Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
How do you treat fatigue symptoms in myasthenia gravis?
Importantly, especially in myasthenia gravis, but also in other neuromuscular disorders, we try to differentiate between peripheral fatigue (i.e., fatigability of the muscles due to reduction in the safety factor at the neuromuscular junction leading to worsening muscular function and fatigability a...
How do you do a levodopa trial in the outpatient setting?
In a patient with Parkinsonism whom I am starting levodopa treatment for, I begin by conducting a detailed motor examination using the MDS-UPDRS III to assess baseline symptoms. Typically, bradykinesia and rigidity respond most consistently and robustly to treatment. While tremor and gait disturbanc...
What other conditions should you consider in someone with presumed Tolosa Hunt but without significant improvement on steroid therapy?
Sufficient workup should ideally be obtained before initiating steroids in order to exclude disorders that may have a similar presentation with quite a different approach to management. These investigations include but are not limited to the following: brain MRI with contrast + thin slices through t...
How do you approach a patient who develops a rest tremor after chemotherapy?
Like many questions in Neurology, this question can be simple or rather complex to answer. If the patient is felt to have a drug-induced tremor, withdrawal of the offending drug or drugs should be the first choice whenever possible. In the chemotherapy setting, a common scenario would be when a dopa...
When do you consider intramuscular indomethacin for the assessment of trigeminal autonomic cephalalgias?
Indomethacin as a preventive treatment should only be considered for paroxysmal hemicrania and hemicrania continua. Both diagnoses are made based on the history. The diagnosis of paroxysmal hemicrania is based on the attack pattern: unilateral headaches lasting 10-30 minutes and occurring multiple t...
How would you determine the safety of anticoagulation in patients with evidence of cerebral microhemorrhages who present with acute stroke secondary to cardioembolism?
This question assumes that the patient already had an MRI showing microhemorrhages. The Boston criteria provide guidelines for the number of microbleeds, associated superficial siderosis, or major hemorrhage to make the diagnosis of cerebral amyloid angiopathy. I would also assume that at least some...
When and how do you deviate from efgartigimod (Vyvgart) dosing from the drug label recommendation of weekly infusions for four weeks in patients with myasthenia gravis?
In the landmark ADAPT study, efgartigimod vs placebo was given in patients with MG initially as weekly infusions x4. The timing of the second and subsequent cycles was determined on a case-by-case basis, based on the patient's clinical response and serial measurement of quantitative MG parameters (M...
Would you consider combining tovorafenib and trametinib as dual therapy?
A phase 1/2 study of tovorafenib and the MEK inhibitor selumetinib is planned through the Developmental Therapeutics Committee of the Children's Oncology Group for low-grade gliomas that have failed appropriate prior MAPK blocking therapy and other patients with BRAF/RAF1, RAS, and NF driven maligna...
How do you track objective clinical response to treatment in CIDP?
The EAN/PNS 2021 guidelines address this point. Symptom improvement is not really objective. There is no recommendation to follow NCS/EMG, and I would discourage it. I perform the MRC exam (sum score comes from this), grip test, INCAT (takes 3 seconds), iRODS, and Timed Up and Go at every visit. The...
How do you decide the length of a routine EEG?
A routine EEG, defined by codes 95819 or 95816, typically lasts 20-40 minutes or up to an hour. Studies lasting 1 to 2 hours (code 95813) lack a clear rationale and are not commonly utilized. "Prolonged" EEGs are the newer (2020) codes that depend on duration and whether or not there is video.The ch...