Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
What do you recommend to reduce/treat skin reactions for those taking anti-CGRP monoclonal antibodies to treat migraine?
Occasionally, we see a skin reaction with the subcutaneously administered antibodies; erenumab, fremanezumab, or galcanezumab. It generally consists of slightly elevated redness at the site of the injection due to inflammation, which can be itchy. We should not interpret the itchiness as indicating ...
How will you select patients with brain metastases for TTFields?
The METIS trial restricted eligibility only to patients with brain metastases from non-small cell lung cancer. Therefore, we would not be able to extrapolate these results and data to other tumor types and histologies. Indeed, a post hoc analysis of the data did demonstrate a greater impact in patie...
What is your timeline for restarting anticoagulants for patients with a recent craniotomy for hematoma evacuation who are also on an LVAD?
As with many clinical situations, this is a clinical decision that should be made by the treating neurosurgical/cardiology team for the specific patient - not from general literature alone, as there is no dedicated randomized controlled study-based guideline for this exact combination. As a general ...
What are best practices to avoid misdiagnosis of multiple sclerosis in patients over 50 years old?
The onset of MS in patients over 50 years old is unusual. At the same time, there are a greater number of conditions, many of them quite common (i.e., chronic microvascular disease), that cause white matter disease that can mimic MS in patients over 50 years. Given that MS incidence is less and MS m...
How do you approach treatment of aceruloplasminemia with biallelic CP mutations and brain iron deposition?
These are difficult. If the hemoglobin is high enough, you can try phlebotomy, but anemia will often restrict this. Chelation is the only other treatment. The neurological decline is often relentless despite these efforts.
Would you consider giving platelet transfusion in a patient with spontaneous intracerebral hemorrhage who is on an irreversible antiplatelet agent such as prasugrel?
This question seems logical, but in fact, there has been a clinical trial, the PATCH trial, that found no benefit of platelet transfusion; in fact, both deaths and poor outcomes were more prevalent in the platelet transfusion group than in the control group.
What outpatient therapies do you recommend for continuous or severe pain from migraine that is refractory to acute therapies?
I assume that what we are dealing with here is what we call a migraine status or status migrainosus. This refers to a migraine headache that has continued well beyond its usual duration, for which we often use the arbitrary three-day mark. We base this mark on the erroneous assumption that migraine ...
How do you work with patients to establish reasonable treatment goals for the management of fibromyalgia-related pain?
Great question. I explicitly tell my patients that I have no magic-bullet– no penicillin or prednisone-adjacent pill – that will swiftly and reliably alleviate their pain. This expectation, that a pill will eradicate disease, makes sense in the wake of the infectious disease revolution, where target...
What is your preferred treatment for rhinorrhea in patients with Parkinson's disease?
According to a recent meta-analysis, rhinorrhea is common in people with PD; present in almost half of patients. I have only prescribed it a few times, but to the best of my knowledge, intranasal ipratropium is what is most commonly tried. Efficacy is variable. And there are no PD-specific studies o...
What factors do you take into account when deciding the length of adjuvant temozolamide in GBM?
The field is evolving from 12 cycles to 6 for IDH-wildtype GBM in recent years, on the basis of some retrospective studies and notably the prospective Spanish study GEINO 14-01 - there does not seem to be much OS benefit, and there are also toxicity concerns (myelosuppression, hypermutation). Extens...