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?
If both are at their max doses, then, in addition to making sure the bedroom environment is safe, I recommend rivastigmine. HA
When should you avoid initiating beta blockers in a patient with myasthenia gravis?
In general, my opinion is that there are very few medications that are absolutely contraindicated in MG, and those are: botulinum toxin, aminoglycosides, macrolide antibiotics, and possibly magnesium supplements (unless the patient has dangerous hypomagnesemia). Many other drugs, especially drugs us...
How do you counsel patients interested in estrogen containing oral contraceptives who have migraine with aura?
Outside of patients whose attacks are suggestive of hemiplegic migraine, I do not typically avoid the use of estrogen-containing OCPs. While it is my understanding that a number of international organizations and many neurologists (as well as Ob/Gyn) recommend their avoidance, there are several revi...
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 approach to screening for cognitive impairment in hospitalized older adults?
Upon admission to the hospital, all older adults should undergo a brief cognitive screening. This initial step helps establish a baseline and can identify previously unrecognized cognitive issues. Several tools are well-suited for this purpose; we use minicog as the screening tool at our hospital. ...
What are your preferred treatments for vasospasm in the setting of RCVS?
In the inpatient setting, I like nimodipine. However, in the outpatient setting, patients may not want to, may not be able to, or may not remember to reliably take the medication every 4 hours. As you can imagine, this would be quite disruptive to their overall daily schedule and possibly their qual...
What follow-up monitoring would you recommend for an adult with self-resolved idiopathic acute pupil-sparing third nerve palsy?
Pupil-sparing third nerve palsy is a relatively common presentation for neuro-ophthalmologists. They typically resolve completely by 12 weeks, and I will typically follow them until they are fully resolved, watching them once a month. The most common are microvascular and associated with a variety o...
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...
How do you taper dopamine agonists for RLS in patients experiencing augmentation?
Slowly. Abrupt withdrawal from agonists can cause mood dysregulation (dopamine agonist withdrawal syndrome) and in RLS patients, would likely exacerbate RLS symptoms.Adding gabapentin to the regimen prior to slow withdrawal of the agonist would probably help avoid worsening RLS symptoms during this ...
How should the possibility of more chronic forms of autoimmune encephalitis influence our neuronal antibody testing thresholds for patients with slower progressive cognitive decline?
I will disclose that I am not a cognitive/behavioral neurology specialist nor a neuroimmunologist per se, but I would exercise caution in interpreting the conclusions of the paper that was cited. I went over the paper briefly, and I realized that 28 patients were diagnosed with "autoimmune dementia"...