Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
Do you routinely recommend a sleep study in patients with clinical history of REM-sleep behavior disorder?
I do routinely recommend and perform in lab sleep testing for patients with suspected REM behavior disorder (RBD). The finding of REM sleep without atonia (RSWA) is supportive of a diagnosis of RBD, as atonia is normally presented in individuals (without RBD) during REM sleep. RBD can be a tricky di...
How would you manage a patient with LGI-1 encephalitis with faciobracial dystonic seizures who has not improved with 3 days of intravenous steroids?
I typically treat with five days of IV steroids. In patients with autoimmune encephalitis, including LGI-1, who do not improve after five days of IV steroids, I would then move to IVIG or plasmapheresis (depending on patient comorbidities, availability of plasmapheresis, and severity of symptoms). I...
How do you mitigate the risk of rebound disease activity when discontinuing S1p inhibitors or Tysabri in patients with multiple sclerosis?
While there is no ideal method as determined by well-designed randomized studies, two options would be: (a) steroid bridge between therapies and (b) minimize wash-out period between switches. For many DMTs, a wash-out period between drugs is not needed. If the question regarding the S1p inhibitor wa...
What nutritional supplements do you recommend for patients with ALS?
I do not recommend specific supplements. If the question relates to the PEG formula, we use basic formulas and higher caloric versions if needed.
In what clinical situations do you switch to Vyalev in patients with Parkinson's disease?
Vyalev (foscarbidopa/foslevodopa) administered by subcutaneous infusion with an external battery-operated pump, was recently FDA-approved. Conceptually, it offers the prospect of continuous levodopa administration which should improve dyskinesia and motor fluctuations. Skin reactions can be problema...
Would you add immunosuppression in ocular myasthenia gravis patients who are symptomatically well-controlled on pyridostigmine?
This requires a shared decision-making approach with the patient because there is no right or wrong answer/choice. Although it has never been demonstrated in a placebo-controlled blinded study, I do believe (for years now) that low-dose prednisone can reduce the risk of generalization of ocular MG.A...
What are preferred sleep aids in elderly patients with dementia?
Melatonin 3-6 mg because of their loss of melatonin-secreting potency with age. Doxepin 10 mg because of the cost of 3 and 6 mg versions. If restless legs or limb movements during sleep, gabapentin or pregabalin. Pregabalin can be better tolerated with less next-day sedation (also can be an issue wi...
Is there a utility in getting repeat antibody testing on GBS patients after PLEX?
No, there is not, for a couple of reasons: Most patients with the most common variant of GBS (AIDP) are negative for ganglioside antibodies or other antibodies against nodal/paranodal proteins. Ganglioside antibodies are more often positive in GBS variants like AMAN, AMSAN, Miller Fisher syndrome, s...
How would you approach the decision to escalate DMT in a patient with relapsing multiple sclerosis who has two to three new T2 lesion but no clinical symptoms?
I would escalate to higher-efficacy DMT in this scenario. As highlighted in the linked article, new T2 lesions show that the patient is at heightened risk for clinical relapses and their disease activity is not well controlled. In the linked study, included patients were on low efficacy DMT (interfe...
How long after a motor vehicle accident would you expect symptoms including memory loss, hypersomnia, and mood changes to be attributable to the accident?
I would love to have the answer to this. I can tell you what the Headache Classification Committee of the International Headache Society says:Post-traumatic headache (PTHA) is defined as a secondary headache that develops within 7 days after head trauma (or after regaining consciousness following he...