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...
Do you recommend anticoagulation for stroke prevention in patients with atrial high rate episodes?
In a patient with atrial high-rate episodes (AHREs) detected by a device, I would generally only recommend treatment with anticoagulation if the episodes are confirmed as atrial fibrillation or atrial flutter based on an ECG/rhythm strip. Detecting AHREs is important to alert treating clinicians of ...
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 decide on extending an NCS for a suspected CIDP patient but so-far negative testing?
I agree with @Dr. First Last that testing 2 upper extremities and at least one lower extremity are appropriate (the guidelines make this point). The upper extremities tend to provide more useful information, as the lower extremity amplitudes can be very low and proximal stimulation is limited. Pleas...
How would you approach the consideration of a levodopa trial in an older adult with a history of schizophrenia, stable on antipsychotic medication, who has changes consistent with drug-induced Parkinsonism vs Parkinson's disease?
The first step is to establish if it is degenerative Parkinsonism, such as Parkinson's disease (presynaptic dopaminergic loss) or drug-induced Parkinsonism DIP (due to postsynaptic dopaminergic blockade). I will order a DaT scan to differentiate between the two. If the DaT scan is abnormal, I will s...
What is the role of inebilizumab in the maintenance treatment of IgG4-related disease?
Inebilizumab may play an important role in the maintenance treatment of IgG4-related disease (IgG4-RD), particularly in patients at high risk for relapse. These are typically patients with multi-organ involvement and elevated serum IgG4 levels who initially respond well to corticosteroids but tend t...
How do you approach a patient who develops a rest tremor after chemotherapy?
Like many questions in Neurology, this question can be simple or rather complex to answer. If the patient is felt to have a drug-induced tremor, withdrawal of the offending drug or drugs should be the first choice whenever possible. In the chemotherapy setting, a common scenario would be when a dopa...
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...
What is your approach to dosing scIG for CIDP in patients stable on IVIG?
There are at least several categories of stable patients (IgG-responders): Stable with no change in initial IVIg dose or interval (minimum effective dose unknown but clinically optimized); Stable with no change in initial IVIg dose or interval (minimum effective dose unknown but NOT clinically opti...