Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
How would you adjust the dose of everolimus for tuberous sclerosis in setting of asymptomatic rising liver enzymes, platelets, and lipid counts?
If a dose reduction of everolimus is needed because of asymptomatic lab value changes, I usually try reducing the dose by 25% for 2-3 months and then reducing by 50% of the original dose if the labs continue to worsen. A fairly moderate dose reduction is often sufficient and can still maintain effic...
At what lab values (ferritin, TSAT%) would you offer IV iron therapy to patients with restless leg syndrome?
1. I am hopeful that practitioners will start understanding that ferritin alone is not enough to assess iron because of its acute phase reactivity. I like to order iron parameters after a 5-9 hour fast so the serum iron is not speciously elevated and get a ferritin and TSAT. If the ferritin is <30 a...
Which patients are good candidates for transcranial electrical stimulation for the treatment of chronic insomnia?
Transcranial magnetic stimulation (TMS) is a noninvasive neuromodulation technique that has demonstrated efficacy in the treatment of insomnia in randomized clinical trials, although evidence supporting its long-term effectiveness remains limited. Studies have reported improvements in both subjectiv...
How effective do you find MAO-B inhibitors for the treatment of Parkinson's disease?
In a new patient with early mild symptoms, especially unilateral (Stage I), MAO-B inhibitors can be used. If you look at the Data from the TEMPO Study and Adagio study, Rasagiline 1 mg daily can have mild symptomatic benefits. In some patients, it may be the only drug they need for the next 2-5 year...
What is the recommendation for women with migraine with aura who are planning to undergo IVF hormone therapy?
I would not change my migraine management approach. With pregnancy planning, I would avoid medications that are not recommended in pregnancy. I would counsel on the safety of different acute and preventative treatments in pregnancy.
When do you usually introduce conversations regarding tracheostomy placement in patients with refractory status epilepticus, or other conditions where one may anticipate delayed awakening?
It depends on the underlying pathology and how long the patient is expected to have impaired airway reflexes requiring prolonged mechanical ventilation. In the Setpoint 2 trial, among patients with severe stroke receiving mechanical ventilation, a strategy of early tracheostomy (</= 5 days), compare...
Do you set mTICI-specific systolic blood pressure targets after successful endovascular therapy for acute ischemic stroke?
I think that there are SBP targets for different repercussion scenarios that make sense. For a typical thrombectomy, I think recent data suggests that a parameter of less than 180 is reasonable, especially for TICI 2b bc you may still want a bit higher BP to perfuse an ischemic area. If I’m doing th...
Which PD patients will you be implementing tavapadon?
I am excited to try this new selective D1/D5 dopamine agonist to address mild-to-moderate motor symptoms of Parkinson's disease and wearing off/motor fluctuations. Being a selective agonist at D1/D5 receptors, tavapadon has the potential for fewer side effects, such as drowsiness, nausea, and impuls...
How do you treat fatigue symptoms in myasthenia gravis?
Fatigue is one of the most common symptoms in patients with MG. Pyridostigmine can give patients symptomatic relief. In addition, we look for other causes, including sleep disorders (insomnia from steroid use, obstructive sleep apnea), comorbidities (heart disease, hypothyroidism, adrenal insufficie...
How do you decide between second-line immunotherapy for multifocal motor neuropathy?
There is no FDA-approved second-line immunotherapy for MMN, and there is no single drug with established efficacy from a randomized placebo-controlled clinical trial. In the 1990s and 2000s, there were a couple of case reports indicating efficacy of cyclophosphamide (Pestronk et al., PMID 7969954, B...