Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
How do you manage pregnant individuals with newly diagnosed idiopathic intracranial hypertension?
Pregnancy in IIH is managed the same as if the patient did not have IIH with one caveat. IIH patients should stay within the recommended weight gain their obstetrician targets. Pregnancy is not a cause of IIH, but the excessive weight gain that can occur can trigger or worsen IIH. Labor and delivery...
When might you soften the post-thrombolysis monitoring requirements for patients receiving TPA for acute stroke?
The recent study by Anderson et al., PMID 40412428, suggests that a pattern of reduced monitoring after tPA was noninferior to standard monitoring in patients with initial NIHSS < 10, treated within 2 hours of symptom onset. This is suggestive that the reduced monitoring protocol is safe in patients...
How long do you typically wait before starting anticoagulation after holding Leqembi/Kisunla in patients with cognitive impairment?
Lecanemab's half-life is about 5-7 days. This means wait for about 3 to 4 weeks before starting anticoagulation. The half-life of Donanemab (Kisnula) is about 12 days, which means waiting for anti-coagulation for about 6 to 8 weeks. These are not hard and fast rules; it is done out of an abundance o...
When do you start cyclophosphamide for the treatment of anti-NMDA receptor encephalitis?
First-line immunotherapy for anti-NMDA receptor encephalitis includes high-dose steroids, intravenous immunoglobulin (IVIg), and plasma exchange (PLEX), sequentially or concurrently. Second-line immunotherapy includes a trial of rituximab first and then cyclophosphamide due to the serious side effec...
What is the effectiveness of transmagnetic stimulation for patients with chronic pain, including chronic headaches?
In addition to repetitive TMS (rTMS) discussed helpfully by Dr. @Dr. First Last, single pulse TMS (sTMS) is an FDA-approved treatment for migraine. In contrast with rTMS administered in a clinical setting, sTMS is administered at home with a lightweight device designed for home administration. Effic...
How do you decide when to pursue genetic testing for cerebral palsy?
Unless there is a very obvious cause that has a very low likelihood of a genetic etiology (e.g., neonatal meningitis, embolic stroke from a discovered source, etc.), I almost always perform genetic testing. Even cases of presumed HIE can have an underlying genetic contributor that increased the risk...
Do you recommend getting a muscle biopsy in a patient with suspected IMNM with statin exposure, weakness, elevated CK, and positive HMGCR antibody?
A patient with a typical clinical presentation of IMNM (muscle weakness, high levels of CPK) and positive anti-HMGCR antibodies leaves no question regarding the diagnosis, and muscle biopsy would not change management. I would reserve muscle biopsy for atypical cases (for example, positive anti-HMGC...
What are your preferred treatments for disrupted nighttime sleep in elderly patients with narcolepsy already taking sodium oxybate?
The treatment depends on what is causing the disruption. Before I consider any medication, I recommend a thorough investigation of possible causes of the disruption. For example, has sleep apnea been ruled out? Is the patient taking alerting substances close to bedtime? What is the sleep environment...
How do you manage a patient with giant cell arteritis treated with weekly tocilizumab and low dose glucocorticoid who develops sudden vision loss?
Fortunately, this scenario is a rare event, as most patients treated with ongoing tocilizumab (TCZ) and prednisone are at a far lower risk for developing new visual loss due to giant cell arteritis (GCA). A recent paper by Amsler et al., PMID 33752737 reviewing the risk for visual loss in patients b...
What treatments have you found to be effective for mal de débarquement after trialing benzodiazepines such as clonazepam?
Try to find an underlying history of migraine. Generally, SSRIs and SNRIs (if headache is a feature) can help, but there are no controlled trials for this. Benzodiazepines should be used temporarily as a bridge for the above. If a history of migraine, even remote, is present, sometimes antimigraine ...