Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
How do you counsel patients who want to understand why sublingual cyclobenzaprine works to relieve their fibromyalgia pain and other related symptoms?
I like to set the stage with patients and make sure they clearly understand the link between sleep disruption and pain sensitivity, particularly in the context of central pain and fibromyalgia. One of my rheumatology attendings during fellowship used to explain this using classic sleep research from...
Do you view the difference between oral and sublingual cyclobenzaprine as clinically significant?
Yes. Oral cyclobenzaprine—a TCA analogue structurally identical to amitriptyline aside from a single double bond—has been used off-label for fibromyalgia for many years. Despite long-standing anecdotal benefit, a prospective placebo-controlled RCT showed only transient improvement at 4 weeks, with n...
How do you decide when to treat transient global amnesia with antithrombotic therapy?
Most cases are idiopathic and do not require treatment. However, as we had earlier reported in 1086, TGA secondary to ICH. Similarly, there can be other etiologies precipitating TGA, including ischemic stroke. Antithrombotic therapy will be useful in cases precipitated by an ischemic stroke/ TIA. Th...
Do you recommend surveillance MRI for patients with MOGAD?
I do not recommend regular surveillance MRI for all patients. It really depends on the case as some MOGAD patients are very stable and don't even require treatment, whereas others can be quite aggressive and resistant to all treatments. The field is still emerging and our understanding of silent dis...
Would patients receiving targeted therapies be eligible for TTFields for brain metastases?
Conceptually, I can certainly hypothesize and conjecture the value of combining TTFields for brain metastases with targeted therapies. However, this specific population was excluded from the current trial, and therefore, we have no direct data to report or answer this question with greater specifi...
How early do you implement PCSK9 inhibitor therapy for stroke patients with very high-risk ASCVD?
For me, it depends case by case. If the patient is statin naive or on a suboptimal dose with above goal LDL and TAG, I will start a statin or increase statin dose/intensity, respectively, with lifestyle and diet changes, and evaluate the trajectory of the parameters in 6 months to see if they are he...
What would be your radiotherapy plan for a patient with recurrent GBM (WHO grade 4, IDH wild-type) s/p 2 prior resections with no prior radiation?
The scenario described in this clinical case is not uncommon. I have had patients who either live several hours away from our center or were unwilling to receive the Stupp protocol of 60 Gy in 6 weeks and were successfully treated with 3 weeks of hypofractionated RT (HFRT). HFRT over 1–3 weeks (25 G...
When do you use olanzapine for acute migraine treatment?
Although off-label and not included in guidelines, olanzapine can be helpful for migraine attacks in the ER and even for prevention in chronic migraine that has failed all other treatments. 10 mg is usually given IM and 2.5 or 5 mg IV. The MOA is probably as a dopamine antagonist and it is often use...
Would you consider antithrombotic therapy in a patient with refractory migraines and antiphospholipid syndrome?
Yes.
Are there any biomarkers, imaging, or other clinical information that can be used to better choose effective therapies for super refractory status epilepticus?
SRSE is a syndrome not a diagnosis. The key determination is if this is immune-mediated, infectious, structural, metabolic, genetic, or drug/toxic-induced. For example, if the lumbar puncture shows significant pleocytosis, in the presence of flare changes in the medial temporal lobes, especially in ...