Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
What interventions have you found most effective for reducing ED utilization in patients with PNES?
I have a frank discussion regarding the difference between epilepsy and PNES and the differing modes of treatment. I also refer them to our behavioral health department for cognitive behavioral therapy. That seems to decrease their ER visits.
Would you stop belimumab in a patient with SLE starting ravulizumab (C5 inhibitor) for myasthenia gravis due to concern for additive immunosuppression?
This is a good question for which there is not a definitive response in the literature. Benlysta has a fairly low rate of related infections though not studied in relation to the ravulizumab. Obviously, the patient should be fully vaccinated against meningitis. I would also want to assess how well t...
How long after starting an antiepileptic drug do you check levels?
Based on the half-life of AED and sometimes case-to-case based. General guidelines is 2-4 weeks of starting the AED.
Do you typically pursue EMG/nerve conduction study in patients who already have a clinical diagnosis of myasthenia gravis?
Depends on antibody status. If the patient is antibody positive (AchR or Musk) and has a classic presentation (e.g., Fatigable ocular and or bulbar weakness) and good response to first or second-line treatment (pyridostigmine, prednisone) then it’s probably not necessary. Seronegative patients or th...
How do you approach the workup for patients with hyperCKemia and positive NXP2 with no clinical symptoms?
I would approach it like any case of hyperCKemia: verify that the high CK occurred in at least two measurements 24 or more hours apart, not shortly after intense physical exercise, get a careful history and exam with special attention also to skin and nail findings. If hyperCKemia is persistent get ...
Provided no side effects, to what dose do you increase propranolol or primidone before considering them ineffective for a patient with essential tremor?
If tolerated maximum dose of 250 mg of Primidone bid would be acceptable. This is my personal experience.
How do you approach handling the many-page disability paperwork of neurological disease such as Parkinson's disease?
It can be daunting when one is handed a long form to fill out for disability in advanced PD patients. Admittedly, it is not my favorite thing to do but it will make all the difference in the life of the patient, so it is extremely important to handle it carefully. In the past, I used to have them re...
In antiphospholipid syndrome with recurrent strokes, would you consider adding antiplatelets to warfarin?
This is a good question, especially noting the high rate of recurrent thrombotic events in non-treated patients with antiphospholipid syndrome (up to 29% if untreated, but still significant among treated patients, especially after an arterial event). Edit: to jump to the punchline, I favor adding AS...
What is the recommended management approach in regard to diagnostic evaluation and treatment for patients with homocystinuria and cerebral thrombosis?
I think it’s reasonable to start anticoagulants for 3 to 6 months after getting complete blood test panels for hypercoagulation states. Be careful while interpreting abnormal hypercoagulation test results since many times you may see abnormalities. I would also repeat them within 3 months when the p...
Are triptans contraindicated in patients with Moya Moya syndrome who have never had an ischemic stroke?
I am not aware of specific evidence regarding triptans and Moyamoya. The contraindication in stroke is not based on data, just from concern about vasoconstriction, for which there is no clear evidence in the intracranial circulation. Hence I would be willing to prescribe a triptan, with appropriate ...