Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
How do you diagnose and treat patients with cervicogenic headache?
I struggle with cervicogenic headaches. Conceptually, it is a secondary headache disorder with headache attributed to a disorder of the cervical spine and its component bony, disc, and/or soft tissue elements. The ICHD-3 criteria help make this causal attribution. If a headache begins in relation to...
Should the schedule of disease modifying therapy medication administration be changed if patient has received high dose steroids for an MS exacerbation?
This is an interesting question. I usually do not withhold or change the schedule of disease-modifying therapy while treating acute relapses with high-dose steroids. This overlap may be a concern for agents such as anti-CD20 monoclonal antibodies in which induced inflammation and subsequent cell dea...
What pre-operative work-up do you follow in your institution prior to EC-IC bypass in patients with a focal intracranial stenosis and patients with MMD?
Great question. There is no standardized workup. You would want to make sure there is impaired flow with poor reserve and signs and symptoms suggestive of ischemia (ischemic stroke or TIA). My practice is to do perfusion pre and post-diamox. The success of revascularization is dependent on demand an...
How would you treat an essential-like tremor secondary to tumor (e.g. glioma)?
This is a great question. The first step in managing tremor in the setting of a tumor or underlying mass is to first determine the phenomenology. It is not uncommon for dyskinesias like chorea or dystonia to arise after onset of tumor or treatment of tumor. Thus, looking for subtle (or not so subtle...
In a patient on ASMs in the EMU that’s diagnosed with a non-epileptic event (i.e. functional seizures), and has a normal EEG, how do you approach coming off meds?
In our EMU, we typically try to wean medications rapidly in patients with suspected non-epileptic events (often ~50% reduction per day for meds with a short half-life and may stop meds with a long half-life, like zonisamide, upon admission). If the patient only has one type of event and it is confir...
When do you recommend checking blink reflex in patients with Bell's Palsy?
I have personally found that blink reflex testing is not as important as emphasized in the literature for the cases of facial palsy that are referred to our Lab. This is because most facial nerve EMGs that we see, are severe cases with profound axonal injury that show poor recovery after 3-4 weeks. ...
Do you typically recommend inpatient stroke evaluation for patients with incidentally found asymptomatic stroke on outpatient imaging?
This of course depends on so many variables, some scenarios and questions that matter in making the decision: Why was the imaging done in the first place? Not relevant to stroke or imaging was done because of TIA? What were the initial symptoms? Are you suspecting a large vessel occlusion (shocking...
Do you utilize post-vaccination IgG titers to detect common variable immunodeficiency in patients who are about to start or are actively on B cell depleting therapy?
I have checked M-M-R, Td, and pneumococcal titers in patients with hx of infection and low Ig levels to see if they are making an immunological response. If any of these immune titers are low or the immunization is “due” by routine schedules, I recommend immunization and repeat testing in 6 weeks. T...
How would you approach grade 2 neurologic toxicity in a patient on daratumumab, dexamethasone, and lenalidomide for relapsed multiple myeloma?
Clarification of the question was made, and it was focused on peripheral neuropathy. The polyneuropathy in Dara/Rev/dex is mostly due to the Revlimid. Most neuropathy from rev, if any, is grade 1- 2. The first step will be to start with gabapentin without reducing the dose of Revlimid. It is a very ...
How would you approach treatment of a patient with recurrent choroid plexus papilloma with intraventricular dissemination?
The management of choroid plexus tumors starts with diversion of the CSF flow, especially in this patient with a recurrence in the 4th ventricle. A gross tumor resection (GTR) is the most significant prognostic factor, but in this patient, it might not be feasible due to the dissemination in the lef...