Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
Do you routinely check CSF cell counts and cultures on patients with external ventricular drains to monitor for infection?
I think protocols still vary widely by institution, but we only check CSF cell counts and cultures from an EVD if there is a clinical concern for hospital-acquired meningitis/ventriculitis. It is clear that the more times you access the EVD setup for CSF collection, you are increasing the risk for i...
How do you counsel patients on wearable heart monitor devices when they ask about specific products and diagnostic accuracy of these devices available on the market?
It depends on the device. If a patient is experiencing palpitations infrequently, or there is an ongoing need to identify the cause of palpitations, I typically recommend a consumer-facing ambulatory ECG device that is FDA-cleared. They are quite accurate for detecting AFib and ectopic beats such as...
What typical lab tests do you send off for evaluation of neuropathy?
Not too much has changed in over a decade regarding the recommendations on how we should approach initial laboratory testing in patients presenting with a neuropathy syndrome. Specifically for cases of distal symmetric polyneuropathy, the AAN practice parameter (reaffirmed in 2022) by England, et al...
What clinical features prompt genetic testing for patients with progressive cerebellar ataxia?
In general, any patient who presents with a chronic progressive cerebellar ataxia and is </=21 years of age deserves genetic testing. If a subacute presentation arises with no clear metabolic, inflammatory, neoplastic, vascular, etc., etiology, I would also recommend genetic testing in this group.Wi...
When and how do you perform genetic testing for congenital myasthenia gravis in seronegative cases?
I believe that these congenital myasthenic syndromes can start at birth or early childhood, as we are all familiar with muscular weakness, particularly extraocular muscles, and bulbar, which is fatigable, worsening with physical activity, and there > 30 genes responsible, and symptoms vary by the Ge...
How do you convert between tetrabenazine, deutetrabenazine, or valbenazine for management of tardive dyskinesia?
I think of these medications as much more clinically similar than different, with the main differences relating to patients who are fast metabolizers. Fast metabolizers often respond well to lower doses of deutetrabenazine or valbenazine compared to tetrabenazine. When converting from one drug to an...
How do you treat depression symptoms in patients with Parkinson's disease?
The management of PD-related depression can be a little complicated, but there are several proposed algorithms out there based on varying degrees of evidence. Personally, I like this reference (Pontone and Mills, PMID 33648830) as a place to start. It makes 3 key points: Distinguishing between PD an...
Do any subgroups of headache patients benefit more from neuromodulation devices compared to pharmacologic treatment?
I think patients with episodic cluster headache benefit greatly from external vagus nerve stimulation (gammaCore) use. This device aborts cluster attacks and has a preventative action as well for future attacks during a cluster bout. It allows for more than 2 treatments per day if the patient is hav...
How do you utilize Diamox in patients with cerebral venous sinus thrombosis and vision symptoms who do not undergo thrombectomy/recanalization?
Diamox (acetazolamide) is often used to treat papilledema with associated visual loss in cases of CVST. While there is a theoretical risk of dehydration from acetazolamide with potential worsening of the thrombosis, 1) acetazolamide is a weak diuretic and 2) the risk of blinding visual loss usually ...
How do you decide between the different oral longer acting levodopa medications?
The question would be, why are you changing, and what are you changing from? (i.e., are one of these your initial agent, a change due to Sinemet side effects, or a change because of motor fluctuations?) The current theory on dopamine replacement is "smoother is better," so the longer (and lower) you...