Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
What is your pharmacologic approach to treating insomnia comorbid with sleep apnea?
I do not usually treat any insomnia, regardless of comorbidities, with any targeted medication for the insomnia itself. If the patient is getting over 5 hours of sleep, then I use CBT-I as this is guideline-recommended (AASM) first-line treatment for insomnia and has efficacy lasting over a year out...
What is your approach to treating babies with IVH secondary to prematurity and a full but soft fontanelle?
The fontanel in a baby can be very deceiving. Studies in trauma have shown that even experts have trouble discerning intracranial pressure based on the fontanel fullness, so in itself it should not be a deciding factor. In this day and age, most hospitals are using the ELVIS protocol to help determi...
How do you make the decision to empirically treat for GCA when a patient is referred but cannot be immediately seen in clinic?
This is an important question because referrals for possible GCA are common scenarios when a rheumatologist may be asked to recommend a treatment before seeing the patient which are often challenging scenarior. The factors I typically rely on to rate the probability of GCA include: - Specific sympto...
When do you add corticosteroids to the treatment of HSV encephalitis?
My practice does not involve adding corticosteroids to confirmed HSV encephalitis unless there is a significant concern for malignant edema and midline shift. We lack large randomized, placebo-controlled trials, therefore their role is uncertain as of yet.
Do you recommend additional spinal MRI’s for an asymptomatic Chiari I malformation?
Age does not matter; the severity of the Chiari does. Although subjective, I would image the spine if I thought the foramen magnum was crowded enough to potentially cause a syrinx. I am not a big believer in "a high incidence" of tethered cord in the Chiari I population, so this concern would play i...
Can bleeding risk when switching from VKA treatment to a NOAC in frail, elderly patients be accurately compared if individual times in therapeutic range while on VKA treatment are not captured?
It has been postulated that, among patients who do not have an INR within therapeutic range, about half have subtherapeutic values and half have supratherapeutic values. Therefore, the latter are at higher risk of bleeding complications. Time in therapeutic range (TTR) ranges around 60-70% in random...
How do you manage patients with glossopharyngeal neuralgia?
Glossopharyngeal neuralgia can be managed similar to trigeminal neuralgia (TN). It presents with pain like TN but located in the glossopharyngeal distribution (posterior part of the tongue, tonsillar fossa, pharynx, or angle of the lower jaw and/or in the ear). Note that neuralgia of the superior la...
When do you use GLP-1 receptor agonists for the management of patients with idiopathic intracranial hypertension (IIH)?
I would use GLP-1 agonists in all overweight IIH patients who did not have a contraindication if it wasn't for the cost. In the IIH treatment trial, 6% weight loss over 6 months lowered intracranial pressure by about 50 mm (acetazolamide also lowered ICP by about 50 mm, but of course, it did it much...
How do you treat idiopathic hypersomnia inadequately responding to modafinil?
I agree with @Dr. First Last. I usually start my patients on modafinil or armodafinil. If those do not work, I will try solriamfetol. I will supplement with as needed amphetamines as well. I do not often go straight to sodium oxybate/low-sodium oxybate, as you need the right patient for this medicat...
How have you implemented digital data into your evaluations of Parkinson's patients?
We have not yet. This may change in the near future.