Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
Do you recommend Alpha Lipoic Acid to patients with diabetic polyneuropathy?
Recommend is a strong word. I mention it to my patients as there's some 'evidence' supporting it. It has minimal side effects and virtually no risk, so it's worth a try. However, it's important to note that very few of my patients report any benefit from it.
Do you recommend encephaloduroateriosynangiosis in pediatric patients with Moyamoya disease?
Only if it's clearly symptomatic.
What are your strategies for preventive migraine therapy in breastfeeding patients?
Transfer to milk depends on how highly a medication is protein-bound. Measurable concentrations occur for drugs <70% bound. >85% bound is not expected to have a measurable concentration in infants. Propranolol, amitriptyline, and Depakote are >90% protein-bound so I consider them first. Botox is not...
In which patients do you recommend craniectomy-watch after acute stroke?
The ideal candidates are younger patients with full MCA distribution stroke. One issue to be mindful of is that the “watch” part should be focused on watching to confirm the radiographic size of the stroke and the presence of cerebral edema. I would caution against watching for clinical deterioratio...
What would be the differential and initial workup for tongue fasciculation?
Tongue atrophy and fasciculations, unless very severe and obvious, can be difficult to determine by clinical exam alone. I have had multiple patients who were told that they have ALS after an inexperienced examiner saw them for an initial visit and thought they had tongue fasciculations without furt...
Does the presence and location of cerebral microbleeds affect your decision for antithrombotic treatment in patients with atrial fibrillation?
That is a great question. Agree, the data is observational and no firm conclusions can be made. My practice is to consider left atrial appendage occlusion in patients with suspected CAA. In patients with hypertensive microbleeds, both resuming anticoagulation and left atrial appendage occlusion are ...
How do you treat congenital paramyotonia symptoms?
Avoid cold- and definitely do not exercise in cold. For the myotonia: mexiletine is my 1st line, if not tolerated or contraindicated, can use lamotrigine, or other sodium channel blockers like carbamazepine, lacosamide, or ranolazine. If the patient has coexistent hyperkalemic periodic paralysis, ...
When do you recommend electrical stimulation (Cefaly device) in patients with chronic migraine, if at all?
The Cefaly device provides transcutaneous electrical nerve stimulation to the supraorbital nerves and has regulatory approval both as an acute and preventive treatment. This device and other neuromodulatory therapies are useful in several settings for the treatment of chronic migraine: Some people ...
Is there utility to ordering biochemical screening labs for global developmental delay?
When suspected, it might be warranted to do an initial screening for metabolic disorders. Genetic testing is also a good idea, starting with a microsomal microarray and fragile X testing. Whole exome sequencing might follow and is becoming more affordable and covered by insurance.
How do you treat patients with stroke thought to be secondary to Lambl excrescence?
Pathophysiologically, these occur through sheer stress to the valvular endocardium causing small areas to be denuded followed by fibrin deposition and microthrombi formation on the endocardial injury, which can embolize. Histopathologically, they have similarities to fibroelastomas (which are larger...