Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
How do you balance the risk of unnecessary treatment with acyclovir against the risk of delaying treatment in encephalitis cases where CSF pleocytosis is absent?
Treatment with IV acyclovir should start as soon as the diagnosis of Herpes simplex encephalitis is considered. Since the question states that CSF pleocytosis is absent, then CSF has been obtained. PCR for HSV should be obtained on that CSF. Early in my career, when acyclovir was investigational and...
In a patient with strong serologic evidence of SLE presenting with isolated bilateral lower limb sensorimotor neuropathy, normal neuroimaging, and CSF, would you initiate cyclophosphamide with pulse-dose steroids upfront, or reserve escalation (e.g., plasma exchange or immunosuppressants) for cases refractory to steroids?
This has been a dilemma for me for over several decades.1. There is no good large data to guide us on this question. I do not think there is one correct answer.2. All sensorimotor neuropathies are not created equally. I assume all other causes of sensorimotor polyneuropathy have been ruled out. Howe...
When do you consider using a paramedian approach for a lumbar puncture?
I consider the paramedian approach for lumbar puncture in several clinical scenarios: When patients are unable to adequately flex their spine. When midline interspaces are narrow (<1 cm). When ultrasound reveals densely calcified spinal ligaments—a common finding in elderly patients that can obscure...
What is your approach to the management of persistent encephalopathy following ischemic injury to bilateral thalami?
This is a challenging case to manage and can be resistant to interventions. I am assuming when you say encephalopathy, you are meaning disorders of consciousness (DoC), in which the patient is comatose or somnolent. In those cases, generally speaking, we will start dopaminergic medications, usually ...
What are some alternatives to dexamethasone for brain edema in patients who are allergic, have an intolerance, or refuse the medication?
Dexamethasone is one of the most frequently prescribed medications in neuro-oncology clinics. Dexamethasone is often favored over other corticosteroids owing to its lower mineralocorticoid effects and high potency as well as essentially 1:1 oral to IV ratio meaning that we use similar IV and oral do...
What is your treatment approach for MAG antibody associated polyneuropathy?
When patients have a classic Distal acquired demyelinating sensory (DADS) Neuropathy phenotype (by clinical +/- EDX criteria), typically an SPEP/IFE is checked first, and if an IgM monoclonal gammopathy is observed, then I typically check MAG antibodies at that point (if clinical and EDX features ar...
When would you obtain optic nerve testing in patients suspected to have multiple sclerosis without a clinical history of optic neuritis?
A key change in the 2024 revision of the McDonald criteria is the addition of the optic nerve as a fifth anatomic location to demonstrate dissemination in space (DIS) in addition to periventricular, cortical/juxtacortical, infratentorial, and spinal cord, which were included in the 2017 criteria. Op...
Do you often encounter compressive neuropathies such as carpal tunnel syndrome in patients with spastic cerebral palsy?
The issue of movement disorders and spasticity, in particular, is very problematic in people with cerebral palsy. I think, unfortunately, what often happens as these patients grow into adults, is that conditions like compressive neuropathies are simply not thought about. As people with cerebral pals...
How do you counsel patients on the cognitive effects of DBS for Parkinson's disease?
Cognitive effects after DBS procedures are multifactorial. Many times, patients are affected by Parkinsonian motor manifestations, such as dyskinesia or tremor, and treating these problems successfully with DBS and subsequent medication adjustments can help substantially with cognitive performance. ...
When do you consider testing autoimmune antibodies for axonal polyneuropathies without clear etiology?
Dr. @Dr. First Last gave an excellent summary of the clinical red flags that should trigger antibody testing in polyneuropathies. I would like to highlight that not all antibodies are pathogenic or cause the same phenotypes/clinical syndromes, therefore, I would like to break it down by antibody gro...