Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
How do you wean patients off cenobamate in the EMU and how long can these patients be off of it before having to restart the two month uptitration?
Our practice includes titration by 50-100mg/day. We then titrate back up 50-100mg/day. We also take into consideration of any history of status or refractory breakthrough seizures. Also, most patients who are on cenobamate are on multiple other ASM so we titrate those first if possible and titrating...
How do you manage a patient with progressive cerebellar ataxia and positive cardiolipin antibodies?
I would be very cautious attributing ataxia to the presence of ACL (even if they were persistent). While an association between ataxia and apl has been described, the differential is extremely broad and should be carefully worked up in conjunction with a neurology team. Some of the more common cause...
What pharmacotherapeutic strategy do you use in catamenial epilepsy to further reduce risk of breakthrough seizures around the time of menses?
Evidence is conflicting and incomplete, but suggests that benzodiazepines may be beneficial. I often prescribe clobazam in the week of menses in those patients who do not want to take the medication continuously all month long. The use of acetazolamide may be beneficial as well in some patients. Alt...
What is the best way to prescribe Dhivy™ (carbidopa/levodopa 25/100mg) as an adjunct medication in the treatment of Parkinson’s Disease?
Patients will very rarely be on these because it's rare for a movement disorders neurologist to prescribe them. As @Dr. First Last seems to be implying, patients may 'present' to movement specialists already on these medications. My humble opinion is these odd dose and pill versions (10/100mg carbid...
At what absolute lymphocyte count do you consider alternative/discontinuing DMT in a patient with MS on fingolimod (or other S1P modulator)?
I have asked this question for a long time, and get different answers. When a patient is hovering below 500, I start to wonder if it’s worth the long term risk/benefit. If they aren’t having infections and are young/healthy I usually leave them alone. If they’re getting older (50s and up) we have th...
When patients develop headaches from luspatercept, do they tend to improve over time?
I've seen two common scenarios with this. One is headaches related to hypertension as a result of luspatercept. By treating the hypertension, the headaches often improve. If the headaches are in the absence of hypertension, I do use a low dose beta blocker to see if it helps, and have had some resul...
Do you typically get muscle MRI in patients with symptoms of myopathy?
Not routinely, but there are some scenarios where MRI is useful. Selection of muscle to biopsy in a chronic progressive myopathy. In the past, we used to select muscles based on the degree of weakness on the MRC scale and the EMG findings. One would avoid muscles with MRC strength of 3/5 or less or...
In what clinical scenarios do you utilize neuromuscular ultrasound?
This is a very open-ended question and the answer can be several pages long. Neuromuscular ultrasound overall is an extremely valuable tool that complements EMG and allows the examiner to assess peripheral nerve and muscle ANATOMY, which EMG cannot do. Therefore, this test can be diagnostically help...
How do you approach the diagnostic workup for patients with suspected Fabry's disease?
Quite simple- if you suspect the disease in a male, you can measure alpha galactosidase enzyme activity in blood; if normal the diagnosis is unlikely, if abnormal you can confirm with GLA gene sequencing. If you suspect the disease in a female (manifesting carrier), you should directly sequence GLA ...
What is your approach to determining if an SPEP abnormality is causal or coincidental in peripheral neuropathy work up?
Because the answer to this question is long and complex, I would refer to a nice recently published review of the topic in Continuum (AAN) which provides a detailed discussion and nice algorithms to investigate the monoclonal gammopathy and determine a possible relationship to the neuropathy (or lac...