Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
Which PD patients will you be implementing tavapadon?
I am excited to try this new selective D1/D5 dopamine agonist to address mild-to-moderate motor symptoms of Parkinson's disease and wearing off/motor fluctuations. Being a selective agonist at D1/D5 receptors, tavapadon has the potential for fewer side effects, such as drowsiness, nausea, and impuls...
For a patient with acute stroke who cannot tolerate statins, what is your preferred second-line agent for secondary prevention?
First question - is the patient experiencing the nocebo effect? I would explore statin-based symptoms. Ezetimibe - if only needs a small reduction. If you need to be more aggressive, I would use PCSK9 inhibitors. If the patient cannot tolerate a PCSK9 inhibitor or if you need more lowering, you can ...
What factors predispose patients who undergo thrombectomy to repeatedly embolize to the same artery despite successful recanalization, other than ICAD?
Intracranial atherosclerotic disease is a well-recognized cause of recurrent ischemic stroke through repeated in situ thrombosis and distal artery-to-artery embolization, predisposing patients to recurrent infarction within the same vascular territory. Likewise, high-risk extracranial atheroscleroti...
When do you use greater occipital nerve block to treat acute refractory migraine?
I frequently offer ONBs for patients with acute migraine when they have persistent headache, despite migraine cocktail & other initial ER interventions. Since occipital nerve blocks are safe, effective, and have Level A recommendations from the American Headache Society, I perform them quite frequen...
What is the best approach to treatment for cenestopathies (sensation of electric current in patient's brain) accompanied by anxiety and inability to sleep?
Thank you for your question. Cenestopathies (referring to the feeling of being ill and this feeling not localized to one region of the body) may not be the correct term for this interesting phenomenon, commonly called "brain zaps". Brain zaps are a poorly understood symptom of antidepressant withdra...
How does progression independent of relapse activity (PIRA) influence your decision to change treatment in relapsing remitting multiple sclerosis?
In a patient who is progressing in the absence of relapse activity, I typically do not change DMT and instead focus on managing the symptoms directly. Such as physical therapy or walking aids, physical worsening, cognitive rehab, OT for fatigue issues, or counseling if mood issues are contributing t...
What criteria do you use to decide the duration of IV steroids in patients with optic neuritis?
This question has long gone unanswered because it is complicated. Short optic nerve segment enhancement (MS):In this situation, I do not routinely recommend steroid treatment. For the optic neuritis of multiple sclerosis, the Optic Neuritis Treatment Trial (Beck and Gal, PMID 18625951) clearly showe...
How do you counsel patients with isolated REM behavioral sleep disorder secondary to antidepressant on the risk of developing a neurodegenerative disease?
If I believe the RBD is truly secondary to antidepressant use, then the risk of developing an alpha synucleinopathy should be very low. However, this may not be able to be clearly discerned. In which case, I believe the patient has the right to know and should know about the risk of developing an al...
Which chronic trigeminal pain patients have you found responded best to peripheral nerve stimulation implants?
Trigeminal neuropathic pain (TNP), i.e., traumatic or unintentional surgical injury to the trigeminal system, is the main indication for neurostimulation. This should be a peripheral procedure targeted at the relevant nerve distribution, e.g., supraorbital or infraorbital. Use a multicontact electro...
What are your go-to options for managing ICU delirium in patients with contraindications to antipsychotics?
Evidence for Ramelteon (Yu et al., PMID 36726202)Delirium with behavioral disturbances Depakote Clonidine Propranolol, especially with TBI Non pharmacological Make sure they're closer to the nursing station. Constant re-orientation. Shades open during the day and close at night. Bring anything they ...