Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
For a patient with acute stroke who cannot tolerate statins, what is your preferred second-line agent for secondary prevention?
First question - is the patient experiencing the nocebo effect? I would explore statin-based symptoms. Ezetimibe - if only needs a small reduction. If you need to be more aggressive, I would use PCSK9 inhibitors. If the patient cannot tolerate a PCSK9 inhibitor or if you need more lowering, you can ...
In older adults with mild cognitive impairment, do you ever prescribe cholinesterase inhibitors and/or memantine?
This is a great question, and of course, "do you ever" will get you in trouble every time! Let me start by saying that, in general, I do not prescribe these drugs for MCI. Cholinesterase inhibitors are clearly indicated for the mild-moderate stage of some kinds of dementia (some people would include...
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 do you do for a patient with Parkinson's Disease and orthostatic hypotension who has failed midodrine, fludrocortisone, droxidopa, pyridostigmine, and atomoxetine?
I would not recommend using amantadine in this situation as it is known to worsen orthostatic hypotension (Perez-Lloret et al., PMID 22336566). This is a tricky situation, and if the patient has failed all of these medications, I would consider an alternate diagnosis, specifically MSA, especially if...
How do you approach a patient with both a resting and action tremor, suggestive of PD and essential tremor together?
This is a wonderful question. To answer this question, we first have to look at the underlying etiology that leads to action tremor in PD. The hallmark of Parkinson's Disease (PD) is rest tremor, and about 75% of patients with PD have rest tremor at some point in their disease course (typically more...
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...
What is the most updated consensus regarding the use of pill in the pocket oral anticoagulation in paroxysmal atrial fibrillation, and populations of patients who are most likely to be considered for enrollment in clinical trials?
I'm not sure that there is a consensus. The best available large trial data would recommend anticoagulation based on a CHADS2Vasc score of 2 or higher, while a score of 0 patients could be off anticoagulation, and if the score is 1, patients would benefit from shared decision-making. For the CHADS2V...
Which clinical or imaging features of cerebral amyloid angiopathy aid in predicting future risk of intracerebral hemorrhage?
Hemorrhagic imaging features of cerebral amyloid angiopathy can help understand the future risk of intracerebral hemorrhage (ICH). Observational studies have found that patients with cortical microbleeds without lobar hemorrhage have an ~5% risk of future ICH. In those with prior lobar ICH, this ris...
What would prompt discontinuing treatment versus switching or sequencing treatment in patients treated with an anti-amyloid therapy for Alzheimer's?
There are guidelines to stop the medication due to ARIA. In my practice, we only discontinued treatment once, and it was due to the personal choice of the patient and family. I do not see a reason to switch from one medication to the other based on the data we currently have.
In advanced Parkinson’s disease, how should clinicians assess symptom management and quality of life when patients are no longer able to communicate themselves?
This is challenging and why palliative care professionals are not familiar with neurodegenerative conditions, questions their efficacy in helping our patients. Using validated tools can help such as the ESAS-rPD. This scale can be used to assess response to interventions. Family members may be able ...