Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
In patients with indomethacin-responsive hemicrania continua, what are the optimal strategies for long-term dosing of indomethacin to maintain symptom control and minimize adverse effects?
I do consider the long-term use of indomethacin for whatever indication an issue because of potential gastrotoxicity and nephrotoxicity. The potential gastrotoxicity I addressed by combining the indomethacin with a proton-pump inhibitor (PPI) and checking the blood every 1/2 year for a decrease in h...
What are the factors that you would consider for the use of ESA in patients with anemia of CKD with a history of stroke or TIA?
Large clinical trials of ESA have indicated increased stroke risk with these medications with TREAT reporting the highest stroke incidence. In this study, "baseline history of cerebrovascular disease was a strong predictor of experiencing a stroke during follow-up; patients with a history of stroke ...
When do you stop dantrolene in a patient with neuroleptic malignant syndrome?
Dantrolene is typically used to treat severe NMS, although the data supporting its use is mixed. The biggest risk with the therapy is hepatotoxicity. It is reasonable to discontinue dantrolene once the hyperthermia and severe muscle rigidity have resolved, or earlier if there is concern for liver in...
When do you evaluate patients with Parkinson's disease and cognitive decline for concurrent Alzheimer's disease?
Parkinson’s disease (PD) often includes Alzheimer’s disease (AD) “co-pathology” in up to 80% of cases. This challenges the notion that PD is a synucleinopathy; it affects many proteins beyond α-synuclein. Thus, cognitive decline in PD may be associated with AD pathology, and one of the strongest pre...
What is your diagnostic approach to patients referred for central sleep apnea on PSG but normal overnight EEG and MRI?
In lab titration study, starting with CPAP (first-line treatment, can work in many cases). If remains, BiPAP-S titration is next (usually same night) with minimum EPAP titrated to prevent apneas and IPAP to prevent hypopneas but care as to avoid too much pressure support and over ventilation. Failur...
What baseline visual testing, if any, do you recommend at diagnosis for patients with multiple sclerosis who deny visual complaints?
I do a baseline eye exam with visual acuity, OCT RNFL, and fundus photos yearly. If I see any abnormalities, then I might consider a repeat exam in six months. If all is normal and there's no history of optic neuritis, I do yearly appointments. If they are on DMTs that have eye side effects, then I ...
What is the first line therapy for demyelinating neuropathy with positive NF-155 antibodies?
Neurofascin-155 IgG antibody-associated neuropathy is a subtype of neuropathy with electrophysiologic features suggestive of demyelination, but distinctly different pathogenesis from classic CIDP, and also distinctly different response to treatments. Unlike CIDP where the target of the immune attack...
Do you consider DBS for Essential Tremor in patients who already underwent Focused Ultrasound Thalamotomy?
In patients with medication-refractory essential tremor, ablative thalamotomy (with focused ultrasound stereotactic surgery, or gamma knife) and deep brain stimulation (DBS) are effective methods for the management of tremor. Ablative thalamotomy with focused ultrasound uses acoustic energy for remo...
How would you approach antithrombotic therapy in patients with acute ischemic infarcts and a non-occlusive intracranial thrombus?
I agree with the previous answer and can expand on a few key management nuances involving stroke size, symptom severity, and etiology. For stroke size, I typically initiate anticoagulation (heparin drip) if less than one-third of the affected territory is involved, extrapolating from tPA guidelines....
How clinically meaningful are the differences in the primary outcome between treatment and placebo groups in the CENTAUR trial?
Defining the term "clinically meaningful" proves challenging. Patients involved in the three positive and approved drug trials are unable to detect a slowdown in the progression rate. Attempts were made to gauge ALS providers' opinions regarding a meaningful change in the ALSFRS-R scale, suggesting ...