Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
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...
When should you seek hyperbaric oxygen therapy for patients with CRAO?
I usually pursue hyperbaric oxygen therapy within the 24-hour window from symptom onset for CRAO. This can be performed following TNK if given. In reality, though, there are multiple barriers to achieving this, including: Few centers offer hyperbaric oxygen therapy Labor intensive Difficulty with i...
Have you had success with the Cala Trio device for essential tremor?
I have had a couple of patients who find it useful to calm their hand tremor for about 60-90 minutes after using the device. They may use it before they are going to an event, or before they plan to do an activity that involves the use of their dominant hand. (NOTE: You can only use it for one limb....
How do you approach anti-seizure medication management when it was started by another team for a seizure-naive patient before/after craniotomy for a tumor?
I would refer you to Dr. @Dr. First Last's answer to a similar question (https://www.themednet.org/question/15031) which beautifully summarizes data and guidelines. I usually counsel patients that everyone regardless of their medical history has a certain risk of seizure under physical stressors, th...
How do you utilize tools such as MMT8 in clinical practice when evaluating myositis?
We test hip flexors in every patient as well as the traditional muscles tested in MMT-8. I agree that it is not ideal that MMT-8 does not include these muscles. In fact, we test all large muscle groups - UE and LE as well as the finger flexors and extensors for complete assessment - then extrapolate...
Over what time frame do EMG/NCS of AIDP patients normalize?
Answering this question is complicated due to the concept of reversible conduction failure in GBS. This concept was introduced by Kuwabara in 1998 (1) and it describes a subset of patients who often had preceding diarrheal illness from Campylobacter and very high GM1-IgG antibody titers, who would n...
How do you treat postherpetic neuralgia not adequately responding to oral neuropathic pain medications, lidocaine, and capsaicin?
By the Q, it is assumed all PO meds and topicals have failed. There are other compounding options but none with high-quality EBM support (i.e., gabapentin, TCA, camphor/menthol, pregabalin, ketamine, NSAIDs, CBZ…). Therefore, if PO and topical treatments fail, only procedures remain. IV therapy - l...
What have you been using in place of tensilon test as a pharmacologic challenge for myasthenia gravis diagnosis?
We rarely do pharmacological challenges for MG diagnosis nowadays, especially after edrophonium was withdrawn from the market. One may do an oral pyridostigmine challenge, but I only do it nowadays in stable outpatients, with high suspicion for ocular or mild generalized myasthenia with ocular sympt...
What have you found helpful in counseling patients with migraine reluctant to take preventative medications?
I think all of the responses here are very reasonable, but often the hesitancy is based less on resistance to a specific medication than on the self-stigmatization we see in patients with chronic headache, migraine, or other primary or secondary headaches. Because migraine is not a life-threatening ...
What workup do you recommend for patients with symptoms suggestive of saphenous neuropathy?
In most cases of isolated saphenous neuropathy, the etiology is pretty straightforward, as it usually occurs after surgery or injury/trauma at the medial knee. Another common cause of more distal saphenous neuropathy is saphenous vein harvesting for CABG surgery (less common nowadays). When there is...