Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
When should you seek hyperbaric oxygen therapy for patients with CRAO?
I usually pursue hyperbaric oxygen therapy within the 24-hour window from symptom onset for CRAO. This can be performed following TNK if given. In reality, though, there are multiple barriers to achieving this, including: Few centers offer hyperbaric oxygen therapy Labor intensive Difficulty with i...
In an older adult hospitalized with recurrent falls, weight loss, without clear injuries, but with an inconsistent or difficult-to-reach caregiver, what findings would make you formally report suspected elder neglect and/or abuse?
I'm so glad that you're thinking about the possibility of abuse/neglect in this scenario! It's important to have it on our differential, or we'll always miss this diagnosis. First, it would be good to see if the patient can explain what is happening and provide contextual information that veers us a...
What is your preferred workup for patients who present with concern for autonomic neuropathy?
When patients report one or more symptoms suggestive of autonomic dysfunction, objective confirmation of impaired autonomic function is required. This may include the standard battery of autonomic tests included in the CASS score (tilt table testing, response of HR and BP to Valsalva maneuver, and ...
How do you counsel patients and caregivers about the trajectory of cognitive decline in Parkinson’s disease?
I address the subject of cognitive impairment fairly early in PD, since patients may notice mild deficits in multitasking and attention even within the first few years of diagnosis. Strategies such as making lists and breaking down individual tasks are effective in preserving independence. Worsening...
For patients with hydrocephalus secondary to leptomeningeal disease, how do you determine what type of shunt device to place?
For my small part, please ask neuro-oncology if they plan to use intrathecal chemo (and need a hybrid with Ommaya).
Would you start cholinesterase inhibitors for a patient with MCI or mild dementia based on MoCA testing, when there is concern for frontotemporal dementia?
No, there is no benefit of cholinesterase inhibitors and even a risk of harm from them in FTD.
Which imaging features do you use when considering Normal Pressure Hydrocephalus to decide whether to proceed with large-volume LP or lumbar drain trial?
At our center, we follow the approach of the NPH clinic at the Imperial College Hospital in London.See this excellent review article for further details: Carswell, PMID 36162853.
In advanced Parkinson’s disease, how should clinicians assess symptom management and quality of life when patients are no longer able to communicate themselves?
This is challenging and why palliative care professionals are not familiar with neurodegenerative conditions, questions their efficacy in helping our patients. Using validated tools can help such as the ESAS-rPD. This scale can be used to assess response to interventions. Family members may be able ...
How do you decide between the different oral longer acting levodopa medications?
The question would be, why are you changing, and what are you changing from? (i.e., are one of these your initial agent, a change due to Sinemet side effects, or a change because of motor fluctuations?) The current theory on dopamine replacement is "smoother is better," so the longer (and lower) you...
Cost and access aside, when might you prefer to start a patient on a triptan instead of a gepant for acute migraine therapy?
For me, the triptans are first line for migraine abortion. They have been on the market for well over three decades, we have a lot of experience with them, a lot of clinical-trial information is available on them, and also in special populations like teenagers and adolescents, as well as pregnant wo...