Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
What is your approach to secondary stroke prevention in patients with atrial fibrillation and intracranial stenosis (>70%)?
The patient clearly needs to be on an anticoagulant for stroke prevention with atrial fibrillation and I would choose apixaban. If an antiplatelet is added to the apixaban, the risk of a major bleeding side effect is significantly increased. It is uncertain if apixaban is effective in reducing the r...
Do you find the UPDRS useful for the care of Parkinson's disease patients outside of research?
The UPDRS and MDS-UPDRS are both useful research tools for Parkinson’s. Parts one, two, and four are interview-based with some rater guidance. Part three is an objective assessment by the clinical rater. Performing part three of either UPDRS test in non-research settings is helpful to improve your u...
What is your approach to Tardive Dyskinesia when VMAT2 inhibitors are ineffective or unaffordable?
In established cases of tardive dyskinesia, in which withdrawal-emergent dyskinesia has been ruled out, and dyskinesia has persisted despite a sufficient washout interval after removal of the offending agent, VAM2 inhibitors such as valbenazine and deutetrabenazine are used for pharmacotherapy. If t...
Would you consider adding gabapentin off label for use in the treatment of glioblastoma at this time?
As an author on the paper, let me emphasize the findings and speculate on the implications. Recently, a number of laboratories have unraveled stunning preclinical and mechanistic findings demonstrating the ability of a subset of malignant glioma cells to usurp neuronal circuitry to promote tumor gro...
How does premorbid dementia affect your decision to offer acute stroke intervention?
I would try to engage the family, along with the patient, about goals of care, quality of life before the stroke, whether APOE status is known (E4E4 is a contraindication for tenecteplase), etc. This would lead to a decision about aggressive therapy, tenecteplase and/or endovascular therapy. Previou...
Are there any patients with newly diagnosed GBM in whom you would adopt Early-Start TTFields based on the TRIDENT study?
The authors of EF-32/TRIDENT should be commended for performing this impressive randomized trial of an already FDA-approved therapeutic in GBM maintenance, asking the question of whether an earlier start of TTF, during chemoradiation, improves overall survival. This is also a big ask of the therapeu...
What pharmacological management do you consider for self-injurious behavior in patients with autism spectrum disorder?
This is a great question but requires a nuanced answer. It all depends. In short, what I think the clinician needs to know is whether the patient with ASD and self-injury has a treatable condition that is driving self-injury. Perhaps the most critical is whether the patient has a medical problem tha...
When would you consider continuing valproic acid (Depakote) for seizure prophylaxis preconception or during pregnancy?
Frequent seizures with attempted wean. Nocturnal events increase the risk of SUDEP. Prior change in ASMs attempted twice pre-pregnancy with acute breakthroughs.
What is your approach to counseling older patients and their families regarding expected recovery of aphasia following a large hemispheric stroke?
There is no precise answer for this question. Every patient follows their own course after a stroke. The size of the infarct and the age of the patient will affect the prognosis. Older patients and those with larger infarcts tend not to have as much recovery. The improvement of aphasia can proceed o...
Do you prescribe respiratory muscle training (RMT) devices to patients with dysphagia?
We encounter dysphagia frequently in our patients with Parkinson's disease and other movement disorders. If there are any concerns about swallowing or aspiration, my first step is to refer to Speech Therapy for evaluation, and I defer to their expertise for specific treatments from there. That said,...