Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
How do you decide on switching to a different preventative anti-CGRP treatment in migraine patients who are experiencing reduced effectiveness with their current treatment?
The CGRP antibodies and gepants are my preventive treatments of choice. In fact, I hardly ever prescribe anything else anymore preventively, including botulinum toxin. Tolerability issues I hardly ever encounter with the antibodies, but sometimes I do with the gepants, in particular fat...
When should lumbar puncture be prioritized for patients with suspected Guillain-Barre Syndrome?
There are two major reasons to do an LP in suspected GBS. One is to see if there is albuminocytologic dissociation supporting the diagnosis of GBS. LP done early in the course may be normal, so CSF does not drive early treatment decisions. It should also be noted that the IGOS study showed that a sm...
How do you counsel patients on wearable heart monitor devices when they ask about specific products and diagnostic accuracy of these devices available on the market?
It depends on the device. If a patient is experiencing palpitations infrequently, or there is an ongoing need to identify the cause of palpitations, I typically recommend a consumer-facing ambulatory ECG device that is FDA-cleared. They are quite accurate for detecting AFib and ectopic beats such as...
What is your first-line therapy for acute migraine treatment in the ER?
Regarding the abortive and preventive treatment of migraine, in the office or ER, we should focus on migraine-specific medications. These are the ergots, triptans, and gepants abortively, and the CGRP antibodies and gepants preventively. The patients who visit ERs every so often tend to have headach...
What typical lab tests do you send off for evaluation of neuropathy?
Not too much has changed in over a decade regarding the recommendations on how we should approach initial laboratory testing in patients presenting with a neuropathy syndrome. Specifically for cases of distal symmetric polyneuropathy, the AAN practice parameter (reaffirmed in 2022) by England, et al...
What clinical features prompt genetic testing for patients with progressive cerebellar ataxia?
In general, any patient who presents with a chronic progressive cerebellar ataxia and is </=21 years of age deserves genetic testing. If a subacute presentation arises with no clear metabolic, inflammatory, neoplastic, vascular, etc., etiology, I would also recommend genetic testing in this group.Wi...
How do you manage seemingly treatment-resistant chronic migraine?
First, let's define refractory migraine. The most recent and strict diagnosis that I use was a proposal by the European Headache Federation (EHF):Refractory Migraine Established diagnosis of 1.1 Migraine without aura and/or 1.2 Migraine with aura or 1.3 Chronic migraine according to ICHD-III criter...
When and how do you perform genetic testing for congenital myasthenia gravis in seronegative cases?
I believe that these congenital myasthenic syndromes can start at birth or early childhood, as we are all familiar with muscular weakness, particularly extraocular muscles, and bulbar, which is fatigable, worsening with physical activity, and there > 30 genes responsible, and symptoms vary by the Ge...
How to approach reversal of TNK in hemorrhagic conversion of ischemic stroke?
There is no specific "reversal agent" for tenecteplase. Once administered, the thrombolytic effect will persist until the drug is fully metabolized and any residual plasmin has been cleared by alpha-2-antiplasmin. So, perhaps the first question is what can you do if there is an acute bleeding event ...
How do you convert between tetrabenazine, deutetrabenazine, or valbenazine for management of tardive dyskinesia?
I think of these medications as much more clinically similar than different, with the main differences relating to patients who are fast metabolizers. Fast metabolizers often respond well to lower doses of deutetrabenazine or valbenazine compared to tetrabenazine. When converting from one drug to an...