Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
How do you manage myasthenia gravis in patients over the age of 90?
Steroids always carry the risk for side-effects and these need to be explained to each patient and weighed against co-morbidities to determine if they are in fact reasonably indicated in a particular instance. Nevertheless, steroids should be first-line agents for elderly MG patients as a significan...
How do you approach the treatment of biopsy proven ABRA (amyloid beta related angiitis)?
I start with a prednisone taper, 60 mg daily to start, taper over a few weeks. If symptoms or scan findings worsen, I would add an immunosuppressive agent such as azathioprine. Howard Kirshner MD
What suspected myositis manifestations drive you to start empiric therapy before the work-up is complete?
When evaluating a patient with myositis, I would consider starting immediate therapy when 1) my suspicion of myositis is high (i.e. characteristic rashes, compatible constellation of symptoms, very high CPK) and 2) the symptoms are severe. It would be the severity of the symptoms that would drive ho...
What is your approach to elevated CK in patients without clinical or serologic evidence of immune mediated myopathy?
Thanks for your great question: This is especially important because we are much more likely to see patients sent for "elevated" CPK than patients with myositis.Unfortunately, I think that the answer to the approach depends a lot the circumstances, including (1) how elevated is the CPK, and (2) how ...
Do you favor the use of maximal inspiratory/expiratory pressure measurement or supine spirometry in the evaluation of a patient with suspected respiratory muscle weakness?
In practice, we often perform both in the same session. Supine spirometry has the advantage of assessing the orthopnea that is a common complaint among my patients with neuromuscular disease. Also, many of our patients report that the MIP/MEP maneuver is difficult to perform and they feel it underes...
How would you approach a patient over the age of 40 with a sub-totally resected frontal oligodendroglioma, WHO Grade II, 1p/19q co-deleted, IDH mutant, with imaging concerning for second site in the pontomedullary junction?
The pontomedullary junction is not usually amenable to a biopsy (unless the lesion is exophytic); as such, there are 2 possibilities: a) the second lesion is related to the one that has undergone subtotal resection, or b) the lesion is of a different nature. Statistically, it is more likely to be a ...
In well-controlled epilepsy patients who suffer an unprovoked seizure with medication compliance, what would prompt you to increase their anti-seizure medication?
If the seizure was really unprovoked (no skipping medications, no intercurrent illness, no severe sleep deprivation or unusual activities, etc.), then the treatment should be increased. That could mean increasing the current dose(s) or adding an adjunct, depending on what the patient was taking (and...
Do you use or recommend clinical severity scores or other parameters in helping prognostication in patients with refractory status epilepticus?
I do not find prognostication scores in status epilepticus to be particularly helpful in driving care and discussing prognosis with families. We track the "Status Epilepticus Severity Score” (STESS) for quality improvement only to determine presentation severity. For prognosis, the refractoriness of...
At what point do you consider implantation of a baclofen pump in patients with cerebral palsy?
I think the key thing about spasticity in somebody who has cerebral palsy is what you are trying to treat and the functional outcome. What is your goal? What is your aim? How does their spasticity adversely affect them and their quality of life? Spasticity treatment is a staged approach. It's usual...
What treatment do you use for stroke prevention in cervical artery dissection?
Two prior RCTs (CADISS and TREAT-CAD) investigated this topic, each with distinct designs. The CADISS trial found no statistically significant difference in primary outcomes between antiplatelet and anticoagulation therapy for extra-cranial dissection. However, the TREAT-CAD trial failed to demon...