Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
When do you consider stopping anti-seizure medications in seizure-free pediatric epilepsy patients?
Prior to 1988, we would never dare take a patient off seizure medicine if the patient was seizure-free.Callaghan's paper published in the New England Journal of Medicine (Callaghan et al., PMID 3127710) clearly showed that patients who were seizure-free on Tegretol for 3 years had a 90% chance of be...
When would you consider elective hospitalization for parenteral treatment for new daily persistent headache?
New daily persistent headaches can have a tension-type headache phenotype or a migraine phenotype. If presenting with a severe daily headache and a migraine phenotype I will treat it as status migrainosus since there is no consistent way to differentiate migrainous NDPH from a status migrainosus las...
How frequently do you recommend ordering labs to monitor for side effects of disease-modifying therapies for multiple sclerosis?
Yes, the monitoring depends on which DMT the patient is on. For patients on B-cell-depleting therapies, I screen for Hep B and latent TB prior to therapy and check a CBC and CMP every 6 months, with yearly immunoglobulin monitoring. For JCV Ab-negative patients on Tysabri, I check a CBC, CMP, and JC...
How do you distinguish between primary progressive MS versus relapsing remitting MS with superimposed relapses in a newly diagnosed patient that is naive to treatment?
Relapsing versus progressive MS are clinical phenotypes lacking clear objective radiologic or paraclinical distinctions. Recent literature emphasizes commonalities between these phenotypes, largely framing them as a spectrum of one disease rather than discrete disorders. Originally, these clinical p...
What is your approach to management and surveillance in low grade traumatic blunt ICA injury?
For blunt cerebrovascular injury (BCVI), I use the Biffl scale to evaluate the extent of vessel trauma. The extracranial neck vessels, such as the cervical ICA or VA, are most commonly affected. The Biffl classification consists of five categories, with Grade 1 representing a low-grade injury. This ...
How often do you consider lamotrigine in patients with myoclonic epilepsy?
When considering juvenile myoclonic epilepsy, I frequently prescribe lamotrigine, especially if a person of childbearing potential. However, I counsel on the possibility that it may exacerbate or not completely control the myoclonic seizures. When considering progressive myoclonic epilepsies (PMEs),...
How do you approach the psychiatric symptom management of Huntington’s Disease?
The neuropsychiatric features of Huntington's disease are not as consistent as the motor or cognitive features. Still, they can cause substantial disability, be prominent early in the disease, and even occur as initial features. The majority of Huntington’s disease (HD) mutation carriers experience ...
What is your approach to DVT prophylaxis in patients who require IVIG but are at increased risk for thrombotic events?
I am unaware of any published data to guide the decision-making for this topic. Empirically, I recommend low-dose aspirin in patients >50 who have to get long-term IVIG especially if there are a lot of underlying risk factors for thrombosis like diabetes, immobility, etc. Again, this is not an evide...
What leads you to consider a non-oral form of levodopa for the treatment of Parkinson’s disease?
I agree with Dr. @Dr. First Last's excellent review. Consider non-oral forms of medication when there are concerns about dysphagia. Additionally, if the dosing frequency becomes too high (e.g., five times a day of levodopa), and the patient finds it difficult to maintain this schedule, consider long...
How do you approach driving clearance when someone has an RNS that is showing seizure activity, but neither the patient nor the patient's family is reporting seizures?
The answer may vary depending on the state, but from what I know, most states operate similarly. The determining factor isn't whether or not you're experiencing a seizure but whether you are having driving-impairing events. Therefore, the specific findings detected by the RNS (such as repetitive spi...