Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
How do you utilize OCT for the diagnosis and management of IIH?
OCT can be a valuable adjunctive objective tool for diagnosing and monitoring papilledema in IIH. However, when it is used, it should not be used alone. It must be integrated with perimetry and fundus exam/photography. It has important limitations that preclude its use as a standalone modality.Limit...
What is the minimum headache or migraine days per month that you would consider starting preventative migraine therapy?
I would start thinking about preventive therapy when headaches get to be about 4-6 times a month. This is the number at which there is evidence that headaches will start to progress to chronic, which is considered to be 15 times a month. If a patient is increasing their abortive use or each migraine...
What is the optimal BP target for patients with diabetes and hypertension to reduce their risk of MI/stroke?
From the 2025 ADA Standards of Care, section 10 discusses Cardiovascular Disease and Risk Management. With proper blood pressure technique, the recommended blood pressure treatment goal is less than 130/80 mmHg if this can be achieved safely. Several randomized controlled trials are referenced with ...
Would you use bupropion for mood disorder or substance use in an adult patient with previous childhood seizures that resolved?
The short answer is maybe, though it would not be my first choice. Bupropion is known to lower the seizure threshold, thus the basis of the question. Selection of an antidepressant depends on multiple factors including response to prior medications, side-effect profile, cost, presence of comorbid sy...
Do you avoid triptans in patients on SSRIs due to the potential risk of serotonin syndrome?
I feel very comfortable using triptans with SSRIs/SNRIs. In 2010, the American Headache Society released a position statement on this very issue:Evans et al., PMID 20618823Their position is that the available evidence does NOT support the claim that triptans should not be used with SSRIs or SNRIs.A ...
How do you explain the use of an AI scribe to patients the first time it is used in their care?
I use an AI scribe in my outpatient clinic, and around 90–95% of my patients agree to it. I obtain consent at the start of each visit and make it clear that it's completely optional—that they can say no at the start or change their mind at any point in the visit, with no impact on their care. I also...
What is your preferred VMAT2 inhibitor to treat tardive dyskinesia; tetrabenazine, valbenazine, or deutetrabenazine?
The base cost of tetrabenazine is much lower than valbenazine or deutetrabenazine, so I generally prefer it. However, due to insurance factors, valbenazine or deutetrabenazine can have lower out-of-pocket costs for some patients. From a purely clinical management perspective, tetrabenazine is much ...
Among patients with secured subarachnoid hemorrhage who are receiving daily TCDs, what is the appropriate frequency of post operative neurological assessments?
I think a textbook might state something like "every 1-2 hours in the acute setting." However, in my opinion, the frequency of neurological examinations should be tailored to the individual patient and involves considerable clinical judgement. Factors that might influence this decision include a) se...
How do you approach a patient who develops a rest tremor after chemotherapy?
Like many questions in Neurology, this question can be simple or rather complex to answer. If the patient is felt to have a drug-induced tremor, withdrawal of the offending drug or drugs should be the first choice whenever possible. In the chemotherapy setting, a common scenario would be when a dopa...
Do you recommend lumbar puncture for suspected early GBS without motor involvement?
If purely for the confirmation of a GBS diagnosis, then no.CSF testing has limited utility for Guillain-Barré syndrome (GBS) diagnosis early in the disease course. Cytoalbuminologic dissociation is only present in 50% of patients in the first four days and rises to ~80% after the first week (Al-Hake...