Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
How do you manage a patient who has history consistent with juvenille myoclonic epilepsy (JME) but does not have the classic polyspike pattern on EEG?
They should be managed like any idiopathic generalized epilepsy (IGE), since JME is but a specific subtype of IGE. SO, broad-spectrum ASMs only.
How do you approach weaning treatments for CIDP in remission?
I usually treat CIDP patients with IVIG first, unless there is a contraindication (e.g., history of anaphylactic reaction, very recent thrombotic event, or worsening kidney function in a person who is not yet on dialysis). I use the regimen proposed by the ICE trial, with a loading dose of 2 g/kg fo...
Would you consider IV thrombolytics in patients with acute ischemic stroke, with or without a large vessel occlusion, if they have a history of von Willebrand disease (VWD), regardless of its type?
I would still consider it unless the INR >1.7 or they are on anticoagulation for some clinical reason.
Do you recommend surveillance lumbar punctures for patients with Mollaret's meningitis after diagnosis or in between clinical episodes?
No. My focus with these patients is to establish the diagnosis, which is often difficult, with false-negative CSF PCR tests, and then do everything I can to prevent and alleviate the attacks. I see no role for surveillance LPs because either the patient is better clinically or they are not, and CSF ...
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 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...
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...