Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
Would you recommend upfront radiosurgery for trigeminal neuralgia caused by AVM abutment at the entry root zone?
Radiosurgery (SRS) at high doses to the dorsal nerve root entry zone is an effective treatment modality for primary or idiopathic trigeminal neuralgia (TN), but is significantly less efficacious when utilized for secondary trigeminal neuralgia, as caused by tumors, plaques, AVMs, etc. There are case...
How slowly do you taper a dopamine agonist to prevent dopamine agonist withdrawal syndrome (DAWS)?
Currently about to do this, myself, though mainly due to symptomatic orthostatic hypotension complicated by PDD/psychosis. I'll recommend cutting back a half tablet for one of the doses (probably first) for a week and then a 1/2 tablet for the 2nd dose for a week -- and so on until the med is fully ...
What is your first line treatment for a patient with epilepsy who is homeless and has a history of poor adherence?
It is likely an indication of my being old school, but if a homeless person needs medication they can’t afford and will take only intermittently, I would suggest phenobarbital. In spite of cognitive and other issues, in this situation, it is inexpensive, has a very long half-life, so withdrawal and ...
What is your approach to treatment of benign fasciculation syndrome?
Most of my patients end up being reassured that it is not a worrisome disease and opt for OTC treatments or no treatment. If there are any signs of hyperirritability on EMG/NCS I send CASPR2 antibodies and a free neuromuscular disorders panel, but assuming those are negative treatment is supportive....
What is your preferred steroid sparing therapy in a patient experiencing a severe checkpoint inhibitor toxicity and not responding to high dose IV steroids?
There are likely two different questions here: 1) For patients who have responded to steroids, but are unable to taper off (or to a minimally acceptable chronic dose), I have favored mycophenolate as a steroid sparing agent. 2) For patients with severe pneumonitis that is refractory to steroid ther...
What interventions have you found most effective for reducing ED utilization in patients with PNES?
I have a frank discussion regarding the difference between epilepsy and PNES and the differing modes of treatment. I also refer them to our behavioral health department for cognitive behavioral therapy. That seems to decrease their ER visits.
Would you stop belimumab in a patient with SLE starting ravulizumab (C5 inhibitor) for myasthenia gravis due to concern for additive immunosuppression?
This is a good question for which there is not a definitive response in the literature. Benlysta has a fairly low rate of related infections though not studied in relation to the ravulizumab. Obviously, the patient should be fully vaccinated against meningitis. I would also want to assess how well t...
How long after starting an antiepileptic drug do you check levels?
Based on the half-life of AED and sometimes case-to-case based. General guidelines is 2-4 weeks of starting the AED.
Do you typically pursue EMG/nerve conduction study in patients who already have a clinical diagnosis of myasthenia gravis?
Depends on antibody status. If the patient is antibody positive (AchR or Musk) and has a classic presentation (e.g., Fatigable ocular and or bulbar weakness) and good response to first or second-line treatment (pyridostigmine, prednisone) then it’s probably not necessary. Seronegative patients or th...
How do you approach the workup for patients with hyperCKemia and positive NXP2 with no clinical symptoms?
I would approach it like any case of hyperCKemia: verify that the high CK occurred in at least two measurements 24 or more hours apart, not shortly after intense physical exercise, get a careful history and exam with special attention also to skin and nail findings. If hyperCKemia is persistent get ...