Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
Do you typically check vitamin B6 levels in patients on Sinemet?
I check B6 levels when a patient is not responding well to carbidopa/levodopa or if I have concerns about nutritional status. I have rarely found that correcting low or high B6 levels results in clinical change in patients. If a patient were to seemingly lose efficacy from ongoing levodopa therapy, ...
How do you approach escalating anti-seizure medication treatment of patients with atypical seizure semiologies?
As usual, it depends on what "atypical" means. If the seizure semiology is atypical, in that I really do not think it is a seizure, I will admit the patient to the Epilepsy Monitoring Unit (EMU) as quickly as possible for full characterization. I may or may not start a medication depending on the hi...
Do you check IgA levels before starting IVIG for other autoimmune conditions?
Whereas it is not mandatory to check IgA levels before starting IVIG, it is prudent to do so in non-urgent situations since the patients with IgA deficiency, especially those who have developed anti-IgA antibodies, are at an increased risk of severe hypersensitivity or anaphylactic reactions from IV...
How do you approach management of an ICU patient with brief potentially ictal rhythmic discharges (BIRDs) on EEG?
This is a very challenging question, and the clinical importance of BIRDs, besides being associated with an increased frequency of seizures (Yoo et al., PMID 24535702 ), is unclear. I am a neurointensivist, and in general, I do not escalate therapy for intermittent BIRDs unless we identify concomita...
What treatment strategies would you utilize in a patient with newly diagnosed HLA-B27+ axial spondyloarthritis (with active and chronic sacroiliitis on MRI) and recent diagnosis of MS that is well-controlled MS ocrelizumab given the need to avoid TNF inhibitors?
This is a very challenging scenario. On one hand, TNFi are generally unsafe for MS due to demyelination risk, and on the other hand, anti-CD20 therapies for MS are linked to new AxSpA, but B-cell depletion might also benefit AxSpA. Thus, management requires specialized care in balancing both disease...
Would you consider anti-IL-5 therapy (mepolizumab or benralizumab) to either prevent or treat the more severe manifestations of eosinophilic granulomatosis with polyangiitis, such as "infiltrative" (e.g., cardiomyopathy, pulmonary infiltrates, or gastroenteritis) or "vasculitic" (e.g., neuropathy, palpable purpura, or glomerulonephritis)?
Yes, I would consider early starting biologics for infiltrative EGPA.
How do you interpret conflicting findings on CSF immunoglobulin tests for work up of multiple sclerosis and its mimics?
Although the specific role of cerebrospinal fluid (CSF) testing has evolved in the successive revisions of the McDonald criteria, it remains an important part of the evaluation of suspected multiple sclerosis (MS), both to provide support for the diagnosis of MS and to look for findings that suggest...
When would you consider prescribing a wakefulness promoting agent for excessive daytime sleepiness from insufficient sleep?
I would never consider prescribing an alerting medication for someone with insufficient sleep. Behaviorally insufficient sleep is a diagnosis in and of itself. The treatment for excessive daytime sleepiness in the case of insufficient sleep is changing behavior to allow for more time in bed. I would...
How effective have you found acupuncture for treatment of chronic migraine?
I would prefer to educate a patient interested in acupuncture for severe headaches about all the other treatments that are available. However, if they would still like to pursue acupuncture, I would support them, just like Dr. @Dr. First Last would say. Some patients can get better, although it is n...
How do you balance the risk of unnecessary treatment with acyclovir against the risk of delaying treatment in encephalitis cases where CSF pleocytosis is absent?
Treatment with IV acyclovir should start as soon as the diagnosis of Herpes simplex encephalitis is considered. Since the question states that CSF pleocytosis is absent, then CSF has been obtained. PCR for HSV should be obtained on that CSF. Early in my career, when acyclovir was investigational and...