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...
Do you typically screen every patient with headaches after the age of 60 with ESR?
I would not. Many patients will have elevated ESR because of other conditions (for example, chronic kidney disease). The history is going to be key in determining which cases to send for lab testing.
Is there a difference in treatment of status epilepticus from alcohol withdrawal vs other causes?
Alcohol status is best managed by using short half-life like Ativan (lorazepam) and valium (diazepam) with long half-life benzos like Librium (chlordiazepoxide) unlike other status which responds to Phosphynition/levetiracetam and lorazepam.
Do you routinely recommend a sleep study in patients with clinical history of REM-sleep behavior disorder?
I do routinely recommend and perform in lab sleep testing for patients with suspected REM behavior disorder (RBD). The finding of REM sleep without atonia (RSWA) is supportive of a diagnosis of RBD, as atonia is normally presented in individuals (without RBD) during REM sleep. RBD can be a tricky di...
How would you manage a patient with LGI-1 encephalitis with faciobracial dystonic seizures who has not improved with 3 days of intravenous steroids?
I typically treat with five days of IV steroids. In patients with autoimmune encephalitis, including LGI-1, who do not improve after five days of IV steroids, I would then move to IVIG or plasmapheresis (depending on patient comorbidities, availability of plasmapheresis, and severity of symptoms). I...
How do you mitigate the risk of rebound disease activity when discontinuing S1p inhibitors or Tysabri in patients with multiple sclerosis?
While there is no ideal method as determined by well-designed randomized studies, two options would be: (a) steroid bridge between therapies and (b) minimize wash-out period between switches. For many DMTs, a wash-out period between drugs is not needed. If the question regarding the S1p inhibitor wa...
How do you implement antipsychotics in the management of agitation in Alzheimer’s patients?
The answer to how you implement antipsychotic medication in the management of agitation in a patient with Alzheimer's dementia involves several steps, outlined here: Ensure the agitation is not related to an acute medical condition and/or delirium. In this case, it is important to treat the underlyi...
What nutritional supplements do you recommend for patients with ALS?
I do not recommend specific supplements. If the question relates to the PEG formula, we use basic formulas and higher caloric versions if needed.
How do you manage seemingly treatment-resistant chronic migraine?
First, let's define refractory migraine. The most recent and strict diagnosis that I use was a proposal by the European Headache Federation (EHF):Refractory Migraine Established diagnosis of 1.1 Migraine without aura and/or 1.2 Migraine with aura or 1.3 Chronic migraine according to ICHD-III criter...
In what clinical situations do you switch to Vyalev in patients with Parkinson's disease?
Vyalev (foscarbidopa/foslevodopa) administered by subcutaneous infusion with an external battery-operated pump, was recently FDA-approved. Conceptually, it offers the prospect of continuous levodopa administration which should improve dyskinesia and motor fluctuations. Skin reactions can be problema...