Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
In what clinical scenarios do you utilize opioids in patients with restless leg syndrome?
I would say in refractory RLS, i.e., the patient has failed all the options below: Iron supplementation if ferritin <50, Gabapentin/pregabalin, Dopamine agonists, and Non-pharmacological options (like the vibrating pad). *I don't love carbidopa/levodopa for RLS. It very often causes augmentation.
When do you consider testing autoimmune antibodies for axonal polyneuropathies without clear etiology?
Dr. @Dr. First Last gave an excellent summary of the clinical red flags that should trigger antibody testing in polyneuropathies. I would like to highlight that not all antibodies are pathogenic or cause the same phenotypes/clinical syndromes; therefore, I would like to break it down by antibody gro...
Does screening for sleep apnea in asymptomatic patients reduce long-term dementia risk?
Obstructive sleep apnea (OSA) is common, underdiagnosed, and increasingly recognized as a potentially modifiable contributor to late-life cognitive decline. Observational studies consistently report associations between OSA, intermittent hypoxemia, sleep fragmentation, cerebrovascular injury, Alzhei...
How would you determine the safety of anticoagulation in patients with evidence of cerebral microhemorrhages who present with acute stroke secondary to cardioembolism?
This question assumes that the patient already had an MRI showing microhemorrhages. The Boston criteria provide guidelines for the number of microbleeds, associated superficial siderosis, or major hemorrhage to make the diagnosis of cerebral amyloid angiopathy. I would also assume that at least some...
How long can demyelinating findings persist on nerve conduction studies (NCS) after AIDP illness?
This question was studied in a retrospective review in Muscle and Nerve (Guémy et al., PMID 36814082) in a group of patients with AIDP. At least one feature of demyelination was present in 23% of the cohort (14 out of 61) up to 2 years after the onset of the AIDP-like illness. Using the EFNS-PNS cri...
How do you counsel post-menopausal women interested in hormone replacement therapy as a treatment for multiple sclerosis?
Postmenopausal HRT is not established as relapse-prevention, neuroprotection, or progression therapy in MS. I do not recommend HRT to treat MS. I support HRT for bothersome menopausal symptoms when there are no contraindications, as treating sleep disruption, hot flashes, mood symptoms, urogenital s...
What do you recommend as a first-line antidepressant in patients with major depressive disorder and migraines?
In my clinical practice, I have found SNRI medication, particularly extended-release venlafaxine (dosed from 37.5 mg to 225 mg), to be helpful for patients with both comorbidities. Other medication classes I have seen used to good effect include TCAs (amitriptyline, nortriptyline) and some SSRIs (se...
Do you routinely obtain a biopsy of a presumed meningioma prior to SRS to confirm grade 1?
There is an emerging and growing body of data using various AI tools and radiomics analysis, as well as the incorporation of advanced imaging, that aim to improve the ability to predict the grade of meningioma. Most of this work remains "limited institution" in terms of applicability. In the current...
What is your first-line therapy for acute migraine treatment in the ER?
When guidelines are based on well-done, randomized trials, I tend to pay more attention to them. The most recent 2025 guidelines for treatment of migraine in the ER, first author Dr. @Dr. First Last, are excellent. Giving IV prochlorperazine cautiously may be a good start. Depending on the timing of...
What is your management approach for CAR-T induced motor neurologic deficits (cyclophosphamide/IVIG/steroids, etc.) and any prophylactic approach to an early, rapid rise in absolute lymphocyte count post CAR-T infusion?
Specifically, this seems to be a question around cilta-cel. There has been some recent guidance to consider pre-emptively starting dexamethasone if the absolute lymphocyte count rises above 3,000 in the period following CAR T administration. This partially stems from the observation that many of the...