Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
How would you manage a patient with secondary progressive multiple sclerosis manifesting with increased neuropsychiatric manifestations (ex. psychosis) with no recent changes on brain MRI?
Exclude the usual suspects such as infections, electrolyte abnormalities, and polypharmacy. If nothing pans out and nutritional causes or deficiencies have been excluded I would direct such patients to psychiatric care. I will also make sure that the patient is not suicidal by doing a Beck Depressio...
How do you approach the workup and management of patients with suspected functional neurologic disorders?
This is not really an answerable question. I would re-frame the question, because it really depends on the kinds of symptoms they have and the neurologic exam that is performed. I disagree with neurologists who say that "functional neurologic disorders" are a diagnosis of exclusion. That is absolute...
Do you use pimavanserin to treat psychotic symptoms in Lewy body dementia?
Yes, if insurance allows. However, it is my medication of last resort after trying cholinesterase inhibitor and SSRI. It can be used in the place of quetiepine. Note that this is an off-label use of the medication.
Would you avoid the use of keppra in patients with TBI due to concerns for worsening agitation?
I suspect that this practice of prophylactic antiepileptic medications for TBI patients will go away over time. History has shown us time and time again that we over-medicate patients.
For patients with significant side effects to a cholinesterase inhibitor, do you try another medication in the class or avoid it altogether?
Firstly, I titrate up the medication so that if there is a side effect, I can retreat to my last tolerated dose. If the side effect is dizziness or faintness, then I will stop trying to escalate the dose. If the side effect is vivid dreaming, then one might try to take the medication in the morning....
When do you recommend driving tests in patients who have memory loss?
I recommend a driving test when: there is any concern by the family, the clinical dementia rating is greater than 0.5, there are visuospatial defects on cognitive testing, there are problems with Trails A or B, and also whenever I cannot be sure.
Do you use acetylcholinesterase inhibitors in patients with cognitive changes in the setting of cerebral amyloid angiopathy?
Many patients with CAA also have cognitive deficits. If so, I use cholinesterase inhibitors, usually donepezil. I would not prescribe these agents if the patient has only microbleeds and no cognitive impairment.
When do you recommend lumbar puncture in patients with concern for memory loss?
Rapidly progressive memory loss/dementia- because you obviously want to exclude diagnoses like CJD, infectious/autoimmune/paraneoplastic encephalitis, lymphoma or other malignancy, etc. When you need to know the patient's "brain amyloid status". E.g. a) Patients with amnestic MCI and atypical cour...
Would you consider AEDs in patients with recurrent TGA?
In the case of recurrent TGA, meaning more than two attacks, I would ask for a focused history on migraine and seizures. If I suspected the latter, I would do a trial of an antiseizure medication, usually levetiracetam.
How frequently do you check CK in patients with Becker's muscular dystrophy?
I do NOT check CK regularly in Becker or other muscular dystrophies after the initial diagnosis. The question is why should we check it regularly when there is no disease-modifying treatment currently FDA approved for the vast majority of muscular dystrophies, and there is no correlation of the leve...