offer riluzole in...
How frequently do you check AED levels in patients with stable epilepsy?
Once a year except in adults except for women in childbearing age every six months. In patients with liver /kidney disease, more frequently. In children, it's different the younger the kid the higher the frequency.
Do you ever do surveillance MR imaging in patients with stable exam and history of cardioembolic stroke?
I typically do not do an MRI unless a patient is having symptoms.
Is IL-6 inhibition an option in patients who are going to be rechallenged with checkpoint inhibitors after previously developing ICI-mediated temporal arteritis?
Yes, using IL-6 drugs is a good option for the patient with GCA post ICI. I think theoretically we should be able to continue immunotherapy and biologic therapy such as tocilizumab, but we do not have evidence and insurance companies have not been very amenable. The goal of my research is to ensure ...
Which triptans do you use in stroke induced migraines?
If the stroke is ischemic, I do not use triptans and would consider a non-constrictive acute care medication such as a gepant (e.g. ubrogepant or rimegepant) or ditan (i.e. lasmiditan). If the stroke is hemorrhagic and the cause has been corrected, I would use any triptan. I have a long term experie...
Would you recommend upfront radiosurgery for trigeminal neuralgia caused by AVM abutment at the entry root zone?
Radiosurgery (SRS) at high doses to the dorsal nerve root entry zone is an effective treatment modality for primary or idiopathic trigeminal neuralgia (TN), but is significantly less efficacious when utilized for secondary trigeminal neuralgia, as caused by tumors, plaques, AVMs, etc. There are case...
How slowly do you taper a dopamine agonist to prevent dopamine agonist withdrawal syndrome (DAWS)?
Currently about to do this, myself, though mainly due to symptomatic orthostatic hypotension complicated by PDD/psychosis. I'll recommend cutting back a half tablet for one of the doses (probably first) for a week and then a 1/2 tablet for the 2nd dose for a week -- and so on until the med is fully ...