Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
How do you work with patients to establish reasonable treatment goals for the management of fibromyalgia-related pain?
Great question. I explicitly tell my patients that I have no magic-bullet– no penicillin or prednisone-adjacent pill – that will swiftly and reliably alleviate their pain. This expectation, that a pill will eradicate disease, makes sense in the wake of the infectious disease revolution, where target...
Do you give TNK to patients presenting with transient global amnesia like symptoms within 4.5 hours?
This is a very interesting clinical question that does not come up practically very often. There is next to no study data available on the matter, so most of what I will propose here can be classified as an expert take. I think that the most direct, and clinically relevant way of approaching such a ...
What are your preferred beta blockers for migraine prevention treatment?
Beta blockers, originally developed for cardiovascular disease, were serendipitously discovered to reduce the frequency and severity of migraine attacks in the late 1960s. They remain the most widely used class of prescription preventive medications for migraine. Among beta-blockers, only propranolo...
What is your preferred treatment for rhinorrhea in patients with Parkinson's disease?
According to a recent meta-analysis, rhinorrhea is common in people with PD; present in almost half of patients. I have only prescribed it a few times, but to the best of my knowledge, intranasal ipratropium is what is most commonly tried. Efficacy is variable. And there are no PD-specific studies o...
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...
What factors do you take into account when deciding the length of adjuvant temozolamide in GBM?
The field is evolving from 12 cycles to 6 for IDH-wildtype GBM in recent years, on the basis of some retrospective studies and notably the prospective Spanish study GEINO 14-01 - there does not seem to be much OS benefit, and there are also toxicity concerns (myelosuppression, hypermutation). Extens...
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...
In patients with suspected reversible cerebral vasoconstriction syndrome (RCVS), is there a role for preventative CCB if the headache has resolved/now asymptomatic?
In short, the use of CCBs in RCVS is only for the prevention of thunderclap headache (TCH) recurrence. Since their purpose is to prevent TCH recurrence, they are often used when the patient is asymptomatic as well (i.e., even after the index TCH has resolved). They do have no impact on eventual clin...
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 is your treatment approach to functional cervical dystonia?
If I am confident that the diagnosis is correct, I generally would treat functional cervical dystonia the same way as any other functional disorder. This includes evaluation of high-risk mental health factors and ideally referral to mental health treatment. In some individuals, functional disorders ...