Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
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, ...
What approach do you use when treating adult diffuse gliomas with H3-G34 mutations, now classified into their own category under the 2021 glioma guidelines?
Although DHG H3G34-mutant diffuse gliomas are more commonly associated with pediatric patients, they can occur in young adults as well. In a recent paper describing 17 patients harboring this rare mutation, the median age at diagnosis was 25 years (range: 19–33). All tumors were hemispheric. All cas...
How do you use muscle MRI in the diagnosis and management of muscular dystrophies?
A similar question about the utility of MRI in muscle diseases has been asked previously and replied to. I do not routinely use MRI in the diagnosis and management of muscular dystrophies. To diagnose muscular dystrophy, I usually rely on history and exam, analysis of family history/pedigree to clar...
How do you taper phenobarbital in a patient with epilepsy?
Since the risk of withdrawal seizures is high, it's best to administer clobazam. The dose depends on the dose of phenobarbital. After a week, clobazam can be discontinued gradually, tapering off without the risk of withdrawal.