Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
How do you manage cases of levodopa intolerance due to nausea or drowsiness?
This is a great question. Side effects from levodopa can be challenging to manage. First, when you start carbidopa-levodopa, ensure you uptitrate it slowly to limit side effects. Carbidopa is most effective in reducing side effects when it is at least 75 mg total daily dose, thus, the 10-100 tablet ...
Do you utilize phrenic nerve EMG in patients with diaphragmatic issues?
Diaphragm muscle needle EMG is definitely a useful tool to assess patients with suspected respiratory muscle weakness/paralysis. It can differentiate neurogenic from myopathic disorders and it can help with prognostication. However, many providers, including myself, are not very comfortable with "bl...
When do you consider spinal cord stimulator for patients with neuropathic pain?
No one answer fits all. Given the dynamics of pain and its interaction with the rest of the person, care must be exercised before creating a protocol, paradigm, or other "easy way out" of considering the pain-person interaction. Not easy.
What considerations guide your decision to perform endovascular therapy in stroke involving acute M2 or M3 occlusions?
When deciding whether to intervene in distal occlusions, I first assess the severity of the neurological deficits, particularly focusing on cortical signs such as aphasia, neglect, or visual field deficits. Based on criteria from prior LVO RCTs, I typically use an NIHSS threshold of 6 or greater...
What is the minimum level of cognitive symptoms that would prompt you to pursue biomarker testing required for anti-amyloid therapies for Alzheimer's?
I would require a clear diagnosis of MCI as defined by evidence of clearly impaired cognition on a valid neuropsychological test battery. I would not accept a patient based on a low-ish score on a single brief measure such as MMSE or MOCA as those tests ultimately lack specificity (as well as sensit...
What treatments are most effective for muscle cramps and stiffness in Isaac's syndrome and other peripheral nerve hyperexcitability disorders?
I believe that the most effective treatments for cramps and fasciculations/peripheral nerve hyperexcitability in Isaac's syndrome are (fast) sodium channel blockers such as carbamazepine and oxcarbazepine. We often prefer the latter due to fewer side effects. I have occasionally found mexiletine hel...
Do you recommend Alpha Lipoic Acid to patients with diabetic polyneuropathy?
Recommend is a strong word. I mention it to my patients as there's some 'evidence' supporting it. It has minimal side effects and virtually no risk, so it's worth a try. However, it's important to note that very few of my patients report any benefit from it.
Do you recommend encephaloduroateriosynangiosis in pediatric patients with Moyamoya disease?
Only if it's clearly symptomatic.
What are your strategies for preventive migraine therapy in breastfeeding patients?
Transfer to milk depends on how highly a medication is protein-bound. Measurable concentrations occur for drugs <70% bound. >85% bound is not expected to have a measurable concentration in infants. Propranolol, amitriptyline, and Depakote are >90% protein-bound so I consider them first. Botox is not...
In which patients do you recommend craniectomy-watch after acute stroke?
The ideal candidates are younger patients with full MCA distribution stroke. One issue to be mindful of is that the “watch” part should be focused on watching to confirm the radiographic size of the stroke and the presence of cerebral edema. I would caution against watching for clinical deterioratio...