Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
What are the differential and workup for a patient with findings suggestive of idiopathic intracranial hypertension without papilledema on examination?
I agree with Dr. @Dr. First Last, and find it less difficult to "justify" a lumbar puncture than Dr. @Dr. First Last, although admittedly very sympathetic to his approach. I would perform an LP. Lumbar puncture is a very low-risk procedure and in this setting, it isn't all about visual loss, althoug...
Do you use dual anti-platelet therapy inpatients with low NIHSS who have had bilateral brainstem strokes?
I usually look at the stroke mechanism in making my decisions about DAPT rather than just relying on the NIHSS alone. If the mechanism is ICAD, branch atherosclerotic disease, SVD (with infarct extension), embolism from the aortic arch plaque, subclavian artery heterogenous plaque, extra-cranial ver...
How do you approach workup for patients with suspected muscular dystrophy?
Muscular dystrophy (MD) is a group of > 30 genetic diseases that cause progressive weakness and degeneration of skeletal muscles with a progressive course affecting voluntary movement. Hallmarked by variables in the age of onset, severity, and pattern of affected muscles. Certain types also affect t...
In the interest of brain health, are you avoiding TCAs in migraine treatment due to increased dementia risk?
One more reason to abandon the old-fashioned non-specific preventive migraine medications: anticonvulsants, tricyclics, and calcium antagonists. The only class of old-fashioned medications that I still use, be it rarely, is that of the beta-blockers, with the exception of propranolol. There is good ...
Do you recommend or have any clinical experience with "migraine surgery"?
I do not as well. My understanding is that most of the plastic surgeons who perform this procedure have been trained by Dr. Bahman Guyuron, who developed the procedure. I think the published studies by Dr. Guyuron, showing some efficacy of this procedure, have a flawed methodology, and I do not thin...
What is your approach to a child with toe walking with a reassuring exam but a family history of difficulty walking?
For all children with toe walking, it is critical to perform a full neurological examination to look for CNS (i.e., CP/HIE or HSP) or neuromuscular (i.e., CMT, myopathy) issues. We also do NCV and EMG (the latter if indicated) even if the examination is normal and have found early CMT in a few of th...
Based on the FIREFLY-1 data, would you consider using tovorafenib monotherapy front-line in pediatric patients who have low grade gliomas that are only amenable to subtotal resection or are unresectable?
Not yet. I think it is important to wait for the results of FIREFLY-2 and also ACNS1831/ACNS1833. We have to keep in mind that the combination of trametinib and dabrafenib is already FDA-approved as frontline treatment for paediatric patients with BRAF V600 mutated LGG. This approval was based on th...
How would you prioritize physiotherapy and cognitive behavioral therapy for functional movement disorders in a resource-limited setting where access to both might be constrained?
I have a dedicated clinic for people with functional movement disorder/functional neurologic disorder (FMD/FND) in New York City and even in a city like New York, it is difficult or actually impossible to refer patients for appropriate therapy.For some people with rather straightforward cases, a ref...
What is the appropriate workup and treatment for patients with SMART syndrome following radiation for brain tumors?
Stroke-like migraine attacks after radiation therapy (SMART) is a late presentation after treatment for a CNS malignancy (or brain radiation for another cause; e.g., prophylactic cranial radiation). It is one of many late effects of radiation therapy. Others may include vasculopathy, cognitive dysfu...
How do you explain the clinical benefit of lecanemab or donanemab to patients?
I do feel that the study outcomes are clinically meaningful, especially for patients with mild cognitive impairment due to AD. A clinically meaningful outcome is the ability to stay at an early symptomatic stage for a longer time than the natural history of the disease would otherwise allow. It appe...