Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
When do you consider pacing in arrhythmogenic epilepsy?
I have seen only rare cases of it. They all had tonic-clonic seizures triggered by profound bradycardia (sinus as well as AV block). In turn, the bradyarrhythmia was triggered by EEG-documented temporal lobe absence seizures. They all resolved long-term with pacing. Regardless of the un...
How do you determine when patients can resume massage therapy, weight lifting, or sports after a spontaneous CSF leak?
I have seen cases where athletes return to intense activity too soon after a blood patch and have a repeat leak. There is guidance from Duke Health that I have used as a guideline when advising patients on resuming activity.
What work-up and treatment do you recommend for exertional headaches?
Primary Exercise Headache Diagnostic Criteria per ICHD-3: At least two headache episodes fulfill criteria B and C Brought on by and occurring only during or after strenuous physical exercise Lasting <48 hours Not better accounted for by another ICHD-3 diagnosis Caveats: Migraine headache worsened o...
How do you approach new-onset idiopathic intracranial hypertension (IIH) with someone who has history of systemic lupus erythematosus?
Since there is not a clinical recurrence of lupus, let's assume the disease is quiescent. The patient may have a clotting tendency so extra care should be taken in MRV interpretation. Does the MRV show the smooth-walled flow-related stenoses of intracranial hypertension or is it more consistent with...
How do you evaluate and diagnose patients with persistent postural-perceptual dizziness?
There are certain criteria. Staab et al., PMID 29036855. There is an identifiable event that is usually disorienting. This can be a vestibular event (vestibulitis, BPPV, vestibular migraine attack), mechanical fall, panic attack, among other events. There is significant head motion sensitivity and v...
What is your approach for treating mononeuritis multiplex in patients with ANCA vasculitis?
Mononeuritis multiplex related to ANCA associated vasculitis generally responds to treatment with rituximab, which would be my treatment of choice. Clinicians need to be aware that neurologic recovery can be very slow, and it is important to distinguish damage from ongoing active nerve inflammation....
What level of relief do you target with acute migraine treatments before you think there is diminishing returns on trialing a different agent?
What I try to do abortively for my migraine patients is to find them a medication, currently generally a triptan or a gepant, that they tolerate without side effects and that consistently provides them with full relief of their headaches within 2 hours of treatment. Excellent tolerability is key bec...
Do you find consumer grade wrist actigraphy useful in measuring sleep quality and duration?
Consumer wearables are advancing quickly, and there is a lot of variation in their performance, particularly in those with sleep disorders. Unfortunately, there is a wide variation in the performance of devices, even ones using the same signals to calculate sleep/wake. Additionally, orthosomnia is a...
Do you recommend routine neurosyphilis testing in patients being evaluated for dementia?
Syphilis is a rare cause of dementia without other evidence of neurological disease, at least in the US and most other industrialized countries. Of course, a careful neurological examination is required for all dementia patients, but the absence of other manifestations of neurosyphilis makes testing...
Would you consider off-label IV thrombolysis in patients taking a DOAC and present with disabling acute ischemic stroke within the window?
I usually do not (since there is still equipoise) unless they are not an acute trial or thrombectomy candidate and have severe disabling deficits, and only if their last DOAC dose was not within 24 hours rather than 48 hours. I also discuss in detail the unknown and the risks with patients or their ...