Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
What is your preferred VMAT2 inhibitor to treat tardive dyskinesia; tetrabenazine, valbenazine, or deutetrabenazine?
The base cost of tetrabenazine is much lower than valbenazine or deutetrabenazine, so I generally prefer it. However, due to insurance factors, valbenazine or deutetrabenazine can have lower out-of-pocket costs for some patients. From a purely clinical management perspective, tetrabenazine is much ...
Would you consider anticoagulation for a young patient with a recent embolic stroke and newly diagnosed global cardiac hypokinesis with ejection fraction of less than 25%?
Yes, I would consider anticoagulation but the evidence is indirect. There is reasonable data in persons with heart failure with reduced ejection fraction that ischemic stroke is reduced with anticoagulation compared to antiplatelet therapy alone. But essentially all large RCTs are limited in that th...
How do you apply the 2HELPS2B score into clinical decision making for determining duration of cEEG testing?
I think there are two important issues to note: Always remember that the study was based on a 1-hour screening EEG, not a typical 20-minute routine. This may or may not make a difference in finding sporadic epileptiform abnormalities or BIRDs. Most of the time you do not need to use this score. Fo...
Is there a good rationale for using vasopressors/induced hypertension in a patient with fluctuating neurologic deficits from symptomatic intracranial stenosis?
I have raised blood pressure in patients with fluctuating stroke deficits, especially in patients with intracranial hypertension, with apparently good results. We usually try fluids first, but pressors are sometimes necessary. This makes sense from the known autoregulation curves, which are shifted ...
Under what circumstances would you recommend using the 2HELPS2B score to decide whether or not to pursue long-term cEEG?
As you rightly point out, 2HELPS2B is a helpful clinical instrument - it has appropriate uses, but should only supplement (and not replace) a clinical assessment. In my personal experience, I find it to be more useful as a communication and educational tool than as a clinical decision-making tool. I...
How do you manage IgM related peripheral neuropathy?
First things first, let's make sure it's IgM related. In patients with precursor disease (MGUS or smoldering) and neuropathy, I check B12, HbA1c, TSH, free T4, hepatitis B surface Ag, hepatitis B total core Ab, hepatitis C antibody, and cryoglobulins. In patients with specific risk factors, I check ...
How do you manage patients with Parkinson's disease when dopaminergic therapy worsens the freezing phenomenon?
Some patients with Parkinson's disease experience freezing of gait (FOG) despite seemingly adequate dopaminergic therapy. Some patients may feel that FOG even worsens after taking their dopaminergic medication. In these situations, it is important to first establish that the dopaminergic regimen is...
Is it reasonable to extrapolate data from Glioblastoma and discuss Tumor Treating Fields in patients with Grade 4, IDH Mutant, astrocytomas?
While more than 90% of Grade 4 gliomas are IDH wildtype tumors (GBMs), this question does come up occasionally. Since I have no personal experience with TTF, I asked my collaborator Chirag Patel, MD, a neuro-oncologist at MDACC who regularly uses TTF in his patients, to provide his opinion. So pleas...
Which novel immunomodulatory treatment(s) do you consider in refractory seronegative bulbar-predominant myasthenia?
Re-evaluate the diagnosis. Acetylcholine receptor and MuSK antibody-negative myasthenia with prominent bulbar symptoms, refractory to all the agents mentioned (steroids, MMF, AZA, IVIG) is an extremely rare scenario. Differential diagnosis includes bulbar onset ALS and numerous myopathies (e.g. IBM...
How do you decide on the treatment target of burst suppression pattern vs seizure cessation for patients with status epilepticus?
There is no high-level data to support burst suppression as superior to electrographic seizure cessation, with data largely coming from case series. In general, those who reach burst suppression seem to have better seizure control, but at the expense of more side effects from the meds. Accordingly, ...