Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
How have you refined your approach to disclosing a new diagnosis of dementia to a patient and their family?
I tend to think about this disclosure as layers of an onion. My general layers are: Explain what dementia is (and is not) and how we got to that diagnosis. Something like "You and your family have noticed memory problems, and the testing we just did confirms that. The memory problem appears signifi...
What is your approach to counseling older patients and their families regarding expected recovery of aphasia following a large hemispheric stroke?
There is no precise answer for this question. Every patient follows their own course after a stroke. The size of the infarct and the age of the patient will affect the prognosis. Older patients and those with larger infarcts tend not to have as much recovery. The improvement of aphasia can proceed o...
Are there any patients with newly diagnosed GBM in whom you would adopt Early-Start TTFields based on the TRIDENT study?
The authors of EF-32/TRIDENT should be commended for performing this impressive randomized trial of an already FDA-approved therapeutic in GBM maintenance, asking the question of whether an earlier start of TTF, during chemoradiation, improves overall survival. This is also a big ask of the therapeu...
Do you switch from Eliquis to Pradaxa in patients who experience a recurrent ischemic stroke while on Eliquis, considering their different mechanisms of action?
I tend not to switch patients from Eliquis/apixaban to Pradaxa/dabigratan. There is no good data to support this and while the mechanistic argument may make sense, especially since dabigatran, a direct thrombin inhibitor, was the only DOAC to reduce ischemic stroke events in a statistically signific...
How do you counsel patients who do you not experience early relief of hemifacial spasm after microvascular decompression surgery?
From a neurology standpoint, I counsel patients (preferably ahead of time) that surgery has a reasonable chance of improving hemifacial spasm but is not always effective. There can also be both early and late (reemergent) persisting spasm. I have treated some patients after MVD with botulinum toxin,...
What elements beyond NEDA-3 do you find valuable for tracking disease progression in MS?
I find NEDA-3 useful, but it is clearly incomplete, particularly for detecting gradual progression that occurs independently of relapses or new MRI lesions. In routine practice, fully quantifying progression and quality of life can be challenging, especially in a busy clinic. For me, what the patien...
What is your approach for monitoring disability progression in patients with MS?
My standard approach to MS patient visits includes asking about past/chronic symptoms and whether they are stable or worsening. I also ask a review of (neuro) systems with particular focus on gait change, bladder dysfunction, and cognitive concerns, as these are strongly associated with disease prog...
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 approach sequentially tapering combination therapy (i.e., IVIG, mycophenolate, rituximab) for dermatomyositis that is in remission?
This process involves trial and error and requires collaboration between the physician and the patient to determine the most appropriate tapering strategy. My personal preference is to begin tapering medications with the highest risk of side effects. Among IVIG, mycophenolate, and rituximab, I would...
How do you approach evaluation of a patient referred for mononeuritis multiplex and +SSB?
Step 1: A clinical syndrome of mononeuropathy multiplex always requires an EMG study. Is the primary mechanism of the MnM axonal or demyelinating? If it is demyelinating, there are only two possible diagnoses: multifocal CIDP (Lewis Sumner syndrome, which can occur in the context of Sjogren's syndro...