Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
Should aTTR mutation with bilateral carpal tunnel alone prompt treatment with a gene silencing drug?
Carpal tunnel syndrome does not qualify as a peripheral neuropathy due to TTR amyloid. The amyloid deposition is in the soft and/or connective tissue and not in the nerve. As such, there is no clear indication to treat as much as one might be tempted. Careful follow-up and treatment as soon as neuro...
What are your preferred second-line medications for trigeminal neuralgia?
My FIRST-LINE medication for trigeminal neuralgia is botulinum toxin. I write about its application in face pain, including trigeminal neuralgia, in Chapter 16 of my book, HEADACHES: Why You Have Them - What You Can Do About Them.
How do you work up patients who present with elevated myoglobin in the setting of normal creatinine kinase and exercise intolerance?
Myoglobin may originate either from cardiac or skeletal muscle; therefore, I would first try pinpointing the origin with troponins and CK fractions. I would work up the exercise intolerance with a non-ischemic forearm test to determine whether a flat lactate curve is present. In that case, I’d typic...
How do you treat nocturnal leg cramps?
Nocturnal leg cramps are similar to daytime leg cramps, but stretching may be less convenient to use as a remedy, as sleep can be further disrupted. Treating and preventing leg cramps typically utilizes some combination of hydration and electrolytes but sometimes, medications can help. Consider the ...
What clinical features predict visual recovery from optic neuritis in NMOSD?
The main clinical feature associated with outcomes is the severity of vision loss at nadir. The more severe the vision loss, the higher the risk of poor outcomes. However, there can be patients with very severe vision loss (no light perception) who can still recover to 20/20. The correlation with ra...
How does progression independent of relapse activity (PIRMA) influence your decision to change treatment in relapsing remitting multiple sclerosis?
In a patient who is progressing in the absence of relapse activity, I typically do not change DMT and instead focus on managing the symptoms directly. Such as physical therapy or walking aids, physical worsening, cognitive rehab, OT for fatigue issues, or counseling if mood issues are contributing t...
When do you find benefit in sequencing different dopamine receptor blockers for emergency treatment of migraine?
I know that these medications given intravenously have been found effective abortively in randomized, double-blinded, placebo-controlled trials. Prior to the advent of the triptans in the early nineties, I often treated migraine headaches abortively with metoclopramide 10 mg orally, in 15 minutes, f...
When do patients with descending paralysis and suspected botulism require inpatient EMG?
If a health care provider suspects botulism in a patient presenting with descending paralysis (beginning from the cranial/bulbar region) and certain clues such as autonomic nerve involvement with dilated poorly reactive pupils, constipation, etc. can help, then treatment must be administered immedia...
How would you balance the risk of intracranial hemorrhage with thrombosis of mechanical valves in patients with infective endocarditis?
I'm not sure that there is a good answer to this question. If you look at it segmentally, clearly, patients with mechanical valves require anticoagulation, especially in the mitral position. In patients with endocarditis and native valves, whether or not to anticoagulate the patient after or before ...
When should we order a DaT scan in patients suspected of Parkinsonism syndrome?
I believe that a good clinical examination can tell you if a patient has parkinsonism or not and that is the same answer one gets from a DaTscan. If the findings are too subtle, then re-examine the patient at intervals. So my answer is it is not necessary. I emphasize "my" answer because not everyon...