Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
When and how do you perform genetic testing for congenital myasthenia gravis in seronegative cases?
I believe that these congenital myasthenic syndromes can start at birth or early childhood, as we are all familiar with muscular weakness, particularly extraocular muscles, and bulbar, which is fatigable, worsening with physical activity, and there > 30 genes responsible, and symptoms vary by the Ge...
How to approach reversal of TNK in hemorrhagic conversion of ischemic stroke?
There is no specific "reversal agent" for tenecteplase. Once administered, the thrombolytic effect will persist until the drug is fully metabolized and any residual plasmin has been cleared by alpha-2-antiplasmin. So, perhaps the first question is what can you do if there is an acute bleeding event ...
How do you convert between tetrabenazine, deutetrabenazine, or valbenazine for management of tardive dyskinesia?
I think of these medications as much more clinically similar than different, with the main differences relating to patients who are fast metabolizers. Fast metabolizers often respond well to lower doses of deutetrabenazine or valbenazine compared to tetrabenazine. When converting from one drug to an...
What is your first-line therapy for acute migraine treatment in the ER?
Regarding the abortive and preventive treatment of migraine, in the office or ER, we should focus on migraine-specific medications. These are the ergots, triptans, and gepants abortively, and the CGRP antibodies and gepants preventively. The patients who visit ERs every so often tend to have headach...
What clinical features prompt genetic testing for patients with progressive cerebellar ataxia?
In general, any patient who presents with a chronic progressive cerebellar ataxia and is </=21 years of age deserves genetic testing. If a subacute presentation arises with no clear metabolic, inflammatory, neoplastic, vascular, etc., etiology, I would also recommend genetic testing in this group.Wi...
How do you counsel patients on how to take abortive migraine medications during the prodrome period?
I do not routinely counsel patients to take abortive treatments during prodrome. It would depend on headache frequency. It would be hard if their headache frequency is high, such as >8-10 headache days per month, as they may run out of their abortive treatment. If they have low headache frequency an...
How do you counsel patients and caregivers about the trajectory of cognitive decline in Parkinson’s disease?
I address the subject of cognitive impairment fairly early in PD, since patients may notice mild deficits in multitasking and attention even within the first few years of diagnosis. Strategies such as making lists and breaking down individual tasks are effective in preserving independence. Worsening...
How do you treat depression symptoms in patients with Parkinson's disease?
The management of PD-related depression can be a little complicated, but there are several proposed algorithms out there based on varying degrees of evidence. Personally, I like this reference (Pontone and Mills, PMID 33648830) as a place to start. It makes 3 key points: Distinguishing between PD an...
Is Migraine with Unilateral Motor Symptoms (MUMS) a diagnostic entity worth considering in patients with migraine and other associated symptoms?
I do not think so. It is not a part of the ICHD-3 criteria. If a patient with migraine disorder presents with weakness, it is possible that the weakness/motor symptoms are symptoms of migraine disorder. There is a diagnostic classification for such a patient already in the ICHD-3 criteria, which wou...
Do any subgroups of headache patients benefit more from neuromodulation devices compared to pharmacologic treatment?
I think patients with episodic cluster headache benefit greatly from external vagus nerve stimulation (gammaCore) use. This device aborts cluster attacks and has a preventative action as well for future attacks during a cluster bout. It allows for more than 2 treatments per day if the patient is hav...