Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
Would you add immunosuppression in ocular myasthenia gravis patients who are symptomatically well-controlled on pyridostigmine?
This requires a shared decision-making approach with the patient because there is no right or wrong answer/choice. Although it has never been demonstrated in a placebo-controlled blinded study, I do believe (for years now) that low-dose prednisone can reduce the risk of generalization of ocular MG.A...
What treatments options may be considered in patients with POTS who also need daily diuretics to treat heart failure and are already wearing compression garments?
Given the epidemiology of POTS and congestive heart failure, you are far more likely to see a patient with neurogenic orthostatic hypotension and CHF than POTS and CHF. I have an article on NOH and CHF in Autonomic Neuroscience 2020. The principals are basically the same however because the managem...
What are preferred sleep aids in elderly patients with dementia?
Melatonin 3-6 mg because of their loss of melatonin-secreting potency with age. Doxepin 10 mg because of the cost of 3 and 6 mg versions. If restless legs or limb movements during sleep, gabapentin or pregabalin. Pregabalin can be better tolerated with less next-day sedation (also can be an issue wi...
Is there a utility in getting repeat antibody testing on GBS patients after PLEX?
No, there is not, for a couple of reasons: Most patients with the most common variant of GBS (AIDP) are negative for ganglioside antibodies or other antibodies against nodal/paranodal proteins. Ganglioside antibodies are more often positive in GBS variants like AMAN, AMSAN, Miller Fisher syndrome, s...
How would you approach the decision to escalate DMT in a patient with relapsing multiple sclerosis who has two to three new T2 lesion but no clinical symptoms?
I would escalate to higher-efficacy DMT in this scenario. As highlighted in the linked article, new T2 lesions show that the patient is at heightened risk for clinical relapses and their disease activity is not well controlled. In the linked study, included patients were on low efficacy DMT (interfe...
How long after a motor vehicle accident would you expect symptoms including memory loss, hypersomnia, and mood changes to be attributable to the accident?
I would love to have the answer to this. I can tell you what the Headache Classification Committee of the International Headache Society says:Post-traumatic headache (PTHA) is defined as a secondary headache that develops within 7 days after head trauma (or after regaining consciousness following he...
How do you adjust the loading and maintenance doses for Keppra when treating status epilepticus in patients with ESRD, patients on HD, or patients on CVVH?
Ideally, if you have a patient with status epilepticus and known ESRD, then Keppra may not be an ideal first option. You should be reaching for your other status anti-seizure meds that aren’t exclusively renally excreted and are readily available in most hospitals; Depakote (40 mg/kg loading dose) o...
How do you counsel patients who experience diarrhea from mycophenolate mofetil (Cellcept)?
I have them stop the drug, and when their bowels are back to normal (usually just a couple of days), I resume with 1 tablet bid of mycophenolate mofetil (MMF, CellCept), then a few days later go up to 1 tab tid, a few days later 2 tabs bid... etc. I instruct them to go down to the most recent dose ...
Does receiving IVIG confound the result of SPEP and/or UPEP?
IVIG being a product of polyclonal immunoglobulins may ‘produce’ a monoclonal spike if the AUC is falsely calculated by the reader. IFE usually shows polyclonal banding but every now and then a monoclonal band is picked up. Being an IgG molecule with a 21 day halflife; and with the assumption that i...
Is there benefit of early initiation of antiplatelet therapy or DVT prophylaxis in patients who present with large MCA infarcts and are being considered for hemicraniectomy?
Both aspirin and DVT prophylaxis can be started early in patients on hemicraniectomy watch. There is data on increased risk of stroke recurrence in the first 7 days post-stroke and benefits or early initiation of aspirin (even in afib) and decreasing vascular events, especially in the first few week...