Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
What makes a patient a good candidate for treatments targeting amyloid such as lecanemab or donanemab?
All the amyloid antibody trials were conducted in patients without the burden of cerebrovascular disease we often see in clinic populations. Many individuals with cognitive impairment have both vascular and neurogenerative contributions to their decline. We don’t yet know from real-world experience ...
What is your clinical threshold for treating a potential monoclonal gammopathy of thrombotic significance?
I strongly advise against routine screening for monoclonal gammopathy in patients with thrombosis. The incidence of MGUS, particularly in older patients, is relatively high and so the signal-to-noise ratio in this setting will be very low. In a patient with recurrent thrombosis and thrombocytopenia ...
How do you manage high-risk MDS IB2 patients on HMA and venetoclax who develop an acute stroke requiring antiplatelet therapy?
Not sure of the current platelet count? Not sure of the age of the patient.Will still use antiplatelet therapy for acute stroke as advised.Support with platelet transfusion as needed for platelet count <20. Hopefully patient responds to HMA and venetoclax, and platelet counts improve.If in CR by mar...
Do you perform EMG and repetitive nerve stimulation in patients with ocular myasthenia gravis, particularly those who are AChR-positive, to assess for electrophysiological evidence of generalized disease?
There is already quite some literature about this question. I have included a recent reference that identified the predictors of generalization of ocular MG in 122 patients evaluated over 24 years in Malaysia. To summarize, in multivariate analysis, positive anti-AChR antibodies, positive RNS (OR 4....
How do you approach prescribing oxcarbazepine when the patient is on an oral contraceptive?
I first would want to ask what the reason is for oxcarbazepine and if there is a safer alternative for pregnancy. If it's for epilepsy, then I would go with lamotrigine. However, if the patient is stable on oxcarbazepine, then I would lower the dosage. I would strongly encourage an IUD, which is loc...
How do you counsel patients with epilepsy who are interested in purchasing a seizure dog?
I recommend getting a dog because it can enhance their quality of life, similar to enjoying a glass of wine or relaxing in a Jacuzzi :-). However, I do not consider it as a medical treatment so it should be at their expense.
Does anyone have concern with giving oral antiseizure medications to patients receiving TPN because of suspected malabsorption syndrome?
Any gastrointestinal issue that alters the transition and absorption of anti-seizure medications can affect seizure medication levels in the blood. So anything from bariatric surgery to malabsorption syndrome, from TPN to prolonged constipation. Essentially, these GI issues can alter the pharmacokin...
How long do you hold pyridostigmine prior to EMG / nerve conduction study in patients with suspected myasthenia?
At least 12 hours prior to repetitive stimulation or SFEMG, per AANEM practice parameter. In our lab we recommend 24 hours if possible. Geiger and Katirji, Myasthenia Gravis and Related Disorders pp 131–152
When do you consider pembrolizumab for the treatment of progressive multifocal leukoencephalopathy?
Progressive Multifocal Leukoencephalopathy (PML) treatment remains a big challenge; the different etiologies leading to PML (HIV, malignancy, primary immunocompromise, iatrogenic, etc.) play a role in the heterogeneity of approach and outcomes. It's helpful to think of potential treatments based on ...
Is it ever appropriate to omit temozolomide in unmethylated glioblastoma?
Perhaps a different perspective on this question would be which unmethylated patients would you be willing to not treat with up-front temozolomide? The genesis of the question and conundrum comes from the modest benefit described in the above-mentioned trials for this subgroup. As Hegi herself descr...