Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
Do you recommend routine neurosyphilis testing in patients being evaluated for dementia?
Syphilis is a rare cause of dementia without other evidence of neurological disease, at least in the US and most other industrialized countries. Of course, a careful neurological examination is required for all dementia patients, but the absence of other manifestations of neurosyphilis makes testing...
How do you decide on head-of-bed positioning after mechanical thrombectomy for acute stroke?
First, there is some evidence that HOB positioning is related to deterioration/improvement before endovascular thrombectomy (EVT) from the ZODIAC trial (Alexandrov et al., PMID 40465238). Second, safety comes first. Follow your ABCs. If the airway is ok, the patient does not develop orthopnea with a...
How do you counsel patients with GCA on the benefits of steroids who have already experienced vision loss?
I first tell the patient they are at considerable risk for further visual loss in the same eye or the other eye over the next 1-2 weeks. I also let them know that, even though their risk of visual loss has been reduced, their best option for preventing further visual loss is immediately starting hig...
What is your preferred treatment for rhinorrhea in patients with Parkinson's disease?
This review paper discusses several treatment options for rhinorrhea in Parkinson's disease: Chen et al., PMID 36382119. This paper discusses exocrine gland dysfunction more broadly: Munhoz et al., PMID 41902376.Keep in mind that some dopamine agonists can increase rhinorrhea, so consider switching ...
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...
What is your preferred first-line treatment for chronic fatigue in patients with long COVID-19?
Assuming that a thorough workup for other causes of fatigue (anemia, thyroid dysfunction, sleep apnea, etc.) has been performed and is negative, no single medication has been proven by a randomized placebo-controlled trial to help chronic fatigue in PASC. Anecdotally, my colleagues who treat PASC ha...
In ischemic stroke patients with low LDL levels (<30-50 mg/dl), would you consider lowering LDL levels to lower values without concern for any side effects?
If LDL levels are already below 70, I don’t target a lower goal. The SPARCL trial showed that reducing LDL to this range has an NNT of about 45 to prevent one stroke, which I find to be modest at best. From my perspective, lowering LDL further (<30-50 range) shifts the focus to treating a number rat...
Do you recommend lumbar puncture for suspected early GBS without motor involvement?
If purely for the confirmation of a GBS diagnosis, then no.CSF testing has limited utility for Guillain-Barré syndrome (GBS) diagnosis early in the disease course. Cytoalbuminologic dissociation is only present in 50% of patients in the first four days and rises to ~80% after the first week (Al-Hake...
Have you changed your practice in treating CRAO with IV thrombolysis?
The recent THEIA trial had a limited sample size to draw conclusions, even though there was a non-significant trend of improved visual acuity initially in the thrombolysis group. Even the TenCRAOS trial had a small sample size with recruitment challenges, where subtle small differences cannot be acc...
Do you require a lumbar puncture to evaluate for infectious etiologies before starting steroids for possible transverse myelitis seen on MRI?
Yes, I would perform a lumbar puncture alongside an MRI of the brain and cervical/thoracic spine with contrast to evaluate for potential infectious and inflammatory etiologies prior to starting steroids. LP is especially important if the patient has a fever, other symptoms of infection, or is immuno...