Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
Under what circumstances do you recommend POCUS guidance for lumbar puncture?
If the circumstances allow for it, I would use ultrasound for guidance for LP every time a LP is performed. This allows for continued practice in identification of the landmarks and improves accuracy in POCUS when it's truly needed, as in obese patients, where landmarks are difficult to palpate. Got...
Will you incorporate the use of tirzepatide in the management of patients with OSA?
Yes! However, the best methods to incorporate GLP-1s into the practice of Sleep Medicine have yet to be determined. Hopefully, our professional organizations can provide us with clinical practice guidelines to better direct our practice in this area.For those that have not had a chance to review, SU...
Do you utilize tumor treating fields in patients with anaplastic pleomorphic xanthoastrocytoma (PXA) III?
I would, but I haven't actually had the opportunity. With more information appearing that TTF is effective in brain metastases, mesothelioma, and pancreatic cancer, why wouldn't you use it if you didn't have a better option? The only real risk is financial.
How do you approach the medical evaluation of new onset psychosis in elderly patients?
The medical evaluation of new-onset psychosis begins with a thorough history (medical, neurologic, and psychiatric history), including a history of the present illness, medications, as well as the use of alcohol and recreational drugs. Obtaining information from family or others who know the patient...
Do you prescribe respiratory muscle training (RMT) devices to patients with dysphagia?
We encounter dysphagia frequently in our patients with Parkinson's disease and other movement disorders. If there are any concerns about swallowing or aspiration, my first step is to refer to Speech Therapy for evaluation, and I defer to their expertise for specific treatments from there. That said,...
How do you determine the time window for which to monitor for cerebral edema development in patients with brain injury?
The type of edema definitely matters. The two big categories of cerebral edema include cytotoxic and vasogenic edema. Cytotoxic results from free water accumulation in dying cells from acute brain injury, while vasogenic edema results in disruption of the blood-brain barrier. The classic teaching is...
What is your approach to managing seronegative myasthenia gravis in patients who have not responded to immunotherapy?
The quick and easy answer is that the diagnosis must be reconsidered. To facilitate the discussion, I would divide the seronegative patients into two groups: ocular and generalized. I assume that patients have been tested for AchR, MuSK antibodies (and possibly LRP4?), and the results are negative....
Would you use a triptan in a patient with a vascular malformation, such as an arteriovenous malformation, cavernous malformation, or developmental venous anomaly?
I see no reason not to use a triptan under the circumstances mentioned. I consider the gepants indicated when there are contraindications to the triptans, which are: poorly or uncontrolled hypertension and (atherosclerotic) vascular disease affecting the heart, brain, bowel, or legs. The above-menti...
How do you manage orthostatic hypotension in patients with Parkinsonian syndromes?
Don’t forget to check for adjunctive medications including urinary alpha antagonists which can cause orthostatic hypotension. If possible, reduce doses of cardiac medications. If this is not possible, then consider small frequent meals, exercise, especially the lower extremity elevating the head of ...
What is your approach when recommending occipital nerve stimulation for refractory cluster headache?
That particular study by Gutierrez et al., PMID 40391557, did not address the efficacy/safety of ONS in chronic/refractory cluster headache disorder, but it was in occipital neuralgia/cervicogenic headache populations.In a randomized controlled trial by Wilbrink et al., PMID 34146510,131 study parti...