Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
What is your approach to REM behavior disorder not adequately treated with melatonin and clonazepam?
Rule out comorbidities like sleep apnea or medications causing RBD. Optimize doses for melatonin and clonazepam, and consider dual therapy with these. Other options are gabapentin or pramipexole. Thanks,Sam Morkous
Do you generally switch aspirin to another antiplatelet agent if a patient has a non-embolic ischemic stroke and isn't a candidate for DAPT?
I do tend to switch, mainly to impress the patient that I am trying hard to prevent another stroke, and not because there is clear evidence of one antiplatelet over another. Clopidogrel or ticagrelor would be candidates, or I might add cilostazol to aspirin, as this combination has little bleeding r...
For stroke patients with ablated paroxysmal atrial fibrillation without known recurrence and ICAD, would you recommend dual antiplatelet therapy or anticoagulation with or without an antiplatelet agent?
Ablation treats cardiopulmonary symptoms, but it has not been adequately tested against anticoagulation for AFib-related stroke. Anecdotally, at least once a month, I will see a patient with an acute embolic-appearing stroke after their cardiologist has stopped their anticoagulation because they wer...
Do you obtain an MSLT or start empiric therapy with modafinil in patients with residual excessive daytime sleepiness despite optimal adherence to PAP therapy?
In this situation I would start either modafinil, armodafinil, or solriamfetol for residual EDS if the OSA was appropriately controlled without need for MSLT. We have an FDA label for these medications in this situation to support this practice. If I felt like there was concern for a combination of ...
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...
At what lab values (ferritin, TSAT%) would you offer IV iron therapy to patients with restless leg syndrome?
1. I am hopeful that practitioners will start understanding that ferritin alone is not enough to assess iron because of its acute phase reactivity. I like to order iron parameters after a 5-9 hour fast so the serum iron is not speciously elevated and get a ferritin and TSAT. If the ferritin is <30 a...
How would you adjust the dose of everolimus for tuberous sclerosis in setting of asymptomatic rising liver enzymes, platelets, and lipid counts?
If a dose reduction of everolimus is needed because of asymptomatic lab value changes, I usually try reducing the dose by 25% for 2-3 months and then reducing by 50% of the original dose if the labs continue to worsen. A fairly moderate dose reduction is often sufficient and can still maintain effic...
Which patients are good candidates for transcranial electrical stimulation for the treatment of chronic insomnia?
Transcranial magnetic stimulation (TMS) is a noninvasive neuromodulation technique that has demonstrated efficacy in the treatment of insomnia in randomized clinical trials, although evidence supporting its long-term effectiveness remains limited. Studies have reported improvements in both subjectiv...
How effective do you find MAO-B inhibitors for the treatment of Parkinson's disease?
In a new patient with early mild symptoms, especially unilateral (Stage I), MAO-B inhibitors can be used. If you look at the Data from the TEMPO Study and Adagio study, Rasagiline 1 mg daily can have mild symptomatic benefits. In some patients, it may be the only drug they need for the next 2-5 year...
When do you consider starting an antiplatelet in a patient with stoke due to septic emboli?
If no ICH or microbleed on MRI and the patient has a strong indication for home antiplatelet, would continue single antiplatelet. Would NOT start for septic embolic stroke. Also avoid medical DVT prophylaxis for the first 1-2 days after endocarditis-related strokes. Initial vessel imaging with CTA o...