Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
What factors would prompt you to refer a patient for a surgical epilepsy evaluation who has not yet failed two anti-seizure medications?
This is a good question, and of course, the discussion with the patient regarding their diagnosis and treatment plan is important. There are also expert consensus guidelines that help to clarify this (Jehi et al., PMID 35842919) and that most of us would ascribe to in these cases. Specifically, when...
How do you decide on switching to a different preventative anti-CGRP treatment in migraine patients who are experiencing reduced effectiveness with their current treatment?
The CGRP antibodies and gepants are my preventive treatments of choice. In fact, I hardly ever prescribe anything else anymore preventively, including botulinum toxin. Tolerability issues I hardly ever encounter with the antibodies, but sometimes I do with the gepants, in particular fat...
How do you approach the use of newer anti-seizure medications for epilepsy patients on DOACs?
Levetiracetam and valproic acid: A nested case-control study published in 2021 (Gronich et al., PMID 34287842) in patients with afib identified an increased risk of stroke/systemic embolism with levetiracetam and valproic acid. This was followed by a few retrospective studies published in 2022 and ...
What lifestyle choices are helpful in reducing the risk of or slowing cognitive decline?
Regular daily physical exercise. A healthy diet: for example, the MIND diet: low in fat and sugar, high in vegetables and fruits, and regular hydration. Be mentally active. Participate in social activities. Get adequate sleep (7-8 hours nightly). Manage stress. Limit alcohol and avoid smoking Perio...
When do you use rozanolixizumab for Musk MG?
I tend to use rozanolixizumab in a few different situations for MuSK myasthenia. The obvious one is when patients have a significant bulbar weakness that needs to be controlled ASAP. Aside from that, I may try rozanolixizumab in patients who do not respond well to prednisone, primarily to get them b...
When do you consider tapering tocilizumab in patients with GCA in remission?
This is a timely question and recent data sheds some light on this important topic. The risk of GCA relapse is approximately 50% (Mainbourg et al., PMID 30951256) in all comers. The GIACTA trial (Stone et al., PMID 28745999) utilized a one-year course of TCZ. A recent publication of the extension ph...
How do you counsel patients with Parkinson's disease who are interested in starting GLP-1 agonists for neuroprotective benefits?
This is an important question, thank you. The Parkinson's disease community has been desperate to find an intervention other than exercise that can slow the progression of the disease and provide neuroprotective benefits. We might be heading in the right direction with glucagon-like peptide-1 (GLP-1...
Have you seen improvement in non-migraine-type headaches with the usage of drugs targeting CGRP?
For prevention, I have only used the 4 monoclonal antibodies or the 2 preventive gepants for documented migraine with and without aura, and also for cluster headache. I tend to use the one that is approved for cluster headache, eptinezumab, at the higher dose of 300 mg via IV infusion. For acute car...
How long would you stop standard GBM radiotherapy if the patient had a fall with minor head trauma?
I would do everything possible to minimize or ideally avoid treatment breaks, given no intracranial bleed. I would evaluate skin dose over the area of laceration and consider adapting the plan to meet skin constraints or lower dose to the suture if possible and not already low. If significant swelli...
What is the role of radiation in intra labyrinthine (cochlear) schwannoma?
This is a bit of a tricky question to answer without knowing the size of the lesion, the age of the patient, their current symptoms, and whether they have serviceable hearing.If the tumor is small, and the patient has residual serviceable hearing, it might be best to delay treatment and order a repe...