Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
Is there a role to continue aspirin in patients with myeloproliferative disorders who have never had a thrombotic event that are starting DOAC for stroke prophylaxis with newly diagnosed atrial fibrillation?
Aside from treating erythromelalgia, transient ischemic attacks (TIA) such as ocular migraine or documented atherosclerotic disease, aspirin has no role in the management of the MPN, despite the widely published recommendations for its use, particularly in so-called "high risk" polycythemia vera (PV...
Would you avoid combining JAK inhibitors with IVIG given the risk of thromboembolism?
The evidence for this is not very clear and limited. I think a honest discussion about the risk of JAKs and IVIG with the patient will be the most important; but as long as there is no clotting history or high risk of DVTs/PEs, and this is documented, and if a patient needs both medications to attai...
How do you counsel patients to reduce post-procedure side effects with onabotulinumtoxinA (Botox) for chronic migraine?
I caution them to not rub/itch the injection sites especially around the corrugators and frontalis sites for the rest of the day. Some people will recommend for 24 hours, but honestly while sleeping they could roll onto their face or rub their face anyway. I also do not recommend they do significant...
Do you always biopsy patients who present with classic skin findings of dermatomyositis?
I actually very rarely perform a skin biopsy to confirm dermatomyositis, much like I rarely biopsy classic psoriasis or classic eczema. Because I see dermatomyositis frequently enough in my practice, most times, I can confidently diagnose it by physical examination alone. I reserve performing skin b...
How do you manage the developmental and behavioral regression seen in Down Syndrome Disintegrative Disorder (DSDD)?
Thank you for this important question. One of the keys is to ensure that the change and regression being seen is DSDD or something else. Sometimes, this is confused with Alzheimer's seen in older individuals with Down syndrome. DSDD is seen in much younger people, late teens, and 20's as a more rapi...
When would you consider intra-arterial thrombolysis for acute ischemic stroke?
The prior answer brings up several valid scenarios where IA thrombolysis may be applicable. I can offer some nuanced perspective based on current practice. Device technology has advanced significantly since the landmark EVT trials of 2015. Today, EVT is increasingly feasible in distal-segment occlus...
How do you utilize FDG PET in the evaluation of dementias?
FDG PET is a regional map of glucose utilization in the brain. It tends to show reduced activity in specific areas in early Alzheimer's disease. It can complement MRI, which shows patterns of atrophy, rules out strokes, etc. Neither test is biologically specific for AD, which would require an amyloi...
Would you avoid triptans in patients with CADASIL?
Most patients with CADASIL have migraines with aura (including hemiplegic migraine and the severe form known as CADASIL encephalopathy). There is no evidence contradicting the use of triptans in CADASIL specifically. However, smaller studies and systematic reviews, and meta-analyses have shown that ...
When do you consider long-term anti-seizure medication for patients who have an acute symptomatic seizure in the setting of a cerebrovascular event?
The question is really which patients who suffer acute symptomatic seizures are at the highest risk of epilepsy and therefore may require long-term antiseizure medication.This recent paper from Neurology Clinical Practice by Sivaraju et al., PMID 39185097 can help shed some light on stratifying thes...
How do you manage cramps in patients with ALS?
Cramps are an extremely common symptom in patients with ALS; one survey study out of Wake Forest noted 95% of their ALS patients had cramps at some point in their history (1), and my clinical population is in the similar range. Despite this, many treatments for cramps do not have a robust evidence b...