Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
How would you manage adjuvant endocrine therapy for a postmenopausal patient with early stage HR+ breast CA who develops an ischemic CVA on an AI?
This is a vexing problem that I myself have had to deal with. My patient developed a TIA on aromatase inhibitor (AI). Work up was negative for predisposing risk factors. The choice was easy in this case. This woman was told by her family friend, who was a doctor, that AIs cause stroke and she refuse...
When can you get a false negative result from RT-QuIC testing?
The current sensitivity of CSF RT-QuIC is thought to be 92%, and the specificity is 100%. The interpretation of the RT-QuIC is affected by the presence of raised CSF red and white cells and elevated total protein concentrations. In VPSPr (Variably Protease-Sensitive Prionopathy), CSF RT-QuIC is posi...
Do you typically screen every patient with headaches after the age of 60 with ESR?
I would not. Many patients will have elevated ESR because of other conditions (for example, chronic kidney disease). The history is going to be key in determining which cases to send for lab testing.
Is there a difference in treatment of status epilepticus from alcohol withdrawal vs other causes?
Alcohol status is best managed by using short half-life like Ativan (lorazepam) and valium (diazepam) with long half-life benzos like Librium (chlordiazepoxide) unlike other status which responds to Phosphynition/levetiracetam and lorazepam.
Do you routinely recommend a sleep study in patients with clinical history of REM-sleep behavior disorder?
I do routinely recommend and perform in lab sleep testing for patients with suspected REM behavior disorder (RBD). The finding of REM sleep without atonia (RSWA) is supportive of a diagnosis of RBD, as atonia is normally presented in individuals (without RBD) during REM sleep. RBD can be a tricky di...
How would you manage a patient with LGI-1 encephalitis with faciobracial dystonic seizures who has not improved with 3 days of intravenous steroids?
I typically treat with five days of IV steroids. In patients with autoimmune encephalitis, including LGI-1, who do not improve after five days of IV steroids, I would then move to IVIG or plasmapheresis (depending on patient comorbidities, availability of plasmapheresis, and severity of symptoms). I...
How do you mitigate the risk of rebound disease activity when discontinuing S1p inhibitors or Tysabri in patients with multiple sclerosis?
While there is no ideal method as determined by well-designed randomized studies, two options would be: (a) steroid bridge between therapies and (b) minimize wash-out period between switches. For many DMTs, a wash-out period between drugs is not needed. If the question regarding the S1p inhibitor wa...
What nutritional supplements do you recommend for patients with ALS?
I do not recommend specific supplements. If the question relates to the PEG formula, we use basic formulas and higher caloric versions if needed.
In what clinical situations do you switch to Vyalev in patients with Parkinson's disease?
Vyalev (foscarbidopa/foslevodopa) administered by subcutaneous infusion with an external battery-operated pump, was recently FDA-approved. Conceptually, it offers the prospect of continuous levodopa administration which should improve dyskinesia and motor fluctuations. Skin reactions can be problema...
Would you add immunosuppression in ocular myasthenia gravis patients who are symptomatically well-controlled on pyridostigmine?
This requires a shared decision-making approach with the patient because there is no right or wrong answer/choice. Although it has never been demonstrated in a placebo-controlled blinded study, I do believe (for years now) that low-dose prednisone can reduce the risk of generalization of ocular MG.A...