Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
How do you counsel patients and doctors on antibiotic avoidance in myasthenia gravis?
I generally recommend avoiding aminoglycosides and most macrolides in MG. The rationale is that there are alternative effective antibiotics for most of the infections covered by the above categories. With fluoroquinolones, however, it's not that simple, because there are some infections that are uni...
Do all patients referred for acute symptoms of TIA or minor stroke require additional imaging with CT/MR angiography, in addition to admission/observation?
Regardless of whether symptoms are minor, improve, or resolve, it is important to obtain vessel imaging to evaluate the underlying head and neck vasculature, as this may guide additional treatments (e.g., carotid revascularization, ICAD management, dissection management, carotid-web management, etc....
Will you do Botox or use injectable CGRP monoclonal antibodies in patients on anticoagulation?
I use Botox and injectable CGRP monoclonal antibodies in patients on anticoagulation. I do not check INR prior to using Botox if patients are on AC. I have been practicing headache medicine since 2013 and have never noticed increased bleeding in patients on AC during a Botox procedure. The injection...
How do you counsel patients on the benefits of immunotherapy for anti-MAG neuropathy?
Not a simple issue. True anti-MAG neuropathy is typically indolent, primarily distal sensory. No treatment has been identified for the neuropathy alone, although there have been and continue to be some treatments in development. So the treatment for anti-MAG neuropathy rests on the treatment of the ...
How do you treat extrapyramidal symptoms secondary to anti-psychotic use in patients who have not benefited from cogentin or benadryl?
In general, when addressing motor symptoms from antipsychotics (or any dopamine-blocking agents including dopamine-blocking antiemetics), I find it useful to break things down more specifically than just EPS. This often will determine the agent that will be most beneficial. First Category: Hypokinet...
What medications do you prioritize or avoid in Parkinson’s Disease-related psychosis and behavioral disturbance?
From an evidence-based perspective, clozapine continues to have the most solid support for its efficacy in Parkinson's disease-related psychosis. Pimavanserin has FDA approval (albeit with some mixed data) specifically for this indication. Quetiapine and olanzapine are perhaps the most frequently us...
Do you ever delay starting levodopa in patients with Parkinson's disease?
With LEAP and the 5-year follow-up study, we can feel comfortable deciding to start patients early on levodopa to maximize quality of life via motor symptom control. In this study, there were no differences in UPDRS scores, the prevalence of wearing off, or levodopa equivalent daily dose between the...
Are the laws regarding prescribing C-2 medications different for mail order pharmacies?
This is an important question and very timely considering the increase in mail order pharmacies. As a practitioner, you can prescribe medications to patients within your state through legitimate mail-order pharmacies located in different states because these pharmacies are licensed to operate acros...
Is there a role to continue aspirin in patients with myeloproliferative disorders who have never had a thrombotic event that are starting DOAC for stroke prophylaxis with newly diagnosed atrial fibrillation?
Aside from treating erythromelalgia, transient ischemic attacks (TIA) such as ocular migraine or documented atherosclerotic disease, aspirin has no role in the management of the MPN, despite the widely published recommendations for its use, particularly in so-called "high risk" polycythemia vera (PV...
Would you avoid combining JAK inhibitors with IVIG given the risk of thromboembolism?
The evidence for this is not very clear and limited. I think a honest discussion about the risk of JAKs and IVIG with the patient will be the most important; but as long as there is no clotting history or high risk of DVTs/PEs, and this is documented, and if a patient needs both medications to attai...