Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
How do you manage ADHD in patients with Tourette syndrome?
Most people start with guanfacine, clonidine, or atomoxetine but you can still try stimulants first.
How do you manage tinnitus in patients with intracranial hypotension?
Tinnitus or hearing loss is "a common complaint" (1) with intracranial hypotension (I do not know if anyone has documented an exact percentage).The etiology of tinnitus or muffled hearing in intracranial hypotension is unknown. Traction or irritation of the acoustic nerve due to "sagging" of the bra...
Do you start Riluzole on all patients diagnosed with ALS?
No. I discuss riluzole with all patients and explain that it prolongs survival in ALS by a variable amount of time, usually around 3-4 months- therefore, if the patient wants to use anything available to prolong their life, they should take it. I also explain, however, that riluzole will not stop di...
What is your steroid-sparing agent of choice to treat GCA given the current tocilizumab shortage?
If at all possible, I continue to use tocilizumab as a glucocorticoid sparing agent for patients with giant cell arteritis. Given the results of the GIACTA trial, the Villiger trial, and lots of observational data, it is clear that tocilizumab provides efficacy in terms of reducing risk of relapse a...
How do you manage Botox injections in patients with cervical dystonia after getting implanted with DBS?
Patients have a remote; ask them to bring it to the appointment and they can turn off and on before and after the procedure to avoid EMG artifact. Importantly, you need to know where the DBS leads are on the back side of head/neck and make sure you don't damage the leads with the injection. Patient...
How do you manage a symptomatic meningioma and associated vasogenic edema in a poor performance status patient?
Superficially, this resembles a straightforward question, but in reality, it is very nuanced, with numerous variables driving decision-making. My sequential "thought-experiment" in a situation like this would proceed as follows:1. Why does the patient have poor KPS? Are there underlying comorbiditie...
How do you counsel young adults with antibody-negative necrotizing myopathy on prognosis and long-term monitoring/treatment?
The first step is to rule out other conditions that are associated with necrotizing myopathy, that can affect treatment and prognosis, like malignancy, thyroid disease, or genetic muscle diseases. History, physical exam, basic laboratory work-up, family history, age-appropriate malignancy screening,...
How do you prescribe Perampanel for use in patients with refractory status epilepticus?
LD: 6-12 mg MD: 12 mg/day Use not recommended in severe renal impairment (CrCl <30 ml/min). Consider dose reduction in mild to moderate hepatic impairment. Use is not recommended in severe hepatic impairment.
How do you approach the management of acute attacks of MOGAD-associated optic neuritis?
If vision loss is severe and has not improved after corticosteroids/IVIG, I would consider plasma exchange (PLEX). Although we do not have controlled studies of PLEX in MOGAD, it is often used for cases of fulminant demyelination in other neuroinflammatory disorders.
For patients with a new diagnosis of active secondary progressive multiple sclerosis (SPMS) without prior trials of disease-modifying therapy, do you treat with siponimod or do you start with a different DMT?
Active SPMS is considered a form of relapsing MS, thus any disease modifying therapy approved for relapsing forms of MS, including siponimod, is appropriate.