Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
When do you consider genetic testing in patients with concern for hemiplegic migraine?
No, a good history will make the diagnosis for you!
How do you treat patients with hemiplegic migraine?
The is no agreed-upon treatment for hemiplegic migraine. I have often used NSAID’s acutely, occasionally triptans, and rarely steroids when nothing is working. The relatively new acute care gepants could be tried, but I have not done that as these patients are hard to find. I would consider adding a...
Do you avoid triptans in patients with migraine with motor aura?
This is still controversial, although there is no evidence to suggest avoiding triptans with "Hemiplegic Migraine" or Migraine with motor aura but people usually anecdotally avoid it. Many people are now using GEPANTS in situations like that. In summary, there is no contraindication but there are be...
When do you consider use of ketamine in patients with migraine with aura?
Never. For the treatment of migraine, like for any other condition, we should rely on specific medications, that is, triptans or gepants for abortive treatment and gepants or CGRP antibodies for preventive treatment.
When do you order genetic testing in patients with dystonia?
I consider genetic testing when dystonia is the major issue, when it is early onset if it is generalized, and if there is a strong family history. Other reasons would be a picture suggestive of DRD or paroxysmal dyskinesia.
What lab levels would lead you to consider switching DMTs for patients with MS on Fingolimod?
Personally, it is always hard to find the balance for someone who is doing well versus the risk. I don’t give the JCV status the same consideration as we do for natalizumab with the mechanistic difference between the drugs, but it is worth factoring in PML potential. In some cases, “legacy” fingolim...
Do you usually recommend PFO closure for patients with frequent migraines with aura?
No, I do not. If in need of preventive treatment, also those patients should be treated with the current standard-of-care preventive medications, that is, gepants or CGRP antibodies.
How do you address incidental small cerebellar infarcts seen on MRI?
I would obtain a CTA of the head and neck to look for vertebrobasilar disease. Probably too low yield to obtain an echocardiogram and Holter monitoring.
What workup do you initiate for thoracic outlet syndrome?
This is a long and complicated topic and I would propose to read the Consensus reporting standards for thoracic outlet syndrome published in 2016 by the Society for Vascular Surgery (see below). I will summarize a few key points from the article: Diagnosis of neurogenic TOS is basically CLINICAL, an...
Do you typically recommend EMG/nerve conduction study for patients with stinger syndrome as a result of an athletic injury?
"Stingers," also known as "burners," refer to transient neuropractic injuries of the upper trunk of the brachial plexus and/or superior cervical roots resulting from mechanical compression, percussion, or traction injury. These injuries typically manifest as pain, and/or sensory or motor dysfunction...