Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
Would you recommend muscle or nerve biopsy in a patient with amyoplasia congenita?
No, I would not for at least 2 reasons. The probability of getting a quality sample is very low, and it is most likely that no muscle would be obtained as the name of the disorder implies (amyoplasia). Furthermore, the likelihood of finding a genetic cause for this is VERY low. In fact, in using WES...
How will your approach to screening and diagnosis of early dementia change given newly available therapies for early Alzheimer's disease?
As it stands, it is not recommended to screen asymptomatic patients for the proteins seen in Alzheimer’s disease outside of clinical trials (i.e., AHEAD 3-45). However, with the emergence of new treatment options in the clinic, I foresee an influx of patients with cognitive symptoms who need a preci...
How do you approach a patient with both a resting and action tremor, suggestive of PD and essential tremor together?
This is a wonderful question. To answer this question, we first have to look at the underlying etiology that leads to action tremor in PD. The hallmark of Parkinson's Disease (PD) is rest tremor, and about 75% of patients with PD have rest tremor at some point in their disease course (typically more...
Where in your treatment approach to fibromyalgia will you recommend sublingual cyclobenzaprine?
The choice of medication for any given patient is based on a lot of factors and, realistically, is often highly dependent on affordability and insurance coverage across different pharmacy plans. Despite other FDA-approved options, oral cyclobenzaprine is usually the medication I reach for first with...
How does the presence of 1-3 microbleeds on MRI influence your choice of anti-amyloid therapies for patients with MCI or mild AD?
1-3 microbleeds is a small number, and the question does not specify that to be suspicious for amyloid angiopathy, the microbleeds should be cortical/subcortical, not deep (as seen in hypertensive individuals). This number, assuming that there are no signs of a larger hemorrhage nor superficial side...
Would you start cholinesterase inhibitors for a patient with MCI or mild dementia based on MoCA testing, when there is concern for frontotemporal dementia?
No, there is no benefit of cholinesterase inhibitors and even a risk of harm from them in FTD.
At what degree of lymphopenia do you switch/discontinue dimethyl fumarate in patients with multiple sclerosis?
I do not check the JC index status for my patients on fumarates. While I do not have recent data, to my knowledge, there are only a handful of PML cases attributed to fumarates used in MS. Even when including fumarates used in treating psoriasis, the PML numbers are small. Since the prognostic value...
What clinical or imaging features help distinguish intracranial atherosclerotic disease from intracranial dissection in the setting of an LVO?
This is a great question and very difficult to answer. I think the first thing I look for is whether there is significant atherosclerosis elsewhere. Lack of significant atherosclerosis elsewhere with a single significantly stenotic intracranial lesion in a young person or someone without significant...
What is your preferred workup for patients who present with concern for autonomic neuropathy?
When patients report one or more symptoms suggestive of autonomic dysfunction, objective confirmation of impaired autonomic function is required. This may include the standard battery of autonomic tests included in the CASS score (tilt table testing, response of HR and BP to Valsalva maneuver, and ...
In advanced Parkinson’s disease, how should clinicians assess symptom management and quality of life when patients are no longer able to communicate themselves?
This is challenging and why palliative care professionals are not familiar with neurodegenerative conditions, questions their efficacy in helping our patients. Using validated tools can help such as the ESAS-rPD. This scale can be used to assess response to interventions. Family members may be able ...