Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
What have you found helpful in counseling patients with migraine reluctant to take preventative medications?
I think all of the responses here are very reasonable, but often the hesitancy is based less on resistance to a specific medication than on the self-stigmatization we see in patients with chronic headache, migraine, or other primary or secondary headaches. Because migraine is not a life-threatening ...
What is the utility of a hypercoagulability workup in recurrent cryptogenic stroke, and what specific tests would you recommend?
Ambulatory monitoring for AFib is probably more helpful than such a thorough clotting workup.
What traditional or herbal medications do you regularly screen for in migraine patients?
I do not particularly screen for any. I go over the medicine and supplement/vitamin list that they are taking. I counsel patients on the option of using OTC vitamins/supplements for migraine disorder prevention. I routinely counsel on magnesium 500 mg daily, riboflavin 400 mg daily, and coenzyme Q10...
What techniques do you use to help reduce procedural pain for headache injection treatments?
In my clinic, none of the providers, to my knowledge, use any specific techniques to reduce procedural pain. We do offer ice packs that patients can use during or after a procedure. We do Botox and pericranial nerve blocks. It would be difficult to coordinate using REN prior to procedures. I suppose...
How do you decide when to discontinue immunotherapy for primary angiitis of the central nervous system (PACNS)?
I take a multidisciplinary approach with involvement of my neurobiology and rheumatology colleagues for the immunotherapy. PACNS can be relapsing or remitting. So needs close monitoring with radiologic (MRI and MRA high resolution vessel wall imaging or CTA/MRA with CSF studies 6 months and then 1 y...
How can I incorporate neuromuscular ultrasound into my practice with limited prior experience?
I think it's awesome when anybody is willing to implement a new tool into their established clinical workflow. My suggestion, if you are already an EMGer, would be to start small and simple with a focus on upper extremity focal neuropathy and practice, practice, practice.Carpal tunnel syndrome and u...
What are your go-to options for managing ICU delirium in patients with contraindications to antipsychotics?
Evidence for Ramelteon (Yu et al., PMID 36726202)Delirium with behavioral disturbances Depakote Clonidine Propranolol, especially with TBI Non pharmacological Make sure they're closer to the nursing station. Constant re-orientation. Shades open during the day and close at night. Bring anything they ...
When do you consider ultrahigh-dose methylcobalamin injections for ALS?
I have noted that several ALS experts are offering this option nowadays to patients. I will analyze herein why I am NOT in favor of this approach, and, if I would offer methylcobalamin to any of my ALS patients, I would prefer to offer the oral form:1) The reason it is offered is a positive randomiz...
Does receiving IVIG confound the result of SPEP and/or UPEP?
IVIG being a product of polyclonal immunoglobulins may ‘produce’ a monoclonal spike if the AUC is falsely calculated by the reader. IFE usually shows polyclonal banding but every now and then a monoclonal band is picked up. Being an IgG molecule with a 21 day halflife; and with the assumption that i...
What is your approach to using intra-arterial or intrathecal vasodilators in patients with vasospasm in subarachnoid hemorrhage despite usage of oral nimodipine?
Bottom line up front: The 2023 AHA/ASA focused update on aSAH recommends IA vasodilator infusion or mechanical angioplasty in clinically significant vasospasm refractory to medical therapy (Class IIa, Level B) and states that intraventricular nicardipine “may be considered” in selected patients (Cla...