Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
How do you approach sequentially tapering combination therapy (i.e., IVIG, mycophenolate, rituximab) for dermatomyositis that is in remission?
This process involves trial and error and requires collaboration between the physician and the patient to determine the most appropriate tapering strategy. My personal preference is to begin tapering medications with the highest risk of side effects. Among IVIG, mycophenolate, and rituximab, I would...
How do you approach the decision of when to perform left heart catheterization in a patient with an NSTEMI who recently had an acute ischemic stroke?
This is a complicated question. Most acute CVA patients have non-MI troponin elevations, and I generally treat them medically. If there is a true NSTEMI associated with CVA, it requires a thoughtful approach. I generally divide my NSTEMI patients into high-risk and non-high-risk. I will perform a di...
How do you manage patients with atrial fibrillation having a thromboembolic infarct despite being on adequate anticoagulation?
This scenario is always challenging. In terms of anticoagulation, the efficacy of DOACs in preventing embolic events in AF patients is around 70%, which is impressive compared to warfarin but not foolproof. In cases of a second embolic event while on anticoagulation, two reasonable approaches are of...
How do you sequence pharmacologic treatments for primary insomnia?
First, be sure you have already addressed deficiencies in sleep hygiene: Room at 65 degrees F Wearing earplugs Complete darkness (no visible hand in front of face) No clock Golden hour before bed ETOH, nicotine, and caffeine reduction with cessation of 4 hours before bed Writing a list of worries B...
How do you manage patients with good relief but intolerable chest tightness with sumatriptan?
An abstract I collaborated on was accepted by the European Society of Cardiology reported that patients with angina diagnosed with migraine have a higher prevalence of vasospastic angina, otherwise known as angina and non-obstructive coronary artery disease (ANOCA). We are recommending that these pa...
Which factors help you choose between intermittent phenobarbital dosing versus continuous pentobarbital infusion for pharmacological burst suppression in refractory status epilepticus?
I am not aware of any guidelines or data that recommend the use of phenobarbital over pentobarbital for burst suppression in refractory status epilepticus. In fact, guidelines tend to favor pentobarbital in patients who have failed propofol and midazolam. Phenobarbital can certainly be used for seiz...
How do you identify patients with false positive AcHR antibodies?
First of all, of course, one should look for the clinical correlation. Even a weakly positive AchR binding antibody is likely to be "real" (true positive) if accompanied by unequivocal clinical signs of MG, e.g., fatigable ptosis with positive ice pack test, or fatigable bulbar/limb weakness. Ideall...
To what extent do you incorporate electrodiagnostic testing and ultrasonography in your clinical practice for evaluating suspected cases of meralgia paresthetica?
In my opinion, meralgia paresthetica is one of the easiest diagnoses of focal entrapment neuropathy that a neurologist (or even GP) can make based on clinical exam alone. I don't know any other disorder that presents with isolated sensory symptoms and signs of sensory loss limited to the lateral thi...
Do you start an anti-seizure medication in a patient with a first unprovoked nocturnal seizure with a normal exam, imaging, and EEG; or wait until the second seizure?
Not with the first seizure unless history suggests otherwise. Also, what is the age of the patient? For example, are benign epilepsy syndromes like rolandic epilepsy on your differential? If age does not fit, monitor the patient clinically. Repeat EEG after a few months with sleep recorded.
How do you approach pain management in patients with idiopathic polyneuropathy?
There are a few different guidelines/recommendations depending on which professional society you search. However, I tend to adhere most closely to the table cited below, with an approach that looks something like: First line: Gabapentin 300mg TID titrating up to 1000mg TID Pregabalin 75mg BID titra...