Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
When do you recommend checking blink reflex in patients with Bell's Palsy?
I have personally found that blink reflex testing is not as important as emphasized in the literature for the cases of facial palsy that are referred to our Lab. This is because most facial nerve EMGs that we see, are severe cases with profound axonal injury that show poor recovery after 3-4 weeks. ...
Do you typically recommend inpatient stroke evaluation for patients with incidentally found asymptomatic stroke on outpatient imaging?
This of course depends on so many variables, some scenarios and questions that matter in making the decision: Why was the imaging done in the first place? Not relevant to stroke or imaging was done because of TIA? What were the initial symptoms? Are you suspecting a large vessel occlusion (shocking...
Do you utilize post-vaccination IgG titers to detect common variable immunodeficiency in patients who are about to start or are actively on B cell depleting therapy?
I have checked M-M-R, Td, and pneumococcal titers in patients with hx of infection and low Ig levels to see if they are making an immunological response. If any of these immune titers are low or the immunization is “due” by routine schedules, I recommend immunization and repeat testing in 6 weeks. T...
How would you approach grade 2 neurologic toxicity in a patient on daratumumab, dexamethasone, and lenalidomide for relapsed multiple myeloma?
Clarification of the question was made, and it was focused on peripheral neuropathy. The polyneuropathy in Dara/Rev/dex is mostly due to the Revlimid. Most neuropathy from rev, if any, is grade 1- 2. The first step will be to start with gabapentin without reducing the dose of Revlimid. It is a very ...
How would you approach treatment of a patient with recurrent choroid plexus papilloma with intraventricular dissemination?
The management of choroid plexus tumors starts with diversion of the CSF flow, especially in this patient with a recurrence in the 4th ventricle. A gross tumor resection (GTR) is the most significant prognostic factor, but in this patient, it might not be feasible due to the dissemination in the lef...
Do patients on eculizumab or ravulizumab require repeat vaccination against meningococcal infection after a certain interval?
Yes, CDC recommends a booster Men B vaccine 1 year after completion of series and then every 2-3 years thereafter, and booster Men C every 5 years.
How do you manage asymptomatic patients with incidental findings of the carotid web?
Terrific question. I would certainly not pursue interventional treatment in asymptomatic patients with carotid web. The role of aspirin is also debatable and not conclusively proven. I would ensure vascular risk factors are controlled and consider starting aspirin if otherwise indicated based on ove...
How do you treat CIDP patients unresponsive to IVIG and steroids?
As a general rule, if a patient tentatively diagnosed with CIDP does not respond to an adequate trial of corticosteroids (e.g. 1 mg/kg prednisone daily for 1 month, or pulse methylprednisolone 500-1000 mg weekly for at least 4 weeks), and IVIG (loading dose of 2 g/kg, followed by 1 g/kg every 3 wee...
In light of the FDA approval of tofersen for SOD1-related ALS, what is your approach to counseling people who are presymptomatic genetic carriers of one of the monogenic ALS genes?
First of all, let's emphasize that there is no standard of care for the management of presymptomatic carriers of ALS genes. In other words, there is no strong scientific evidence in humans yet, that early initiation of any ALS treatment, will delay either the onset of clinical disease, or the progre...
Would you recommend temporary EVD or more permanently VPS to lower ICP?
We only place EVDs in patients who meet criteria with a GCS of 8 or less. If they are a GCS 9 or greater, we empirically manage cerebral edema if we think it is present, but do not monitor ICP with invasive devices. With regards to VPS, we never use them acutely to lower ICP. Shunts are only used i...