Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
Do you ever delay starting levodopa in patients with Parkinson's disease?
With LEAP and the 5-year follow-up study, we can feel comfortable deciding to start patients early on levodopa to maximize quality of life via motor symptom control. In this study, there were no differences in UPDRS scores, the prevalence of wearing off, or levodopa equivalent daily dose between the...
Are the laws regarding prescribing C-2 medications different for mail order pharmacies?
This is an important question and very timely considering the increase in mail order pharmacies. As a practitioner, you can prescribe medications to patients within your state through legitimate mail-order pharmacies located in different states because these pharmacies are licensed to operate acros...
Is there a role to continue aspirin in patients with myeloproliferative disorders who have never had a thrombotic event that are starting DOAC for stroke prophylaxis with newly diagnosed atrial fibrillation?
Aside from treating erythromelalgia, transient ischemic attacks (TIA) such as ocular migraine or documented atherosclerotic disease, aspirin has no role in the management of the MPN, despite the widely published recommendations for its use, particularly in so-called "high risk" polycythemia vera (PV...
Would you avoid combining JAK inhibitors with IVIG given the risk of thromboembolism?
The evidence for this is not very clear and limited. I think a honest discussion about the risk of JAKs and IVIG with the patient will be the most important; but as long as there is no clotting history or high risk of DVTs/PEs, and this is documented, and if a patient needs both medications to attai...
How do you counsel patients to reduce post-procedure side effects with onabotulinumtoxinA (Botox) for chronic migraine?
I caution them to not rub/itch the injection sites especially around the corrugators and frontalis sites for the rest of the day. Some people will recommend for 24 hours, but honestly while sleeping they could roll onto their face or rub their face anyway. I also do not recommend they do significant...
Do you always biopsy patients who present with classic skin findings of dermatomyositis?
I actually very rarely perform a skin biopsy to confirm dermatomyositis, much like I rarely biopsy classic psoriasis or classic eczema. Because I see dermatomyositis frequently enough in my practice, most times, I can confidently diagnose it by physical examination alone. I reserve performing skin b...
Is there any contraindication to the use of ezetimibe in patients with a history of statin-induced necrotizing myopathy?
These types of questions are always great to discuss. The reality is there is a risk-benefit ratio to be considered. On one hand, there is a concern for the need for lipid-lowering to prevent cardiovascular disease, and some situations are more pressing than others. A diabetic with a known cardiovas...
When do you offer TNK for ischemic stroke patients with a large vessel occlusion presenting outside the 4.5-hour window?
I agree with Dr. @Dr. First Last. Generally, I do not treat with TNK if EVT is available, but I do treat if no EVT is available, assuming favorable imaging as per the TRACE-III trial. However, as with all decisions, there are nuances. Since the benefit and risk ratio of TNK was only slightly favorab...
How do you manage the developmental and behavioral regression seen in Down Syndrome Disintegrative Disorder (DSDD)?
Thank you for this important question. One of the keys is to ensure that the change and regression being seen is DSDD or something else. Sometimes, this is confused with Alzheimer's seen in older individuals with Down syndrome. DSDD is seen in much younger people, late teens, and 20's as a more rapi...
When would you consider intra-arterial thrombolysis for acute ischemic stroke?
The prior answer brings up several valid scenarios where IA thrombolysis may be applicable. I can offer some nuanced perspective based on current practice. Device technology has advanced significantly since the landmark EVT trials of 2015. Today, EVT is increasingly feasible in distal-segment occlus...