Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
What do you do for a patient with Parkinson's Disease and orthostatic hypotension who has failed midodrine, fludrocortisone, droxidopa, pyridostigmine, and atomoxetine?
I would not recommend using amantadine in this situation as it is known to worsen orthostatic hypotension (Perez-Lloret et al., PMID 22336566). This is a tricky situation, and if the patient has failed all of these medications, I would consider an alternate diagnosis, specifically MSA, especially if...
How do you decide when to discontinue immunotherapy for primary angiitis of the central nervous system (PACNS)?
I take a multidisciplinary approach with involvement of my neurobiology and rheumatology colleagues for the immunotherapy. PACNS can be relapsing or remitting. So needs close monitoring with radiologic (MRI and MRA high resolution vessel wall imaging or CTA/MRA with CSF studies 6 months and then 1 y...
What medications do you prioritize or avoid in Parkinson’s Disease-related psychosis and behavioral disturbance?
From an evidence-based perspective, clozapine continues to have the most solid support for its efficacy in Parkinson's disease-related psychosis. Pimavanserin has FDA approval (albeit with some mixed data) specifically for this indication. Quetiapine and olanzapine are perhaps the most frequently us...
Do you recommend any medical management for patients with evidence of intracranial atherosclerosis without evidence for stroke?
I would focus more on primary prevention strategies, including lifestyle modifications and high-intensity statin therapy if LDL is elevated. The evidence supporting antiplatelet therapy for primary prevention in patients with stroke risk or intracranial atherosclerosis is either lacking or not stron...
What is your approach to bloody CSF (that does not clear with sequential tubes) in a patient without acute findings on a head CT?
I still think there is value in looking for xanthochromia if CSF is obtained >12 hours after onset of symptoms. Yes, there are occasional false positives of xanthochromia with traumatic taps, but if a patient presents to the ED with sudden onset of a severe headache, a negative CT, lots of RBCs in t...
What is your stepwise therapeutic approach to acute headache without red flag features in hospitalized patients who have underlying renal, hepatic, and/or cardiac dysfunction?
Headache is an extremely common complaint during hospitalization, and so few of our patients have no contraindications to some standard therapies. Medically complex inpatients tolerate very few of the standard acute headache drugs, so therapy is built on agents that are not organ-toxic and do not ac...
What is your approach to managing hallucinations in dementia?
One thing to remember is that hallucinations are not always disturbing to the patient, but to the caregiver! If the patient is fine with seeing a little girl or dog (often in LBD), the family just needs to be educated to let it go. They don’t need to AGREE that the hallucinations are present; they j...
What patient factors most strongly influence your decision to start biologic agents in mild cognitive impairment?
1.Absence of need for anticoagulants ( this is exclusionary) 2. Absence of APOE e4 homozygosity (although we do treat e4 homozygotes, but with much greater precautionary measures - especially the dosing protocol) 3. High functional ability, and adherence to healthy lifestyle measures (exercise, die...
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...
Do you recommend a "washout" period for anti-CGRP medications before conception?
Wise advice from Dr. @Dr. First Last. We are presenting a talk at AHS demonstrating that women who conceive on monoclonal antibodies have an elevated risk of spontaneous abortion in the first trimester. Remember that 50% of pregnancies are unplanned. I advise women on CGRP-targeted therapies to be o...