Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
How do you manage patients with good relief but intolerable chest tightness with sumatriptan?
Triptan sensations are described as tightness, often in the chest, which may be accompanied by sensations like burning or tingling. These symptoms are reported in 1-7% of patients compared to 1-2.5% of placebo. They have been investigated with the cause still being unclear, but are not a manifestati...
What workup do you suggest for patients with concern for opsoclonus-myoclonus syndrome?
Opsoclonus-myoclonus syndrome (OMS) is characterized by fast and irregular multidirectional eye movements combined with generalized myoclonus and often ataxia. The common etiologies include paraneoplastic, autoimmune, and infectious/parainfectious causes. The approach in children and adults is diffe...
How do you treat persistent headache after a CVST diagnosis?
Follow the phenotype - usually migraine preventives, nerve blocks work well, or neuroleptics with gabapentin or Lyrica. Can be very difficult to treat.
At what point do you refer patients to neurology for evaluation of tics?
I will only refer to neurology if there are other neurologic signs or other movement issues.
Does a patient’s ability to get risk factors under control influence your recommendation for surgical vs. medical management of asymptomatic carotid disease?
No, because in CREST-2, stenting was better than medical therapy for stroke prevention in patients with >70% asymptomatic carotid stenosis. I would, however, still want such patients to aggressively control their vascular risk factors.
When have you found the Nidra TOMAC device to be helpful for refractory restless leg syndrome?
I have one patient who found it helpful with breakthrough symptoms in refractory RLS, but was unable to get enough coverage to continue using it.
How do you taper steroids for CAA-ri?
Thank you for the question. I have treated two patients so far for CAA-ri, one biopsy-confirmed. I also reviewed the literature on the entity. An oral steroid taper over several months is recommended to reduce the chances of recurrence. There’s no established standard timeline I have found. Monitori...
How do you approach management of an ICU patient with brief potentially ictal rhythmic discharges (BIRDs) on EEG?
This is a very challenging question, and the clinical importance of BIRDs, besides being associated with an increased frequency of seizures (Yoo et al., PMID 24535702 ), is unclear. I am a neurointensivist, and in general, I do not escalate therapy for intermittent BIRDs unless we identify concomita...
When do you check Lp(a) in patients with a first-time ischemic stroke?
I don’t routinely check Lp(a) in my stroke patients, including first-time cryptogenic stroke patients. Evidence suggests that the elevated Lp(a) amplifies cardiovascular risk in patients with pre-existing atherosclerosis due to LDL-C. We already have high-quality evidence that in patients with strok...
What is your approach to escalating therapies for stiff person syndrome that is refractory to IVIG and steroids?
Step 1: Make sure the diagnosis is correct, especially if seronegative or very weakly positive for GAD65 antibodies.Misdiagnosis of SPS is common and diagnostic criteria have been recently proposed (Reference 1). Patients who complain of subjective stiffness/muscle spasms, but do not have objective ...