Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
What is your management approach for CAR-T induced motor neurologic deficits (cyclophosphamide/IVIG/steroids, etc.) and any prophylactic approach to an early, rapid rise in absolute lymphocyte count post CAR-T infusion?
Specifically, this seems to be a question around cilta-cel. There has been some recent guidance to consider pre-emptively starting dexamethasone if the absolute lymphocyte count rises above 3,000 in the period following CAR T administration. This partially stems from the observation that many of the...
How do you counsel patients with dermatomyositis on sun protection?
We make sure patients know that sun exposure can trigger flares, so we strongly recommend staying out of direct sunlight between 10 AM and 4 PM, using broad spectrum, SPF30+ sunscreen daily even when indoors (as UVA can penetrate through windows), and wearing sun protective clothing (ideally UPF-rat...
Do you obtain an MSLT or start empiric therapy with modafinil in patients with residual excessive daytime sleepiness despite optimal adherence to PAP therapy?
In this situation I would start either modafinil, armodafinil, or solriamfetol for residual EDS if the OSA was appropriately controlled without need for MSLT. We have an FDA label for these medications in this situation to support this practice. If I felt like there was concern for a combination of ...
Do you recommend getting a muscle biopsy in a patient with suspected IMNM with statin exposure, weakness, elevated CK, and positive HMGCR antibody?
A patient with a typical clinical presentation of IMNM (muscle weakness, high levels of CPK) and positive anti-HMGCR antibodies leaves no question regarding the diagnosis, and muscle biopsy would not change management. I would reserve muscle biopsy for atypical cases (for example, positive anti-HMGC...
What is the optimal BP target for patients with diabetes and hypertension to reduce their risk of MI/stroke?
From the 2025 ADA Standards of Care, section 10 discusses Cardiovascular Disease and Risk Management. With proper blood pressure technique, the recommended blood pressure treatment goal is less than 130/80 mmHg if this can be achieved safely. Several randomized controlled trials are referenced with ...
In which subset of patients with concussion do you recommend further brain imaging?
I recommend further imaging of a concussion patient in a subset of patients. If the patient had a seizure with the head injury or any sign of declining mentation within the first few hours, they should have a CT head emergently. If it is within 1 week from injury and they report steadily worsening e...
What are your preferred treatments for disrupted nighttime sleep in elderly patients with narcolepsy already taking sodium oxybate?
The treatment depends on what is causing the disruption. Before I consider any medication, I recommend a thorough investigation of possible causes of the disruption. For example, has sleep apnea been ruled out? Is the patient taking alerting substances close to bedtime? What is the sleep environment...
How do you manage a patient with giant cell arteritis treated with weekly tocilizumab and low dose glucocorticoid who develops sudden vision loss?
Fortunately, this scenario is a rare event, as most patients treated with ongoing tocilizumab (TCZ) and prednisone are at a far lower risk for developing new visual loss due to giant cell arteritis (GCA). A recent paper by Amsler et al., PMID 33752737 reviewing the risk for visual loss in patients b...
Would you recommend switching to DAPT for patients on anticoagulation who develop symptoms of a TIA secondary to ICAD?
It is important to remember that there is more to stroke secondary prevention than antithrombotics. Our use of DAPT in ICAD comes from the SAMMPRIS trial, in which patients in the control group did better than expected compared to historical controls with ICAD in the WASID trial. Recall however, tha...
What treatments have you found to be effective for mal de débarquement after trialing benzodiazepines such as clonazepam?
Try to find an underlying history of migraine. Generally, SSRIs and SNRIs (if headache is a feature) can help, but there are no controlled trials for this. Benzodiazepines should be used temporarily as a bridge for the above. If a history of migraine, even remote, is present, sometimes antimigraine ...