Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
How do you treat medically refractory sleep related movement disorders?
Nonpharmacological Rx like TED stockings, hot baths. Klonopin or low-dose opioids and clonidine all have some activity. CHECK ferritin and make sure you are not dealing with iron deficiency.
Do you recommend genetic testing after a patient on clopidogrel has a stroke based on the results of the CHANCE-2 trial?
No, the data from CHANCE-2 (Wang et al., PMID 34708996) was based on a strictly Asian population and results need to be validated elsewhere for it to change practice.
What is your surveillance strategy in patients with brain metastases who are getting systemic therapy?
Generally, I’d consider a repeat MRI every 2-3 months, earlier if warranted. Assuming no evidence of disease progression for 1 or 2 years, I’d consider every 3-6 months.
How do you counsel patients on anti-seizure medication necessity (or lack thereof) in the setting of PNES without comorbid epilepsy?
I discuss in detail and openly with the patients regarding the etiology of epileptic seizures in comparison with the current understanding of etiology in PNES and help them understand why traditional anticonvulsants won't work for PNES. I also explain that taking a medication that may not be indicat...
Would you generalize the data from the CHANCE-2 trial to a broader clinic population given that the study was specific to Han Chinese patients?
I believe the results of CHANCE-2 (Wang et al., PMID 34708996) are generalizable to non-Chinese populations. CHANCE (Wang et al., PMID 23803136), performed in China, and POINT (Johnston et al., PMID 29766750), performed worldwide but excluding China, produced strikingly similar results in dual antip...
How do you switch/cross-titrate regular Levodopa to Rytary in a patient with Parkinson's disease?
The manufacturer has a suggested conversion table in the package insert: https://rytary.com - pi.pdf (impaxlabs.com) However, many patients do not respond well using this table, so be prepared to make adjustments over the next few days. I find the duration of action varies from 4 to 8 hours and mot...
What workup do you do for patients who have PL-7 elevation when screening for myopathy?
In the literature, the PL-7 antibody has been associated with the antisynthetase syndrome and aside from myositis, interstitial lung disease (ILD). Patients with PL-7 autoantibodies are at high risk of ILD. Referral to pulmonary should be considered. One would also consider assessing pulmonary funct...
How do you interpret a mildly positive NT5C1A lab test in patients with hyperCKemia?
Seropositivity, in general, ought to support the clinical features of the given disease in the patient. In this instance, the patient should have selective medial forearm flexor weakness, quadriceps atrophy/weakness, and dysphagia (if in later stages). In the rare case that the phenotype has not yet...
For patients with MS on natalizumab, at what JC virus antibody titer do you consider switching DMTs?
I am comfortable continuing Tysabri as long as the JCV index remains below 0.9. I would discuss switching therapies or would consider extending-interval dosing (treating every 6 to 8 weeks, instead of every 4 weeks), if the index is between 0.9 and 1.5. I would not continue Tysabri if the index is a...
Does the overall conclusion of the CHANCE-2 trial make ticagrelor + ASA a worthwhile transition given the data showing cumulative hazard of stroke diverged during the first week and was subsequently similar, which suggests the benefit of ticagrelor over clopidogrel is seen predominantly soon after stroke?
Given the fact that clopidogrel costs 11 cents a day and ticagrelor costs almost $8/day and the fact that most patients will not be tested for slow CYP2c19 metabolizer (or have the results back in a timely fashion), it seems that the combination of ASA plus clopidogrel is the best option from a publ...