Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
Do you prescribe respiratory muscle training (RMT) devices to patients with dysphagia?
We encounter dysphagia frequently in our patients with Parkinson's disease and other movement disorders. If there are any concerns about swallowing or aspiration, my first step is to refer to Speech Therapy for evaluation, and I defer to their expertise for specific treatments from there. That said,...
Is moderate-intensity statin plus ezetimibe just as effective as high-intensity statin monotherapy in preventing major cardiovascular events?
The secondary stroke prevention trial showed that high/moderate-intensity statin therapy combined with ezetimibe and titrated to achieve LDLc <70 were equally effective (compared to goal LDLc <100). Overall, the most important determinant of risk reduction is the achieved LDLc, and so moderate inten...
Is it necessary to prescribe a steroid taper after two weeks of high-dose prednisone (60 mg daily)?
Interesting question. Not being an endocrinologist, I don't have the expertise to advise but the reference below makes the statement that even short-term steroids can be an issue. I suspect that if you have to stop abruptly from 60 mg daily for 2 weeks, it would probably be fine in most instances bu...
What is your step-wise approach to treating worsening ocular myasthenia gravis symptoms?
I will assume that the patient is AChR antibody positive or seronegative (MuSK is a different discussion).Usually, I start with pyridostigmine, with gradual titration of dose up to approximately 240 mg (60 mg 4 times a day). Higher doses are not likely to provide additional benefit, and cholinergic ...
Do you view the difference between oral and sublingual cyclobenzaprine as clinically significant?
Yes. Oral cyclobenzaprine—a TCA analogue structurally identical to amitriptyline aside from a single double bond—has been used off-label for fibromyalgia for many years. Despite long-standing anecdotal benefit, a prospective placebo-controlled RCT showed only transient improvement at 4 weeks, with n...
How would you approach the upfront management of a patient with acute unilateral vision loss with strong clinical risk factors for both cardioembolic stroke and GCA if an expedited MRI is not possible due to the presence of an AICD?
I'm definitely not an expert in this topic, but you have many clinical tools to increase/decrease your clinical suspicion for GCA vs. cardioembolic stroke. Some things I would ask: Is this patient currently in Afib? What's their CHADSVASC? Are they anticoagulated? Can we get a TTE to check for vege...
Do you obtain an MSLT or start empiric therapy with modafinil in patients with residual excessive daytime sleepiness despite optimal adherence to PAP therapy?
In this situation I would start either modafinil, armodafinil, or solriamfetol for residual EDS if the OSA was appropriately controlled without need for MSLT. We have an FDA label for these medications in this situation to support this practice. If I felt like there was concern for a combination of ...
How do you decide what type of spinal cord stimulator to utilize for pain control?
If by “type” we mean percutaneous vs. paddle, they each have pros and cons. Perc leads are less invasive and can have a greater craniocaudal span. Paddles can be more power efficient, have more programming options in a mediolateral dimension, but are more invasive to place. I generally favor paddles...
How do you counsel patients interested in primary prevention of MS?
While there is now general consensus regarding the role of EBV infection as a trigger of disease, to date, EBV vaccines are not available and haven't been shown to prevent disease. Similarly, there is evidence of a relationship between low vitamin D and MS, though data related to prenatal supplement...
What follow-up monitoring would you recommend for a patient with self-resolved idiopathic pupil-sparing third nerve palsy?
Pupil-sparing third nerve palsy is a relatively common presentation for neuro-ophthalmologists. They typically resolve completely by 12 weeks, and I will typically follow them until they are fully resolved, watching them once a month. The most common are microvascular and associated with a variety o...