Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
Do you typically pursue EMG/nerve conduction study in patients who already have a clinical diagnosis of myasthenia gravis?
Depends on antibody status. If the patient is antibody positive (AchR or Musk) and has a classic presentation (e.g., Fatigable ocular and or bulbar weakness) and good response to first or second-line treatment (pyridostigmine, prednisone) then it’s probably not necessary. Seronegative patients or th...
How do you approach the workup for patients with hyperCKemia and positive NXP2 with no clinical symptoms?
I would approach it like any case of hyperCKemia: verify that the high CK occurred in at least two measurements 24 or more hours apart, not shortly after intense physical exercise, get a careful history and exam with special attention also to skin and nail findings. If hyperCKemia is persistent get ...
Provided no side effects, to what dose do you increase propranolol or primidone before considering them ineffective for a patient with essential tremor?
If tolerated maximum dose of 250 mg of Primidone bid would be acceptable. This is my personal experience.
How do you approach handling the many-page disability paperwork of neurological disease such as Parkinson's disease?
It can be daunting when one is handed a long form to fill out for disability in advanced PD patients. Admittedly, it is not my favorite thing to do but it will make all the difference in the life of the patient, so it is extremely important to handle it carefully. In the past, I used to have them re...
In antiphospholipid syndrome with recurrent strokes, would you consider adding antiplatelets to warfarin?
This is a good question, especially noting the high rate of recurrent thrombotic events in non-treated patients with antiphospholipid syndrome (up to 29% if untreated, but still significant among treated patients, especially after an arterial event). Edit: to jump to the punchline, I favor adding AS...
What is the recommended management approach in regard to diagnostic evaluation and treatment for patients with homocystinuria and cerebral thrombosis?
I think it’s reasonable to start anticoagulants for 3 to 6 months after getting complete blood test panels for hypercoagulation states. Be careful while interpreting abnormal hypercoagulation test results since many times you may see abnormalities. I would also repeat them within 3 months when the p...
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...