Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
Do you recommend neuromodulation treatments with an implantable device for patients with chronic painful diabetic neuropathy who have not responded to common oral therapies such as Gabapentin and Amitriptyline?
Absolutely.I am a board-certified neurologist and pain medicine physician. By the time patients are referred to neurology, they have typically failed conservative oral or topical therapies. In this context, spinal cord stimulation represents a transformative option.Conventional oral medications usua...
Should IVIG dosing in patients with autoimmune disease (i.e., dermatomyositis) who become pregnant continue to be based on actual weight at the time of each infusion, or should it be limited to pre-pregnancy weight?
This is a very interesting and incredibly pragmatic question, but not one with an easy answer.By way of background:The treatment of pregnant DM patients is understandably complicated by the need to balance adequately treating disease activity against the maternal/fetal toxicity of medications. In ad...
How do you approach the management of neurocognitive and memory deficits in post-concussive syndrome?
I answered this on a similar question before, but my answer still applies here: I typically ask the patient what scenarios they experience cognitive issues in. The various examples they provide usually relate to difficulty following conversations, forgetfulness within their working memory, and conce...
How do you counsel patients who develop DVT or atrial fibrillation requiring anticoagulation when being treated with lecanemab or donanemab?
I do not think that anticoagulation is contraindicated in patients with these Alzheimer's disease antibodies, but I would want to check APOE status. I would not initiate the AD treatment if the patient is E4E4, and even one E4 would make me hesitant to have a patient on anticoagulation and an Alzhei...
In ischemic stroke patients with low LDL levels (<30-50 mg/dl), would you consider lowering LDL levels to lower values without concern for any side effects?
If LDL levels are already below 70, I don’t target a lower goal. The SPARCL trial showed that reducing LDL to this range has an NNT of about 45 to prevent one stroke, which I find to be modest at best. From my perspective, lowering LDL further (<30-50 range) shifts the focus to treating a number rat...
How do you transition from Levetiracetam to Brivaracetam, particularly at doses of 1500 mg BID or higher?
You can follow the ILAE guidelines (Asadi-Pooya et al., PMID 35894673)Brivaracetam/levetiracetamBrivaracetam at 50 mg could be replaced by 1,000 mg levetiracetam, 100 mg of brivaracetam by 2,000 mg levetiracetam, and 200 mg of brivaracetam by 3,000 mg levetiracetam 9. In case of need, these two drug...
When do you restart anticoagulation in patients with atrial fibrillation who just had an ischemic stroke?
The recent ELAN trial (Fischer et al., PMID 37222476) and now the published CATALYST meta-analysis (Dehbi et al., PMID 40570866) all support the concept that early anticoagulation (within 4 days of stroke) with a DOAC is safe and effective. There appears to be no interaction with clinical factors su...
How do you evaluate and manage patients with recurrent multifocal subcortical ischemic infarcts of unclear etiology?
Presuming the search for a large vessel or cardiac source was negative, I would assume the cause is small vessel disease. To reduce the risk of recurrence, vascular risk factors such as hypertension and elevated cholesterol should be maximally controlled. An antiplatelet drug should also be used, ei...
Which multiple sclerosis DMTs would you consider in patients with concurrent Crohn's disease and elevated JCV Ab titers?
This may depend on the course/activity of both the MS and Chron's. S1P inhibitors, specifically ozanimod, have minimal risk of PML and are FDA-approved for both UC/Crohn's and MS. While the treatment landscape continues to shift, S1P inhibitors are generally considered either moderate or high-effica...
How do you counsel eligible patients on how to decide between lecanemab vs donanemab?
Donanemab is not yet offered at my institution, though we expect it to be soon. With that caveat, it is my view that lecanemab will almost always be my recommendation because of the lower rate of ARIA, especially in e4 carriers. While the Q4W dosing regimen of donanemab is an attractive feature for ...