Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
How do you approach the symptomatic management of central vertigo in a patient with minimal improvement on (or contraindication to) meclizine?
Central vertigo is a difficult symptom to manage and can be frustrating for the patient (and their doctor). Depending on the etiology, treating the underlying cause would be the best first step (e.g. migraine prophylaxis). However, some causes of vertigo may be intractable or take a long time to rec...
How do you treat lupus-associated small fiber neuropathy?
Treatment of small fiber neuropathy associated with SLE consists mainly of symptomatic treatment for neuropathic pain and, if present, autonomic symptoms. Commonly used treatments for neuropathic pain include topical agents such as lidocaine, tricyclic antidepressants such as amitriptyline or nortri...
What are your recommendations for a patient with metastatic non-mutated lung adenocarcinoma who previously had headaches responsive to prednisone but with negative temporal artery biopsy for GCA?
GCA is often a challenging diagnosis to make in the absence of objective findings of halo sign, pathologic evidence of vasculitis, or large vessel vasculitis on imaging. Headache of any type will often respond to prednisone so the first step, in this case, is to determine if the patient truly has GC...
How long do you maintain a patient with seropositive Neuromyelitis Optica Spectrum Disorder on disease modifying therapy?
Neuromyelitis optica never goes away, as far as we know. Stopping immunotherapy will likely lead to a relapse at some point. Some meds provide a short "honeymoon" period of durable risk reduction beyond the treatment period - that may include eculizumab according to the phase 2 trial in NMO. But sto...
Is LP indicated for patients with recurrent thunderclap headaches over a 4-week period and negative head imaging for SAH?
I think this depends on what kind of head imaging was done to rule out SAH. If the patient has had a totally normal head MRI and MRA (not only ruling out SAH, aneurysm but also RCVS), then LP is warranted to insure there is no inflammatory or infectious component as a cause for the headache. I think...
How do you manage TTFields for a patient with glioblastoma in the setting of disease progression?
Continuation of Tumor Treating Field (TTF) therapy at progression is an individualized decision for each patient.In the EF-14 trial upon which TTF was approved for newly diagnosed GBM after chemoradiotherapy, TTF was able to be continued until second progression. In this study, 18% more patients wer...
How would you work up focal periventricular leukomalacia presenting in adulthood?
This depends on the location, appearance, size, and PMH of the patient. However, I usually start with giving contrast (aware it is encephalomalacia) and as known, most won't enhance. What is the age of this adult patient? Is there any previous history to suggest MS? If ischemic, why did it happen? D...
What medication do you consider in patients who cannot take indomethacin or triptans with a diagnosis of Hemicrania Continua?
1) DIAGNOSIS First, ensure you have the correct diagnosis. If purely unilateral but no convincing and significant ipsilateral cranial autonomic symptoms, the much more likely diagnosis is migraine. Also, consider cervicogenic headache in these cases. Hence, you would treat as migraine. If convincing...
Do you ever check antibodies against EBV as part of a workup for MS in a patient with white matter lesions of unclear etiology on MRI?
Generally, we do not check for antibodies against either viral capsid antigen (VCA) or Epstein Barr nuclear antigen (EBNA) for our patients with MS or when MS.EBV is considered a common infection. A large portion of the adult population, 90-95%, is seropositive for EBNA antibodies (Lincoln et al., P...
How do you manage drug-induced thrombocytopenia when the implicated drug is essential?
I feel obliged to answer this one as a question of medical sociology as much as a direct medical question, because "essentialness" is nearly always in the eye of the beholder, and I have not personally been in the position of the hematologist who has to confront this question with an interventional ...