Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
What do you consider when deciding to use a high-efficacy DMT as an initial treatment in multiple sclerosis?
I'd say the question is when would you "not" consider a high-efficacy DMT in MS. High-efficacy therapies (specifically, B-cell depleting therapies) have a good risk profile and are exceptionally effective in treating relapsing MS. Evidence would suggest that you get the largest "bang for your buck" ...
Do you typically consider Botox for patients with TMJ?
I do a fair number of Botox injections for TMJ (only small doses (5 to 7.5 units) when using Botox for migraines. Patients do report that it is helpful.
What is your treatment approach to neurological Sjogrens disease with both peripheral neuropathy and transverse myelitis?
For transverse myelitis associated with Sjogren syndrome, many (if not the majority) test positive also for anti-AQP4 antibody. This is different from other autoimmune disorders such as Behcet in which the patients usually are seronegative. Therefore, I usually treat with rituximab for myelitis. As ...
How would you evaluate and manage someone with leukoaraiosis and an acute ischemic stroke?
Many patients with acute ischemic stroke have some degree of leukoaraiosis, and unless it is very severe, it would not alter my decision to give thrombolytic or endovascular thrombectomy treatment. If you have a prior MRI available, it would be nice to see a gradient echo to see if there is cerebral...
When do you consider starting an anticholinergic in patients with tremor-predominant Parkinson's disease?
Generally, you want to avoid anticholinergics if possible, given the cognitive side effects but they are worth considering in those who have very refractory tremor that does not respond to dopaminergic therapy or amantadine.
How do you treat behavioral disturbances in patients with dementia with Lewy bodies?
The best medication for behavioral symptoms and Lewy body disease is a cholinesterase inhibitor. It reduces hallucinations and dream-like delirium. When more is needed, a small dose of quetiapine at night may be helpful. SSRIs reduce anxiety and can reduce aggression.
Should one perform a subsequent screening CTA or MRA head for mycotic aneurysm after cardio-embolic strokes in a setting of endocarditis with initial unremarkable CTA or MRA head/neck?
If the initial CTA is unremarkable and there is no intracranial hemorrhage, I do not routinely obtain follow-up imaging. In my practice, CTA is preferred over MRA due to the lower sensitivity of non-contrast/TOF imaging in detecting small mycotic aneurysms. As mentioned above, CTA may also miss s...
How do you decide on initial and sequential anti-CD20 therapy for patients with multiple sclerosis given the availability of rituximab, ocrelizumab, ublituximab, and ofatumumab?
In my practice, I generally discuss the B cell depleter drug class with patients, as these drugs have similar clinical profiles. I do not have a particular preference for sequencing one anti-CD20 drug over another. Treatment decisions are primarily driven by practical differences for patients, such ...
How do you approach long-term blood pressure parameters in ischemic stroke patients with severe symptomatic intracranial stenosis?
Every patient is unique and I just try to be as low and slow as possible. 4-6 weeks seems to be where most people do well with others tolerating more (I'm able to get them to under 140 or even 120 during their hospitalization over a few days). In the acute setting, I've found it helpful to make sure...
Do you use alcohol to trigger seizures in patients you suspect to have JME to confirm diagnosis?
In the EMU, I use ETOH as a seizure trigger, if the patient tells me drinking alcohol makes them have a seizure or they have one the next day. I do this regardless of their epilepsy syndrome, not specifically for JME.