Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
When would you consider using occipital nerve blocks to treat episodic cluster headaches?
For many years, it has been known that occipital nerve blocks containing steroids help for a few days in episodic cluster headache. But giving steroids by mouth for 3-5 days also works well and lasts for several days (for migraine attacks, I prefer occipital nerve blocks with local anesthesia and no...
What is your approach to the diagnostic workup of small fiber neuropathy in patients with known rheumatic disease?
Small fiber sensory neuropathy (SFN), in general, including in patients with rheumatic diseases, should be suspected based on symptoms (positive more than negative sensory symptoms) and ideally confirmed by clinical examination showing altered temperature and/or pain/pinprick perception in the limbs...
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...
When do you use seizure prophylaxis in patients on clozapine?
The topic of the use of anticonvulsants for primary prophylaxis of clozapine-induced seizures continues to be debated. The idea of prescribing anticonvulsants prophylactically for patients taking >600 mg/day of clozapine was suggested by Devinksy et al., PMID 2006003 in 1991. Clozapine-induced seizu...
Will OCEANIC-STROKE change your approach to secondary stroke prevention for high-risk TIA and non-cardioembolic stroke?
I would consider the OCEANIC-STROKE study a major contribution to the literature on secondary stroke prevention. The study included only noncardioembolic and nonlacunar strokes, with evidence of intracranial or general atherosclerosis (at least one of the above categories). It showed a significant b...
How, if at all, do you anticipate incorporating Pixclara PET into the evaluation of suspected recurrent or progressive glioma after treatment?
In pediatric high-grade glioma, I think there's an opportunity to use it selectively when conventional MRI leaves uncertainty between true progression and treatment-related change (pseudoprogression), rather than as part of routine surveillance. The clearest need is in diffuse midline glioma after r...
How do you manage an MS patient who has had attacks in spite of being on B-cell depleting therapy?
In patients with continued disease activity on B-cell suppression, generally, I do not switch from one B-cell therapy to another, as there is no clear evidence that one works better than another (Torkildsen et al., PMID 42384870). Largely, efficacy has been shown for nearly all drugs in this class o...
How do you determine personalized blood pressure targets after ischemic stroke?
This is an excellent question and really takes careful consideration of individual patient characteristics. This also requires detailed discussions with your Neuro-Interventional Radiology Team so that you can best understand what happened during thrombectomy and how successful reperfusion therapy w...
In what cases, if any, do you find the use of naltrexone to augment lifestyle interventions (i.e., cognitive behavioral therapy, graded exercise therapy) for chronic fatigue to be helpful?
Yes
How do you approach treatment of a glioblastoma in pregnancy?
Glioblastoma during pregnancy could be treated safely (to mother and fetus) with certain precautions and modifications. Collaboration and consultation with the patient’s obstetrician are essential. External shielding over the patient’s abdomen during treatment will decrease the external scatter radi...