Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
Do you routinely perform muscle biopsies in patients presenting with the classic symptoms of Inclusion Body Myositis along with positive CN1A antibody?
YES. There are new consensus guidelines from ENMC about the diagnosis of IBM (Lilleker et al., PMID 38522330). They define the clinical presentation of IBM as typical (age >45, progression over >12 months, long finger flexor weakness > deltoid weakness, quadriceps weakness > hip flexors), or atypica...
Which methods of tracking response to treatment in myasthenia gravis do you find most helpful?
To me, it is still a combination of history and clinical examination supplemented by MG-specific scales. Thus, it is the global impression of how a patient is doing rather than any one metric. Amongst the MG-specific scales, I use the MG activities of daily living (MG-ADL) and MG Composite (MGC) sco...
What is the stepwise investigation of patients suspected of inflammatory myopathy?
I have published an algorithmic approach to suspected inflammatory myopathy in Continuum Lifelong Learning in Neurology from AAN (Manousakis, PMID 36537973). Unfortunately, the article is not free, and I can't attach the algorithm in this response, because it's a PPT file. Happy to provide it upon r...
How will your approach to screening and diagnosis of early dementia change given newly available therapies for early Alzheimer's disease?
As it stands, it is not recommended to screen asymptomatic patients for the proteins seen in Alzheimer’s disease outside of clinical trials (i.e., AHEAD 3-45). However, with the emergence of new treatment options in the clinic, I foresee an influx of patients with cognitive symptoms who need a preci...
In what clinical situation would you consider using benzodiazepines in patients with dementia?
I would avoid long-term benzodiazepines treatment if someone has full-blown dementia syndrome or frontal lobe syndrome due to the potential of paradoxical disinhibitions along with amnestic and ataxic side effects. However, I would consider clonazepam for RBD and related REM sleep issues in dementia...
Would you recommend PFO closure in patients >60 years old with presumed paradoxical embolism as their mechanism of stroke?
Technically, based on the available clinical trial evidence, PFO closure is not indicated for patients over age 60 or for patients whose stroke was > 6 months ago. However, we frequently need to extrapolate from clinical trial populations to manage the patients we see in practice. Also, presumably, ...
What is the expected timeframe for the development of radiation myelitis and therapies that have helped with neurologic symptoms?
The incidence and the timeframe of the development of radiation myelopathy are influenced by total radiation dose, radiation dose per fraction, time between courses of radiation, and associated chemotherapy or immunotherapy. Older age, the presence of diabetes, and previous exposure to radiation are...
Have you found sphenopalatine blocks to be an effective treatment for headaches secondary to subarachnoid hemorrhage?
Anecdotally, yes, but we have only been doing this as part of a small research project at our institution. The literature is largely limited to case reports and there is at least one clinical trial (NCT07116408) looking specifically at this, scheduled to finish enrollment in 2026. There are commerci...
How long would you continue chronic transfusion therapy for adult sickle cell patients who have had a stroke?
Management of stroke in adults is not informed by the data that is available for children. Assuming that this was not a hemorrhagic stroke and that there was no moya-moya, I would continue transfusions indefinitely. To slow iron accumulation, I would use an exchange transfusion aiming for an HbS lev...
How do you manage autonomic symptoms in patients with myasthenia gravis?
MG is a pure motor syndrome. Patients should not have any autonomic symptoms unless they have LEMS (dry mouth) or if it is medication-related (e.g., Mestinon’s SE includes excessive salivation, sweating, and GI hypermotility). Thus, if a patient with MG has autonomic symptoms (unless explained by LE...