Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
Has MR spectroscopy ever led you to forego a planned stereotactic biopsy in a patient with a suspected intracranial neoplasm?
I have never had spectroscopy allow me to forego a stereotactic biopsy when I suspected active/progressive neoplasm; however, if I suspected necrosis more than recurrence or tumor and spectroscopy was in accordance with that, then I have been able to save people a biopsy in that situation.
How do you manage Moya-Moya disease medically for patients that are unable to receive EC-IC bypass?
It depends on the cause. Usually for patients either moya moya disease (in contrast to moya moya syndrome where symptomatic patients would benefit from EDAS or surgical management ) due to atherosclerosis or radiation induced if someone has continued ischemic events or silent infarcts on aspirin mon...
How do you decide on switching to a different preventative anti-CGRP treatment in migraine patients who are experiencing reduced effectiveness with their current treatment?
The CGRP antibodies and gepants are my preventive treatments of choice. In fact, I hardly ever prescribe anything else anymore preventively, including botulinum toxin. Tolerability issues I hardly ever encounter with the antibodies, but sometimes I do with the gepants, in particular fat...
What has been your experience with CGRP-targeted medications for vestibular migraine?
As with every migraine treatment, there are non-responders, super-responders, and patients in between, but in my experience there is a clear signal that CGRP-targeted therapies are worth trying in vestibular migraine, particularly in patients with significant side effects from or contraindications t...
How do you manage orthostatic symptoms from autonomic neuropathy due to diabetes?
Try conservative measures such as hydration, pressure stockings, abdominal binder, exercises, and precautions prior to positional change. Addition of midodrine or other medications like flourinef and adjustment of doses of their antihypertensive medications. There are other medications that can be u...
When do you consider tapering tocilizumab in patients with GCA in remission?
This is a timely question and recent data sheds some light on this important topic. The risk of GCA relapse is approximately 50% (Mainbourg et al., PMID 30951256) in all comers. The GIACTA trial (Stone et al., PMID 28745999) utilized a one-year course of TCZ. A recent publication of the extension ph...
What clinical features predict visual recovery from optic neuritis in NMOSD?
The main clinical feature associated with outcomes is the severity of vision loss at nadir. The more severe the vision loss, the higher the risk of poor outcomes. However, there can be patients with very severe vision loss (no light perception) who can still recover to 20/20. The correlation with ra...
How do you manage daytime somnolence without a clear cause?
I have a cohort of probably 5-10 patients now, mostly female in their late teens to early twenties, who report needing 10-14 hours of sleep per day and still not feeling refreshed. Excessive daytime somnolence (falling asleep in class or while driving). I tried modafinil and stimulants with modest s...
What workup do you recommend for otherwise healthy migraine patients that develop dizziness with episodes?
The workup should exclude other potential causes of vertigo including CNS disorders, and Meniere's disease, with neurology examination, MRI brain, videonystagmography, or electronystagmography. An article also evaluated vestibular migraine versus migraine without vertigo and found in several studies...
How do you treat extrapyramidal symptoms secondary to anti-psychotic use in patients who have not benefited from cogentin or benadryl?
In general, when addressing motor symptoms from antipsychotics (or any dopamine-blocking agents including dopamine-blocking antiemetics), I find it useful to break things down more specifically than just EPS. This often will determine the agent that will be most beneficial. First Category: Hypokinet...