Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
What is your approach to managing seronegative myasthenia gravis in patients who have not responded to immunotherapy?
The quick and easy answer is that the diagnosis must be reconsidered. To facilitate the discussion, I would divide the seronegative patients into two groups: ocular and generalized. I assume that patients have been tested for AchR, MuSK antibodies (and possibly LRP4?), and the results are negative....
Would you use a triptan in a patient with a vascular malformation, such as an arteriovenous malformation, cavernous malformation, or developmental venous anomaly?
I see no reason not to use a triptan under the circumstances mentioned. I consider the gepants indicated when there are contraindications to the triptans, which are: poorly or uncontrolled hypertension and (atherosclerotic) vascular disease affecting the heart, brain, bowel, or legs. The above-menti...
How do you manage orthostatic hypotension in patients with Parkinsonian syndromes?
Don’t forget to check for adjunctive medications including urinary alpha antagonists which can cause orthostatic hypotension. If possible, reduce doses of cardiac medications. If this is not possible, then consider small frequent meals, exercise, especially the lower extremity elevating the head of ...
What is your approach when recommending occipital nerve stimulation for refractory cluster headache?
That particular study by Gutierrez et al., PMID 40391557, did not address the efficacy/safety of ONS in chronic/refractory cluster headache disorder, but it was in occipital neuralgia/cervicogenic headache populations.In a randomized controlled trial by Wilbrink et al., PMID 34146510,131 study parti...
Do you find onabotulinumtoxinA injections effective for the treatment of trigeminal neuralgia?
I use botulinum toxin (off-label) for two face pain conditions, one rare, i.e., trigeminal neuralgia, and one common, i.e., temporomandibular disorder (TMD). For trigeminal neuralgia, I use a tiny needle to inject very small amounts of the toxin into the affected area of the skin and, if involved in...
How do you determine when to wean patients with idiopathic intracranial hypertension off of acetazolamide?
As a neuro-ophthalmologist, my greatest concern is vision-threatening papilledema in IIH. So if there is no papilledema, that threat should be resolved for the time being, right? Not so fast. Accurate direct ophthalmoscopy has become an "optional" skill set for most neurologists. Subtle papilledema ...
When do you use seizure prophylaxis in patients on clozapine?
The topic of the use of anticonvulsants for primary prophylaxis of clozapine-induced seizures continues to be debated. The idea of prescribing anticonvulsants prophylactically for patients taking >600 mg/day of clozapine was suggested by Devinksy et al., PMID 2006003 in 1991. Clozapine-induced seizu...
Do you recommend immunomodulating treatments such as steroids or IVIG for West Nile Virus neuroinvasive disease?
In review of the literature and CDC recommendations, the outcomes when using IVIG in this setting are variable. It has been utilized in immunocompromised patients such as solid organ transplant recipients. I have not found enough evidence to support using it in a non-immunocompromised patient. The s...
When do you switch to a different DMT in multiple sclerosis patients planning for pregnancy?
There are several key differences between the reported French study and the often-used practice in the US. In the French registry, nearly 50% of patients with the diagnosis of relapsing MS (diagnosed by either Poser or early McDonald criteria) were not on DMT. While it was common in the early 1990s ...
How do you manage daytime somnolence without a clear cause?
Throw a broad net out for the evaluation because we don't know how much has a physiological component and how much is mental/emotional. At intake, I get a moderately comprehensive set of labs. Rating Scales like HAMA, HAM-D, PHQ-9, Epworth Sleepiness Scale, and a ROS (Review of Systems) are done. I...