Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
What would be the differential and initial workup for tongue fasciculation?
Tongue atrophy and fasciculations, unless very severe and obvious, can be difficult to determine by clinical exam alone. I have had multiple patients who were told that they have ALS after an inexperienced examiner saw them for an initial visit and thought they had tongue fasciculations without furt...
Does the presence and location of cerebral microbleeds affect your decision for antithrombotic treatment in patients with atrial fibrillation?
That is a great question. Agree, the data is observational and no firm conclusions can be made. My practice is to consider left atrial appendage occlusion in patients with suspected CAA. In patients with hypertensive microbleeds, both resuming anticoagulation and left atrial appendage occlusion are ...
How do you treat congenital paramyotonia symptoms?
Avoid cold- and definitely do not exercise in cold. For the myotonia: mexiletine is my 1st line, if not tolerated or contraindicated, can use lamotrigine, or other sodium channel blockers like carbamazepine, lacosamide, or ranolazine. If the patient has coexistent hyperkalemic periodic paralysis, ...
When do you recommend electrical stimulation (Cefaly device) in patients with chronic migraine, if at all?
The Cefaly device provides transcutaneous electrical nerve stimulation to the supraorbital nerves and has regulatory approval both as an acute and preventive treatment. This device and other neuromodulatory therapies are useful in several settings for the treatment of chronic migraine: Some people ...
Is there utility to ordering biochemical screening labs for global developmental delay?
When suspected, it might be warranted to do an initial screening for metabolic disorders. Genetic testing is also a good idea, starting with a microsomal microarray and fragile X testing. Whole exome sequencing might follow and is becoming more affordable and covered by insurance.
How do you treat patients with stroke thought to be secondary to Lambl excrescence?
Pathophysiologically, these occur through sheer stress to the valvular endocardium causing small areas to be denuded followed by fibrin deposition and microthrombi formation on the endocardial injury, which can embolize. Histopathologically, they have similarities to fibroelastomas (which are larger...
Do you use amyloid lowering therapy in patients on chronic anticoagulation?
I wouldn’t feel comfortable doing this because of the elevated risk of ARIA-H. The Alzheimer’s Association Therapeutics Work Group advised that patients receiving anticoagulants should not be offered lecanemab (Cummings et al., PMID 37357276).
Do you recommend plasmapheresis for treatment of patients with osmotic demyelination?
No. There are insufficient data to routinely recommend plasmapheresis for the treatment of ODS at this time. Current evidence is based predominantly on case series. In the absence of a control group, it is difficult to assess the effectiveness of plasmapheresis in the treatment of ODS.
When do you consider complement inhibitors or FcRN inhibitors in patients with myasthenia gravis?
In my opinion, those meds should be considered for a patient with AchR antibody-positive MG who has suboptimal control of MG symptoms on: Pyridostigmine + prednisone + oral immunosuppressant drugs like azathioprine or MMF. Pyridostigmine + oral immunosuppressant + severe intolerance to steroids (si...
Do you find the UPDRS useful for the care of Parkinson's disease patients outside of research?
The UPDRS and MDS-UPDRS are both useful research tools for Parkinson’s. Parts one, two, and four are interview-based with some rater guidance. Part three is an objective assessment by the clinical rater. Performing part three of either UPDRS test in non-research settings is helpful to improve your u...