Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
How would you approach a patient over the age of 40 with a sub-totally resected frontal oligodendroglioma, WHO Grade II, 1p/19q co-deleted, IDH mutant, with imaging concerning for second site in the pontomedullary junction?
The pontomedullary junction is not usually amenable to a biopsy (unless the lesion is exophytic); as such, there are 2 possibilities: a) the second lesion is related to the one that has undergone subtotal resection, or b) the lesion is of a different nature. Statistically, it is more likely to be a ...
In well-controlled epilepsy patients who suffer an unprovoked seizure with medication compliance, what would prompt you to increase their anti-seizure medication?
If the seizure was really unprovoked (no skipping medications, no intercurrent illness, no severe sleep deprivation or unusual activities, etc.), then the treatment should be increased. That could mean increasing the current dose(s) or adding an adjunct, depending on what the patient was taking (and...
Do you use or recommend clinical severity scores or other parameters in helping prognostication in patients with refractory status epilepticus?
I do not find prognostication scores in status epilepticus to be particularly helpful in driving care and discussing prognosis with families. We track the "Status Epilepticus Severity Score” (STESS) for quality improvement only to determine presentation severity. For prognosis, the refractoriness of...
At what point do you consider implantation of a baclofen pump in patients with cerebral palsy?
I think the key thing about spasticity in somebody who has cerebral palsy is what you are trying to treat and the functional outcome. What is your goal? What is your aim? How does their spasticity adversely affect them and their quality of life? Spasticity treatment is a staged approach. It's usual...
How do you manage cases of levodopa intolerance due to nausea or drowsiness?
This is a great question. Side effects from levodopa can be challenging to manage. First, when you start carbidopa-levodopa, ensure you uptitrate it slowly to limit side effects. Carbidopa is most effective in reducing side effects when it is at least 75 mg total daily dose, thus, the 10-100 tablet ...
Do you utilize phrenic nerve EMG in patients with diaphragmatic issues?
Diaphragm muscle needle EMG is definitely a useful tool to assess patients with suspected respiratory muscle weakness/paralysis. It can differentiate neurogenic from myopathic disorders and it can help with prognostication. However, many providers, including myself, are not very comfortable with "bl...
When do you consider spinal cord stimulator for patients with neuropathic pain?
No one answer fits all. Given the dynamics of pain and its interaction with the rest of the person, care must be exercised before creating a protocol, paradigm, or other "easy way out" of considering the pain-person interaction. Not easy.
What considerations guide your decision to perform endovascular therapy in stroke involving acute M2 or M3 occlusions?
When deciding whether to intervene in distal occlusions, I first assess the severity of the neurological deficits, particularly focusing on cortical signs such as aphasia, neglect, or visual field deficits. Based on criteria from prior LVO RCTs, I typically use an NIHSS threshold of 6 or greater...
What is the minimum level of cognitive symptoms that would prompt you to pursue biomarker testing required for anti-amyloid therapies for Alzheimer's?
I would require a clear diagnosis of MCI as defined by evidence of clearly impaired cognition on a valid neuropsychological test battery. I would not accept a patient based on a low-ish score on a single brief measure such as MMSE or MOCA as those tests ultimately lack specificity (as well as sensit...
What treatments are most effective for muscle cramps and stiffness in Isaac's syndrome and other peripheral nerve hyperexcitability disorders?
I believe that the most effective treatments for cramps and fasciculations/peripheral nerve hyperexcitability in Isaac's syndrome are (fast) sodium channel blockers such as carbamazepine and oxcarbazepine. We often prefer the latter due to fewer side effects. I have occasionally found mexiletine hel...