Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
What do you recommend to patients when they are having an acute flare of fibromyalgia symptoms?
Great, this is a really important area and unmet need in the field of fibromyalgia management. Unlike other nociplastic disease states (e.g., migraine), there are no rigorously studied abortive therapies to rapidly treat a flare of centralized pain. Indeed, all the therapies we use for FM are intend...
Which imaging features do you use when considering Normal Pressure Hydrocephalus to decide whether to proceed with large-volume LP or lumbar drain trial?
At our center, we follow the approach of the NPH clinic at the Imperial College Hospital in London.See this excellent review article for further details: Carswell, PMID 36162853.
What do you recommend as a first-line antidepressant in patients with major depressive disorder and migraines?
In my clinical practice, I have found SNRI medication, particularly extended-release venlafaxine (dosed from 37.5 mg to 225 mg), to be helpful for patients with both comorbidities. Other medication classes I have seen used to good effect include TCAs (amitriptyline, nortriptyline) and some SSRIs (se...
What is your approach to Tardive Dyskinesia when VMAT2 inhibitors are ineffective or unaffordable?
In established cases of tardive dyskinesia, in which withdrawal-emergent dyskinesia has been ruled out, and dyskinesia has persisted despite a sufficient washout interval after removal of the offending agent, VAM2 inhibitors such as valbenazine and deutetrabenazine are used for pharmacotherapy. If t...
How do you treat idiopathic hypersomnia inadequately responding to modafinil?
I agree with @Dr. First Last. I usually start my patients on modafinil or armodafinil. If those do not work, I will try solriamfetol. I will supplement with as needed amphetamines as well. I do not often go straight to sodium oxybate/low-sodium oxybate, as you need the right patient for this medicat...
How do you differentiate between HIV associated neurocognitive disease (HAND) and other causes of neurocognitive impairment?
This is a great question. In the era of test and treat, where many people with HIV have never had significant immunocompromise, cognitive impairment due to HIV itself is now relatively rare. On the other hand, people with HIV experience conditions of aging about 10 years earlier than people without ...
When would you consider testing for LGI1 antibodies in patients with unexplained neuropathic pain?
I would strongly consider testing CASPR2 and LGI1 antibodies in any patient with unexplained, subacute or chronic "neuropathic-sounding" pain (e.g. described as hot/burning, stabbing, "pins-needles", etc) especially if: exacerbated by heat, experienced diffusely in a "non-length dependent" pattern (...
How do you counsel patients and caregivers about the trajectory of cognitive decline in Parkinson’s disease?
I address the subject of cognitive impairment fairly early in PD, since patients may notice mild deficits in multitasking and attention even within the first few years of diagnosis. Strategies such as making lists and breaking down individual tasks are effective in preserving independence. Worsening...
What strategies do you find helpful in advanced care planning with patients/families who are very "miracle" centered?
Hope for the miracle yourself! Broaden: “Are there any other things you are hoping for?” Hope for the best, prepare for the worst: “I see how much you want a miracle. I wonder if we can talk about what we should do if this doesn’t happen.” Consider involving a religious leader if relevant.
How do you manage problematic disinhibited behaviors in patients with neurocognitive disorders?
This requires a problem-centered approach. I suggest the following thought process. Analyse the root cause: Is it disinhibition? Unmet needs? Under/Overstimulating environment? Medication side effect? For disinhibition (frontal lobe dysfunction): I have had success with gabapentin and low-dose Depa...