Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
Have you found sumatriptan to be an effective bridging therapy for trigeminal neuralgia exacerbations until a new maintenance prophylaxis dose becomes effective?
I do not have experience with using sumatriptan in the treatment of trigeminal neuralgia. It would not be part of a standard treatment. I have never had a patient who has tried this.
When would you repeat antibody testing for seronegative myasthenia gravis?
I will usually recheck in 1-2 years, but I mostly focus on acetylcholine receptor antibodies. I have never seen seroconversion from MuSK negative to MuSK positive. Also, if initial antibody testing for Acetylcholine receptor binding/modulating and MuSK antibodies is negative by RIA assay, I recommen...
What brain imaging findings do you find reliable to help support a diagnosis of idiopathic intracranial hypertension?
In a study by Bidot et al., PMID 26457687, transverse venous sinus stenosis (TVSS) was the most useful sign of IIH because of its high pooled sensitivity (97%) and specificity(93%). Orbital findings, such as optic nerve head protrusion, posterior scleral flattening, optic nerve tortuosity, and diste...
Do you still obtain Tensilon (edrophonium) testing for myasthenia gravis, and what do you feel is the added value over serum testing?
Edrophonium has not been available commercially for years. Neostigmine can be used intramuscularly instead, given with atropine, and the effect assessed 30-45 minutes later. Some seronegative patients will have a positive test, so it can be helpful when you still suspect myasthenia and want further ...
How often do you consider lamotrigine in patients with myoclonic epilepsy?
When considering juvenile myoclonic epilepsy, I frequently prescribe lamotrigine, especially if a person of childbearing potential. However, I counsel on the possibility that it may exacerbate or not completely control the myoclonic seizures. When considering progressive myoclonic epilepsies (PMEs),...
What is your treatment/management approach for an asymptomatic dissecting aneurysm with associated thrombus?
Management depends primarily on whether the dissecting aneurysm is extracranial or intracranial, given the differing risks of thromboembolism and subarachnoid hemorrhage (SAH). The presence of intraluminal thrombus is particularly important because it can increase the risk of artery-to-artery emboli...
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...
What is your preferred first-line agent to treat anxiety in patients with Parkinson's disease?
Any standard SSRI/SNRI can be tried. I like to try the SNRIs duloxetine or venlafaxine. If comorbid insomnia is a problem, mirtazapine may be a good choice. Think about talk therapy too. It is important to make sure episodic anxiety is not a non-motor symptom fluctuation related to levodopa or oth...
In a young patient with recurrent low-grade glioma s/p gross total resection, is there any role for further observation instead of radiation and chemotherapy?
As simple as this question seems to be on the surface, it is actually a very difficult clinical scenario to opine with certainty, primarily because of a lack of data. So, let us address this with each option in mind, weighing the pros and cons: Observation: We do know that in resected patients, radi...
How do you approach immediate management of paraspinal extramedullary hematopoiesis in patients with transfusion-dependent thalassemia when lesions are enlarging or causing neurologic symptoms?
In general, the goal of transfusion therapy in transfusion-dependent thalassemia (TDT) is to suppress ineffective erythropoiesis. It is the rationale for maintaining a higher pre-transfusion hemoglobin level, at 9.5-10.5 g/dl, well above the general threshold for PRBC transfusion used in oncology pa...