Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
Would you use a triptan in a patient with a vascular malformation, such as an arteriovenous malformation, cavernous malformation, or developmental venous anomaly?
I see no reason not to use a triptan under the circumstances mentioned. I consider the gepants indicated when there are contraindications to the triptans, which are: poorly or uncontrolled hypertension and (atherosclerotic) vascular disease affecting the heart, brain, bowel, or legs. The above-menti...
How do you manage orthostatic hypotension in patients with Parkinsonian syndromes?
Don’t forget to check for adjunctive medications including urinary alpha antagonists which can cause orthostatic hypotension. If possible, reduce doses of cardiac medications. If this is not possible, then consider small frequent meals, exercise, especially the lower extremity elevating the head of ...
What is your approach when recommending occipital nerve stimulation for refractory cluster headache?
That particular study by Gutierrez et al., PMID 40391557, did not address the efficacy/safety of ONS in chronic/refractory cluster headache disorder, but it was in occipital neuralgia/cervicogenic headache populations.In a randomized controlled trial by Wilbrink et al., PMID 34146510,131 study parti...
Do you recommend immunomodulating treatments such as steroids or IVIG for West Nile Virus neuroinvasive disease?
In review of the literature and CDC recommendations, the outcomes when using IVIG in this setting are variable. It has been utilized in immunocompromised patients such as solid organ transplant recipients. I have not found enough evidence to support using it in a non-immunocompromised patient. The s...
When do you switch to a different DMT in multiple sclerosis patients planning for pregnancy?
There are several key differences between the reported French study and the often-used practice in the US. In the French registry, nearly 50% of patients with the diagnosis of relapsing MS (diagnosed by either Poser or early McDonald criteria) were not on DMT. While it was common in the early 1990s ...
What factors would prompt you to refer a patient for a surgical epilepsy evaluation who has not yet failed two anti-seizure medications?
This is a good question, and of course, the discussion with the patient regarding their diagnosis and treatment plan is important. There are also expert consensus guidelines that help to clarify this (Jehi et al., PMID 35842919) and that most of us would ascribe to in these cases. Specifically, when...
How do you approach the use of newer anti-seizure medications for epilepsy patients on DOACs?
Levetiracetam and valproic acid: A nested case-control study published in 2021 (Gronich et al., PMID 34287842) in patients with afib identified an increased risk of stroke/systemic embolism with levetiracetam and valproic acid. This was followed by a few retrospective studies published in 2022 and ...
What lifestyle choices are helpful in reducing the risk of or slowing cognitive decline?
Regular daily physical exercise. A healthy diet: for example, the MIND diet: low in fat and sugar, high in vegetables and fruits, and regular hydration. Be mentally active. Participate in social activities. Get adequate sleep (7-8 hours nightly). Manage stress. Limit alcohol and avoid smoking Perio...
When do you use rozanolixizumab for Musk MG?
I tend to use rozanolixizumab in a few different situations for MuSK myasthenia. The obvious one is when patients have a significant bulbar weakness that needs to be controlled ASAP. Aside from that, I may try rozanolixizumab in patients who do not respond well to prednisone, primarily to get them b...
How do you counsel patients with Parkinson's disease who are interested in starting GLP-1 agonists for neuroprotective benefits?
This is an important question, thank you. The Parkinson's disease community has been desperate to find an intervention other than exercise that can slow the progression of the disease and provide neuroprotective benefits. We might be heading in the right direction with glucagon-like peptide-1 (GLP-1...