Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
How do you work up incidentally found papilledema in the emergency room?
The term "papilledema" should be reserved for optic disc swelling due to increased intracranial pressure - but I assume that this question is asking what to do if the fundus examination looks abnormal (blurred disc margins perhaps) when there are no visual symptoms or symptoms of increased intracran...
When do you consider nerve blocks for headache management in patients admitted to the neuro-intensive care unit with subarachnoid hemorrhage?
For aneurysmal SAH, I try different medication combinations for the first 5-7 days. After this time frame, if headache pain is still severe and/or the patient uses opioid meds too frequently, I request an occipital nerve block from our pain management team. In my experience, about two-thirds of pati...
Do you repeat a lumbar puncture in a patient living with HIV diagnosed with and treated for neurosyphilis and if so, when?
This is a complex issue, and there isn't a one-size-fits-all approach. There are no hard and fast guidelines in place. If the initial CSF abnormalities include only reactive CSF VDRL, along with modest protein elevation and mononuclear pleocytosis (both of which are consistent with HIV infection), a...
What role do anti-seizure medication levels, such as levetiracetam, serve in seizure-free patients?
In patients with epilepsy who are being treated with antiseizure medication, the change in doses has to be driven by clinical data, mainly by seizure recurrence and/or adverse events. If a patient has been seizure-free and is not having adverse events, there is no need to check for blood levels, as ...
How do you approach the management of patients on lamotrigine who develop a minor rash?
Lamictal rash can be dangerous but if we stop or switch lamictal for any rash during treatment we can run out of options soon. Get a good history and pictures, if possible. How long have they been on lamictal and was there a recent dose change or did the pharmacy change their generic brand? Have an...
How do you manage myasthenia gravis in patients over the age of 90?
Steroids always carry the risk for side-effects and these need to be explained to each patient and weighed against co-morbidities to determine if they are in fact reasonably indicated in a particular instance. Nevertheless, steroids should be first-line agents for elderly MG patients as a significan...
How do you approach the treatment of biopsy proven ABRA (amyloid beta related angiitis)?
I start with a prednisone taper, 60 mg daily to start, taper over a few weeks. If symptoms or scan findings worsen, I would add an immunosuppressive agent such as azathioprine. Howard Kirshner MD
What suspected myositis manifestations drive you to start empiric therapy before the work-up is complete?
When evaluating a patient with myositis, I would consider starting immediate therapy when 1) my suspicion of myositis is high (i.e. characteristic rashes, compatible constellation of symptoms, very high CPK) and 2) the symptoms are severe. It would be the severity of the symptoms that would drive ho...
What is your approach to elevated CK in patients without clinical or serologic evidence of immune mediated myopathy?
Thanks for your great question: This is especially important because we are much more likely to see patients sent for "elevated" CPK than patients with myositis.Unfortunately, I think that the answer to the approach depends a lot the circumstances, including (1) how elevated is the CPK, and (2) how ...
Do you favor the use of maximal inspiratory/expiratory pressure measurement or supine spirometry in the evaluation of a patient with suspected respiratory muscle weakness?
In practice, we often perform both in the same session. Supine spirometry has the advantage of assessing the orthopnea that is a common complaint among my patients with neuromuscular disease. Also, many of our patients report that the MIP/MEP maneuver is difficult to perform and they feel it underes...