Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
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...
How do you approach malignant plexopathy?
Typically, in a patient with prior cancer history who develops unilateral flaccid arm weakness, the differential concern is radiation plexopathy (if radiation to that area before, can be years from symptom onset, usually is painless and insidiously progressive) vs malignant infiltration (typically q...
Other than B12 repletion, is there any further treatment or work-up indicated in pernicious anemia with positive parietal cell antibodies?
Pernicious anemia is an autoimmune disorder that can occur as a componet of multiple endocrine adenopathies, so evaluating the patient for thyroid, parathyroid, adrenal, etc. disorders is indicated both short and long term. More controversial is how to monitor the increased risk of stomach cancer as...
Do you recommend continuous antibiotic prophylaxis for patients on complement inhibitors such as eculizumab?
This is an extremely important and timely question. There simply isn’t enough data or firm guidelines on this leading to different practices. The reality is that there have been a number of meningococcal breakthrough infections in those vaccinated against meningococcal disease. Complement therapies ...