Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
How long do you hold pyridostigmine prior to EMG / nerve conduction study in patients with suspected myasthenia?
At least 12 hours prior to repetitive stimulation or SFEMG, per AANEM practice parameter. In our lab we recommend 24 hours if possible. Geiger and Katirji, Myasthenia Gravis and Related Disorders pp 131–152
When do you consider pembrolizumab for the treatment of progressive multifocal leukoencephalopathy?
Progressive Multifocal Leukoencephalopathy (PML) treatment remains a big challenge; the different etiologies leading to PML (HIV, malignancy, primary immunocompromise, iatrogenic, etc.) play a role in the heterogeneity of approach and outcomes. It's helpful to think of potential treatments based on ...
Is it ever appropriate to omit temozolomide in unmethylated glioblastoma?
Perhaps a different perspective on this question would be which unmethylated patients would you be willing to not treat with up-front temozolomide? The genesis of the question and conundrum comes from the modest benefit described in the above-mentioned trials for this subgroup. As Hegi herself descr...
When do you consider CSF testing for patients with suspected ALS?
I have been evaluating and treating ALS (and other motor neuron disease) patients in a tertiary setting for >13 years. CSF testing in my opinion rarely changes the diagnosis, and in typical scenarios with patients showing progressive bulbar onset or limb onset muscle weakness, with combined clinical...
What do you do when headache appears clinically attributed to intracranial hypotension but imaging and opening pressure are normal or not obtainable?
Regarding the IHS classification and diagnostic criteria, it is important to remember the following: The initiative came from Glaxo Pharmaceuticals in order to make it possible for the company to pursue the development of sumatriptan for migraine abortion globally. The company also paid for the fir...
How do you decide on the timing of carotid stenting after thrombectomy for an intracranial large vessel occlusion with ipsilateral carotid stenosis?
There are ongoing randomized trials that are attempting to tackle this question. So, a data-driven status will be available soon. In the meantime, clinical considerations apply: Sometimes one has to stent to gain access to the intracranial circulation, perhaps due to a very tight extracranial carot...
When is it useful to test for multiple amyloid-related biomarkers for patients undergoing work-up for cognitive impairment?
If a patient has a presentation consistent with MCI or early dementia due to AD (slow progressive decline, STM loss, no hallucinations, no neuro deficits), I will get an MRI and amyloid blood-based biomarkers. If the goal is just a diagnosis, I stop there. If they are interested in “mab” therapy, I ...
What is your approach to bothersome dyskinesias in Parkinson disease patients?
This is an interesting recent article in which a meta-analysis of various anti-Parkinson medications and surgical interventions was looked at for their effect on controlling dyskinesias as compared to placebo. The meta-analysis showed that DBS of the GPI (globus pallidus interna) was more effective ...
How effective do you find MAO-B inhibitors for the treatment of Parkinson's disease?
In the earlier stages of PD, MAO inhibitors have a perceptible effect, and in the early stages of treatment of PD, they are used alone or more effectively in combination with L-DOPA.
What experience do you have with paralysis or myasthenia-like symptoms developing on temozolomide?
This is not an established toxicity of temozolomide and would warrant further investigation.