Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
What treatment strategies would you utilize in a patient with newly diagnosed HLA-B27+ axial spondyloarthritis (with active and chronic sacroiliitis on MRI) and recent diagnosis of MS that is well-controlled MS ocrelizumab given the need to avoid TNF inhibitors?
This is a very challenging scenario. On one hand, TNFi are generally unsafe for MS due to demyelination risk, and on the other hand, anti-CD20 therapies for MS are linked to new AxSpA, but B-cell depletion might also benefit AxSpA. Thus, management requires specialized care in balancing both disease...
Would you consider anti-IL-5 therapy (mepolizumab or benralizumab) to either prevent or treat the more severe manifestations of eosinophilic granulomatosis with polyangiitis, such as "infiltrative" (e.g., cardiomyopathy, pulmonary infiltrates, or gastroenteritis) or "vasculitic" (e.g., neuropathy, palpable purpura, or glomerulonephritis)?
Yes, I would consider early starting biologics for infiltrative EGPA.
How do you interpret conflicting findings on CSF immunoglobulin tests for work up of multiple sclerosis and its mimics?
Although the specific role of cerebrospinal fluid (CSF) testing has evolved in the successive revisions of the McDonald criteria, it remains an important part of the evaluation of suspected multiple sclerosis (MS), both to provide support for the diagnosis of MS and to look for findings that suggest...
When would you consider prescribing a wakefulness promoting agent for excessive daytime sleepiness from insufficient sleep?
I would never consider prescribing an alerting medication for someone with insufficient sleep. Behaviorally insufficient sleep is a diagnosis in and of itself. The treatment for excessive daytime sleepiness in the case of insufficient sleep is changing behavior to allow for more time in bed. I would...
How effective have you found acupuncture for treatment of chronic migraine?
I would prefer to educate a patient interested in acupuncture for severe headaches about all the other treatments that are available. However, if they would still like to pursue acupuncture, I would support them, just like Dr. @Dr. First Last would say. Some patients can get better, although it is n...
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...
How do you balance the risk of unnecessary treatment with acyclovir against the risk of delaying treatment in encephalitis cases where CSF pleocytosis is absent?
Treatment with IV acyclovir should start as soon as the diagnosis of Herpes simplex encephalitis is considered. Since the question states that CSF pleocytosis is absent, then CSF has been obtained. PCR for HSV should be obtained on that CSF. Early in my career, when acyclovir was investigational and...
In a patient with strong serologic evidence of SLE presenting with isolated bilateral lower limb sensorimotor neuropathy, normal neuroimaging, and CSF, would you initiate cyclophosphamide with pulse-dose steroids upfront, or reserve escalation (e.g., plasma exchange or immunosuppressants) for cases refractory to steroids?
This has been a dilemma for me for over several decades.1. There is no good large data to guide us on this question. I do not think there is one correct answer.2. All sensorimotor neuropathies are not created equally. I assume all other causes of sensorimotor polyneuropathy have been ruled out. Howe...
When do you consider using a paramedian approach for a lumbar puncture?
I consider the paramedian approach for lumbar puncture in several clinical scenarios: When patients are unable to adequately flex their spine. When midline interspaces are narrow (<1 cm). When ultrasound reveals densely calcified spinal ligaments—a common finding in elderly patients that can obscure...
What is your approach to the management of persistent encephalopathy following ischemic injury to bilateral thalami?
This is a challenging case to manage and can be resistant to interventions. I am assuming when you say encephalopathy, you are meaning disorders of consciousness (DoC), in which the patient is comatose or somnolent. In those cases, generally speaking, we will start dopaminergic medications, usually ...