Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
Do you screen adults in your practice with sickle cell disease for silent cerebral infarcts?
The details of the ASH guidelines regarding adults are complex. It was not my practice to screen all patients. More than 50% of adults have silent infarction. Screening requires MRI and this, according to the guidelines, needs careful attention to many details before it is reliable. There are no pro...
Would you hold CGRP (calcitonin gene-related peptide) monoclonal antibodies such as Eptinezumab-jjmr (Vyepti) before, during, or after lung SBRT?
No, I will not hold CGRP monoclonal antibodies during lung SBRT as at present, there is no data suggesting the detrimental effect of doing so. Moreover, the drug is conveniently given q 3months while SBRT is usually completed within 2 weeks. Therefore, most lung SBRT can be scheduled outside of the ...
Is there a role for unilateral hippocampal sparing?
There is some lateralization of hippocampus function which may impact decision making.The left hippocampus seems to play more of a role in episodic verbal memory, while the right plays more of a role in spatial processing. Our neurosurgeon has told me before that a left hippocampectomy is much worse...
How do you approach the workup of transverse myelitis without any abnormality on spine MRI?
If you are highly suspecting TM on clinical features, and other etiologies seem unlikely, then consider LP, checking labs (autoimmune, demyelinating, infectious, metabolic, etc), starting immunotherapy (if infection is unlikely, maybe check with Infectious Disease on that decision), and then in a fe...
Do you ever refer patients for surgery with significant peripheral neuropathy and lumbosacral radiculopathy?
A few factors should be considered to help with making the decision such as asymmetry of distal weakness related to lumbosacral radiculopathy, presence or absence of active denervation on needle EMG especially denervation in the proximal muscles of affected root/paraspinal muscles or asymmetric dene...
How do you approach the treatment of restless leg syndrome in pregnancy?
External leg compression device like home Scd’s can be helpful.
Do you send only serum paraneoplastic panels or also include CSF evaluation in patients with concern for paraneoplastic neuropathy?
Ideally, you should send both serum and CSF. There are several cases where the antibodies are positive only in CSF and not in serum.References: Graus et al., PMID 34006622 McKeon et al., PMID 21422462
When do you order SSEPs for evaluation of multiple sclerosis?
Occasionally, I order Visual EPs. SSEPs are largely worthless and Auditory VEPs, though occasionally helpful are rarely worth the trouble. A good thorough history, a detailed neurologic examination, a 3T MRI, and if necessary spinal fluid with good analysis for bands, IgG index, and kappa light chai...
In a patient with neurosarcoidosis who required infliximab for initially refractory symptoms but is now stable, how do you decide on the optimal time to de-escalate therapy?
I typically base this decision on several factors: Severity of initial symptoms, tolerability or side effects of treatment, degree/timeline of radiographic improvement, and patient preferences. I begin to consider tapering off or de-escalating infliximab after around 12-24 months of clinical and rad...
What are the main reasons that exercise trials have collectively failed to demonstrate sufficient evidence for disease modification in Parkinson's disease?
This paper by Ruiz et al discusses your question: On Disease Modifying and Neuroprotective Treatments for Parkinson's Disease: Physical Exercise. A big problem with studying exercise in any disease is that patients who can exercise are generally healthier than patients who cannot, so studies compari...