Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
When do you check Lp(a) in patients with a first-time ischemic stroke?
I don’t routinely check Lp(a) in my stroke patients, including first-time cryptogenic stroke patients. Evidence suggests that the elevated Lp(a) amplifies cardiovascular risk in patients with pre-existing atherosclerosis due to LDL-C. We already have high-quality evidence that in patients with strok...
What is your approach to escalating therapies for stiff person syndrome that is refractory to IVIG and steroids?
Step 1: Make sure the diagnosis is correct, especially if seronegative or very weakly positive for GAD65 antibodies.Misdiagnosis of SPS is common and diagnostic criteria have been recently proposed (Reference 1). Patients who complain of subjective stiffness/muscle spasms, but do not have objective ...
How do you counsel patients interested in estrogen containing oral contraceptives who have migraine with aura?
Outside of patients whose attacks are suggestive of hemiplegic migraine, I do not typically avoid the use of estrogen-containing OCPs. While it is my understanding that a number of international organizations and many neurologists (as well as Ob/Gyn) recommend their avoidance, there are several revi...
Do you maintain a strict platelet threshold of >50k when performing a lumbar puncture, or are there situations in which you feel comfortable with a lower threshold?
Our institution still uses 50k as a best practice guideline, though many of our proceduralists are comfortable performing the procedure with platelets slightly lower than 50k, and will have a risk/benefit discussion with the patient/team about the bleeding risk prior to proceeding; I myself would be...
How will you select patients with brain metastases for TTFields?
The METIS trial restricted eligibility only to patients with brain metastases from non-small cell lung cancer. Therefore, we would not be able to extrapolate these results and data to other tumor types and histologies. Indeed, a post hoc analysis of the data did demonstrate a greater impact in patie...
Do 5HT4 agonists such as Metoclopramide actually lead to improvement in symptoms for patients with diabetes related gastroparesis?
Yes, sometimes when the gastroparesis is frequent or the symptoms are tough, I do use Reglan to help. By the time they wind up in the hospital, they are really willing to have me use anything on them that might help. I explain to every patient the side effects of Reglan, including tartive dyskinesia...
How do you counsel cluster headache patients interested in treatment via N,N-dimethyltryptamine (DMT) and psychadelics?
My opinion is that the efficacy and safety of psychedelics in the treatment of cluster headache disorder are not fully known.Per the review article by Im and Sandoe, PMID 40782223, there is some data that comes from case reports, small open-label studies, 1 very small RTC (10 patients) showing some ...
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, ...
What is the expected timeframe for the development of radiation myelitis and therapies that have helped with neurologic symptoms?
The incidence and the timeframe of the development of radiation myelopathy are influenced by total radiation dose, radiation dose per fraction, time between courses of radiation, and associated chemotherapy or immunotherapy. Older age, the presence of diabetes, and previous exposure to radiation are...
Do you order screening echocardiograms for patients with migraine with aura?
I do not and would not, based on that abstract. We would need higher-quality studies to prove that closing PFO decreases adverse vascular outcomes in patients with migraine disorder with aura.