Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
What pharmacological management do you consider in patients with Autism Spectrum Disorder whose primary behavior is aggression?
As with all of my child patients, my approach is never to medicate behavior but rather to medicate suffering. This means that I view “aggression” of all forms as a kind of communication that something is wrong inside and that other means of effective communicating or managing that discomfort or what...
What strategies do you find helpful in advanced care planning with patients/families who are very "miracle" centered?
Hope for the miracle yourself! Broaden: “Are there any other things you are hoping for?” Hope for the best, prepare for the worst: “I see how much you want a miracle. I wonder if we can talk about what we should do if this doesn’t happen.” Consider involving a religious leader if relevant.
Which imaging features do you use when considering Normal Pressure Hydrocephalus to decide whether to proceed with large-volume LP or lumbar drain trial?
At our center, we follow the approach of the NPH clinic at the Imperial College Hospital in London.See this excellent review article for further details: Carswell, PMID 36162853.
How do you evaluate for improvement in tremor from FUS in essential tremor?
The best method for the assessment of improvement in tremor after a FUS thalamotomy is by using a standardized clinical rating scale. These include the Essential Tremor Rating Scale (TETRAS) or the Clinical Rating Scale for Tremor [also known as the Fahn-Tolosa-Marin (FTM) score]. The TETRAS scale h...
What is the role of inebilizumab in the maintenance treatment of IgG4-related disease?
Inebilizumab may play an important role in the maintenance treatment of IgG4-related disease (IgG4-RD), particularly in patients at high risk for relapse. These are typically patients with multi-organ involvement and elevated serum IgG4 levels who initially respond well to corticosteroids but tend t...
What is the role of skin biopsy for evaluating small fiber neuropathy in patients with rheumatic disease who have treatment recalcitrant pain?
I have a shared decision-making discussion with the patient, especially alluding to the fact that the result would not change my therapy (i.e., use neuropathic analgesics for treatment) for small fiber neuropathy (SFN). Where I find it especially useful is in a patient with systemic lupus (SLE) or S...
How does LV non-compaction on TTE change your secondary stroke prevention management?
Left ventricular non-compaction is a rare condition where the L atrial wall is thick and irregular and can contain areas of clot. I would favor anticoagulation in this situation, rather than antiplatelet therapy, but of course there are no clinical trials regarding this uncommon finding.
When would you prescribe pharmacologic DVT prophylaxis in bedbound neuromuscular patients?
Short answer: I would still not prescribe pharmacologic DVT prophylaxis routinely for all my bedbound neuromuscular patients in the outpatient setting. The point raised by the question is more than reasonable. Ideally, a randomized trial of prophylaxis vs. placebo should occur before we change our p...
How do you treat steroid-refractory MS flares when PLEX is unavailable?
There is limited evidence on the efficacy of IVIG for MS relapses. A repeat course of IV methylprednisolone within 2-3 weeks could be considered. If the patient is not already on high-efficacy DMT, then I would also promptly initiate anti-CD20 therapy.
When is it useful to test for multiple amyloid-related biomarkers for patients undergoing work-up for cognitive impairment?
If a patient has a presentation consistent with MCI or early dementia due to AD (slow progressive decline, STM loss, no hallucinations, no neuro deficits), I will get an MRI and amyloid blood-based biomarkers. If the goal is just a diagnosis, I stop there. If they are interested in “mab” therapy, I ...