Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
What is your preferred antiepileptic medication for a patient with treatment refractory epilepsy who also has alcohol use disorder?
If the patient has alcohol use disorder, it is best to avoid any medications that could cause elevated liver enzymes, because that could be misconstrued as alcohol-related liver issues. This would eliminate the first-generation anti-seizure medications such as phenytoin, phenobarbital, and valproate...
How do you approach malignant plexopathy?
Typically, in a patient with prior cancer history who develops unilateral flaccid arm weakness, the differential concern is radiation plexopathy (if radiation to that area before, can be years from symptom onset, usually is painless and insidiously progressive) vs malignant infiltration (typically q...
Other than B12 repletion, is there any further treatment or work-up indicated in pernicious anemia with positive parietal cell antibodies?
Pernicious anemia is an autoimmune disorder that can occur as a componet of multiple endocrine adenopathies, so evaluating the patient for thyroid, parathyroid, adrenal, etc. disorders is indicated both short and long term. More controversial is how to monitor the increased risk of stomach cancer as...
Do you recommend continuous antibiotic prophylaxis for patients on complement inhibitors such as eculizumab?
This is an extremely important and timely question. There simply isn’t enough data or firm guidelines on this leading to different practices. The reality is that there have been a number of meningococcal breakthrough infections in those vaccinated against meningococcal disease. Complement therapies ...
How do you treat episodes of profuse sweating in Parkinson’s patients?
By far most common situation is OFF-related hyperhidrosis, such as overnight OFF, and so this needs to be explored with patients paying close attention to when these things tend to happen and whether they correlate with motor worsening; trials of dopaminergic dose alterations could be considered and...
How do you account for a normal EMG/NCS in the setting of prolonged clinical symptoms suggestive of a radiculopathy?
There are several references, but basically the sensitivity of NCS/EMG for radiculopathy is not great to begin with. In the context of radiculopathy, electrodiagnostic studies are mostly useful for picking up on motor axon loss because you are primarily assessing the amplitude of compound muscle act...
What is your preferred medical treatment of carpal tunnel syndrome that recurs after carpal tunnel release?
I am supposing that patient has initial recovery and symptoms are happening at least after a year. A good history to know is it really CTS or tenosynovitis. A repeat EMG/NCV test and compare from pre-release surgery to see how much improvement happened. If numbers are close to normal and surgery don...
When do you investigate for genetic causes in a young patient presenting with new-onset Parkinsonism?
I rarely order genetic testing for Parkinsonism, as I do not feel that it alters management. However, should a patient still be of child-bearing potential, a genetics consult can be helpful, and testing could be done as part of family planning. There is active research examining the utility of genet...
What would your next line treatment be for a patient previously treated with repeat resection, craniospinal irradiation, and initial cisplatin/vincristine/CCNU with medulloblastoma?
As you will agree, this is an extremely unfortunate situation. I am assuming this patient has progressed either while on therapy or soon after completion? Depending on his age, a potential option is to enroll him on any available clinical trials. PBTC58 study uses intrathecal omburtumab along with c...
When treating sialorrhea in ALS patients, what treatment schedule do you use?
I have treated one patient. We used 12 Gy in 3 fractions, delivered twice weekly. The dose was based on a systematic review that did not show a dose response above 12 Gy. Hawkey et al., PMID 26152655The 2015 study above also showed equivalency in response to therapy with 10 Gy in 2 fractions and 20 ...