Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
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?
Weighted cutlery. There is a device called "Liftware" that has been effective in some of my patients...
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 ...
When do you initiate immunosuppressant drugs for patients with a diagnosis of myasthenia gravis?
I assume the question refers to non-steroid immunosuppressant drugs such as azathioprine, mycophenolate, methotrexate, etc. I use those drugs predominantly in generalized MG (although a few patients with ocular MG may also require them), a) in any patient that requires prednisone doses of >20 mg dai...
How does evidence of cerebral amyloid angiopathy/microbleeds affect choices for secondary stroke prevention in patients with a history of ischemic stroke and atrial fibrillation?
This is a discussion I have with the patient, mentioning that the positive predictive value of cortically based cerebral microhemorrhages is not absolute, especially when there is a small number of them and there are no other signs of small vessel disease (such as FLAIR changes or enlarged peri-vasc...
How do you manage random-OFF periods in patients with Parkinson's disease who are otherwise having good control of their motor symptoms?
That's a great question. This clinical scenario is perfect for the use of Parkinson's "rescue therapies." Rescue therapies are those that have a quick-onset of action to provide quick relief, without a significant duration of effect and limited side effects. There are two relatively new drugs on th...
When do you consider a levodopa trial in patients with new-onset dystonia?
Levodopa trials are recommended in all children with any type of dystonia and also adults whose phenotype could be consistent with dopa-responsive dystonia (DRD). An observed levodopa trial (generally up to 300–400 mg of levodopa daily in adults or 4–5 mg/kg/day in children) for at least a month is ...