Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
How do you approach evaluation of a patient referred for mononeuritis multiplex and +SSB?
Step 1: A clinical syndrome of mononeuropathy multiplex always requires an EMG study. Is the primary mechanism of the MnM axonal or demyelinating? If it is demyelinating, there are only two possible diagnoses: multifocal CIDP (Lewis Sumner syndrome, which can occur in the context of Sjogren's syndro...
What is your approach to secondary stroke prevention in patients with atrial fibrillation and intracranial stenosis (>70%)?
The patient clearly needs to be on an anticoagulant for stroke prevention with atrial fibrillation and I would choose apixaban. If an antiplatelet is added to the apixaban, the risk of a major bleeding side effect is significantly increased. It is uncertain if apixaban is effective in reducing the r...
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...
How do you utilize Diamox in patients with cerebral venous sinus thrombosis and vision symptoms who do not undergo thrombectomy/recanalization?
Diamox (acetazolamide) is often used to treat papilledema with associated visual loss in cases of CVST. While there is a theoretical risk of dehydration from acetazolamide with potential worsening of the thrombosis, 1) acetazolamide is a weak diuretic and 2) the risk of blinding visual loss usually ...
How do you decide between the different oral longer acting levodopa medications?
The question would be, why are you changing, and what are you changing from? (i.e., are one of these your initial agent, a change due to Sinemet side effects, or a change because of motor fluctuations?) The current theory on dopamine replacement is "smoother is better," so the longer (and lower) you...
How do you manage incidentally found venous sinus thrombosis?
I would make sure first that it is not simply a congenitally small sinus. If there is truly a CVST, I would probably treat with a DOAC for 3 months and reassess with CTV.
How do you wean off of primidone in patients with essential tremors?
If a patient has been on primidone for less than one month, it can be simply discontinued in most cases. Slower withdrawal may be necessary in patients with seizures, patients on multiple other medications, or with other abnormal metabolism. For patients needing a slower taper, generally lowering th...
Do you recommend routine neurosyphilis testing in patients being evaluated for dementia?
Syphilis is a rare cause of dementia without other evidence of neurological disease, at least in the US and most other industrialized countries. Of course, a careful neurological examination is required for all dementia patients, but the absence of other manifestations of neurosyphilis makes testing...
How do you decide when to extend rituximab redosing beyond a 6 month interval for replasing multiple sclerosis?
In light of the published study, the discussion that I've had with patients revolves around utilizing CD19/CD20 counts to guide infusion frequency.
How do you work up patients who present with elevated myoglobin in the setting of normal creatinine kinase and exercise intolerance?
Myoglobin may originate either from cardiac or skeletal muscle; therefore, I would first try pinpointing the origin with troponins and CK fractions. I would work up the exercise intolerance with a non-ischemic forearm test to determine whether a flat lactate curve is present. In that case, I’d typic...