Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
In patients chronically treated for Wilson's disease with trientine hydrochloride (Syprine®), would you expect development of neurologic symptoms?
On trientine, patients with asymptomatic WD should remain asymptomatic. The onset of neurological symptoms in someone with only hepatic disease on maintenance therapy represents treatment failure. Precise rates and etiologies of treatment failure are lacking, though one cohort review documented 19% ...
Do you screen for any environmental exposures in patients with newly diagnosed ALS?
I would at least ask the questions when obtaining history-specifically regarding occupational exposure to heavy metals like mercury, lead or arsenic. There is also a theory about BMAA a toxic aminoacid made by Cyanobacteria that may explain clusters of ALS-like or Parkinsonian syndrome that occurred...
Do you typically encounter phrenic involvement in patients with CIDP?
No. Respiratory involvement is very unusual in CIDP, unlike GBS (AIDP) where it is common. In CIDP frequency of phrenic nerve involvement is <10%, probably below 5. Of course, there are always exceptions to the rule. If the phrenic nerve is involved and the mechanism is predominantly demyelinating (...
Do you use isosorbide dinitrate spray for the treatment of neuropathic pain?
I don’t and I think it’s mostly due to lack of availability- I don’t think you can get the spray form in the US to use for neuropathic pain. It’s more popular in the UK and other countries following a publication about its efficacy in diabetic neuropathy in 2002: Yuen et al., PMID 12351464.
How do you approach the management of purposeless groaning/involuntary humming in PSP?
Involuntary and purposeless vocalizations, such as groaning, are commonly observed in Progressive Supranuclear Palsy. They can be intermittent or more continuous in nature, typically not associated with pain, and more bothersome to the caregiver than the patient. SSRIs, such as escitalopram, have be...
How do you recommend tapering IVIG in patients whose inflammatory myositis has achieved remission?
This is a very good question without any right or wrong answer. My practice is to start tapering the IVIG 6 months after the patient has achieved clinical remission. I usually start decreasing the dose of the IVIG, but the other option is to extend the interval between the patient's infusions. The e...
How do you incorporate cell-phone videos when diagnosing seizures vs seizure-like episodes?
I regularly review cell phone videos in clinic if they are available or request them of my patients. A video is often worth more than 1000 words. They can be helpful to diagnose episodes in established patients with new types of events and to better understand the episodes patients new to epilepsy c...
What dose do you provide of folic acid in pregnant patients with epilepsy?
I recommend all people of child-bearing potential take 1mg folic acid. If they are taking a prenatal vitamin, are really opposed to taking another vitamin and are not actively trying to become pregnant, I'm ok with the 800mcg included in most standard PNVs. Once they are trying to conceive, however,...
How do you define impaired distal fusion in patients with ICAD?
Once they're out of the acute phase, I define it clinically, i.e., are they having symptoms, and if so are they triggered (low BP, etc) or untriggered? It's helpful to have a baseline perfusion study for future comparison in case they become symptomatic and you want to triage whether off-label hyper...
Do you typically see peripheral neuropathy in patients with castleman syndrome?
Castleman's is a rare disorder. It has been associated with POEMS in which severe neuropathy is part of the syndrome, but is not as common an association as myeloma. But neurologists only see the patients who have neurologic symptoms. My brief look at review articles on Castleman's suggests that POE...