Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
What are your preferred treatments for disrupted nighttime sleep in elderly patients with narcolepsy already taking sodium oxybate?
The treatment depends on what is causing the disruption. Before I consider any medication, I recommend a thorough investigation of possible causes of the disruption. For example, has sleep apnea been ruled out? Is the patient taking alerting substances close to bedtime? What is the sleep environment...
How do you manage a patient with giant cell arteritis treated with weekly tocilizumab and low dose glucocorticoid who develops sudden vision loss?
Fortunately, this scenario is a rare event, as most patients treated with ongoing tocilizumab (TCZ) and prednisone are at a far lower risk for developing new visual loss due to giant cell arteritis (GCA). A recent paper by Amsler et al., PMID 33752737 reviewing the risk for visual loss in patients b...
Would you recommend switching to DAPT for patients on anticoagulation who develop symptoms of a TIA secondary to ICAD?
It is important to remember that there is more to stroke secondary prevention than antithrombotics. Our use of DAPT in ICAD comes from the SAMMPRIS trial, in which patients in the control group did better than expected compared to historical controls with ICAD in the WASID trial. Recall however, tha...
What treatments have you found to be effective for mal de débarquement after trialing benzodiazepines such as clonazepam?
Try to find an underlying history of migraine. Generally, SSRIs and SNRIs (if headache is a feature) can help, but there are no controlled trials for this. Benzodiazepines should be used temporarily as a bridge for the above. If a history of migraine, even remote, is present, sometimes antimigraine ...
Do you recommend neuromodulation treatments with an implantable device for patients with chronic painful diabetic neuropathy who have not responded to common oral therapies such as Gabapentin and Amitriptyline?
Absolutely.I am a board-certified neurologist and pain medicine physician. By the time patients are referred to neurology, they have typically failed conservative oral or topical therapies. In this context, spinal cord stimulation represents a transformative option.Conventional oral medications usua...
Should IVIG dosing in patients with autoimmune disease (i.e., dermatomyositis) who become pregnant continue to be based on actual weight at the time of each infusion, or should it be limited to pre-pregnancy weight?
This is a very interesting and incredibly pragmatic question, but not one with an easy answer.By way of background:The treatment of pregnant DM patients is understandably complicated by the need to balance adequately treating disease activity against the maternal/fetal toxicity of medications. In ad...
How do you approach the management of neurocognitive and memory deficits in post-concussive syndrome?
I answered this on a similar question before, but my answer still applies here: I typically ask the patient what scenarios they experience cognitive issues in. The various examples they provide usually relate to difficulty following conversations, forgetfulness within their working memory, and conce...
How do you counsel patients who develop DVT or atrial fibrillation requiring anticoagulation when being treated with lecanemab or donanemab?
I do not think that anticoagulation is contraindicated in patients with these Alzheimer's disease antibodies, but I would want to check APOE status. I would not initiate the AD treatment if the patient is E4E4, and even one E4 would make me hesitant to have a patient on anticoagulation and an Alzhei...
In ischemic stroke patients with low LDL levels (<30-50 mg/dl), would you consider lowering LDL levels to lower values without concern for any side effects?
If LDL levels are already below 70, I don’t target a lower goal. The SPARCL trial showed that reducing LDL to this range has an NNT of about 45 to prevent one stroke, which I find to be modest at best. From my perspective, lowering LDL further (<30-50 range) shifts the focus to treating a number rat...
How do you transition from Levetiracetam to Brivaracetam, particularly at doses of 1500 mg BID or higher?
You can follow the ILAE guidelines (Asadi-Pooya et al., PMID 35894673)Brivaracetam/levetiracetamBrivaracetam at 50 mg could be replaced by 1,000 mg levetiracetam, 100 mg of brivaracetam by 2,000 mg levetiracetam, and 200 mg of brivaracetam by 3,000 mg levetiracetam 9. In case of need, these two drug...