Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
At what point do you refer patients with medication refractory epilepsy for surgical evaluation?
The definition of medically refractory epilepsy is any patient who has failed two or more appropriately chosen and dosed antiseizure medications with the failure of the med not due to side effects. Any patient who is medically refractory should be referred to an epilepsy center for evaluation of pot...
What workup and management plan is indicated for patients with orthostatic tremor?
Work-up can include a surface EMG recording of the patient in multiple positions (i.e. lying, sitting, standing) with confirmation of high-frequency (~15hz) tremor in the standing position (after several minutes of standing, typically).Regarding management, clonazepam, gabapentin, and propranolol ar...
Should patients with cerebral amyloid angiopathy have any statin medications discontinued?
There is equipoise about use or discontinuation of statin in patients who have had an intraparenchymal hemorrhage attributed cerebral amyloid angiopathy. A multicenter clinical trial is investigating this question (https://clinicaltrials.gov/ct2/show/NCT03936361). I would base continuing vs disconti...
How do you approach the use of biologics in patients with a history of Guillain-Barre syndrome?
Onset of demyelinating neuropathies after TNF-inhibitor treatment has been reported in a small fraction of patients treated with these agents. Although their effects on patients with a history of GBS have not been systematically studied, TNF inhibitors are generally avoided in patients with history ...
When do you consider lesion therapy (such as pallidotomy or subthalamotomy) instead of DBS in patients with Parkinson's disease?
Although lesion therapy can be beneficial for motor symptoms of PD, the response is variable, and PD itself changes over time so the benefit will likely wane over time. Thus, the best candidates for lesion therapy are persons with limited life expectancy or substantial contraindications to DBS such ...
In what situations would you consider memantine when treating multiple brain metastases with SRS?
The study by Brown et al., PMID 23956241 showing the benefit to memantine in terms of delay/decrease in neurocognitive function was in patients receiving whole brain radiation therapy. That is why I routinely offer memantine to patients receiving WBRT. (Even with the study results, I almost always h...
When do you trial pyridostigmine in a patient with suspected myasthenia gravis?
I usually try it very early on if I have a reasonable suspicion. Compared to the tensilon test and even the neostigmine test, a diagnostic trial of pyridostigmine is safer and more resource-efficient. Diagnostic trials of pyridostigmine are not particularly evidence-based, nor is treatment, but this...
What do you routinely recommend for non-pharmacologic management of essential tremor?
Similar to above, I introduce the essentialtremor.org website, pull it up in clinic if I have time, and review the assistive devices tab (hand printouts to patients not internet savvy) which I have found very helpful. I have also found some useful wrist weights on amazon. The Cala Trio device is ty...
How do you treat paroxysmal phenomena such as paroxysmal dysarthria or dyskinesia in multiple sclerosis?
Paroxysmal dyskinesia/dystonia and dysarthria can develop in patients with MS and there is a variety of ways this is managed. There are reports that this can improve with steroids however, I typically manage paroxysmal symptoms similarly to how I manage tonic spasm and Llhermitte's. I typically use ...
How do you approach the timing of COVID-19 vaccination for patients with multiple sclerosis on B-cell depleting therapies?
B-cell depleting agents can interfere with a patient's ability to develop an adequate humoral response. With regards to the infusions such as rituximab and ocrelizumab, I recommend holding off on getting SARS-CoV2 vaccinations until at least 3 months and up to, at minimum, 2 weeks prior to the next ...