Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
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)?
Just to add to the discussion above, there are some risk profiles you can consider as reported in Rabinak and Nirenberg, PMID 20065130. Those who developed DAWS had higher dopamine agonist dosage and higher overall levodopa equivalence daily dosage, prolonged exposure to agonists, and lower UPDRS mo...
What is your first line treatment for a patient with epilepsy who is homeless and has a history of poor adherence?
It is likely an indication of my being old school, but if a homeless person needs medication they can’t afford and will take only intermittently, I would suggest phenobarbital. In spite of cognitive and other issues, in this situation, it is inexpensive, has a very long half-life, so withdrawal and ...
What is your approach to treatment of benign fasciculation syndrome?
Most of my patients end up being reassured that it is not a worrisome disease and opt for OTC treatments or no treatment. If there are any signs of hyperirritability on EMG/NCS I send CASPR2 antibodies and a free neuromuscular disorders panel, but assuming those are negative treatment is supportive....