Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
How do you counsel patients interested in estrogen containing oral contraceptives who have migraine with aura?
Outside of patients whose attacks are suggestive of hemiplegic migraine, I do not typically avoid the use of estrogen-containing OCPs. While it is my understanding that a number of international organizations and many neurologists (as well as Ob/Gyn) recommend their avoidance, there are several revi...
How would you approach evaluation and treatment of a patient on pembrolizumab therapy who presents with symmetric, proximal, upper extremity and lower extremity painful weakness without an elevated CK?
Pembrolizumab, like other checkpoint inhibitors, is associated with a number of immune mediated neuromuscular syndromes including GBS/CIDP, a myasthenic syndrome, and myositis. A patient with symmetric proximal weakness and normal CK could have any of the above conditions. Normal CK does not exclude...
How do you approach treatment of vasospasm after AVM rupture?
In my practice, ruptured AVMs are managed in a way somewhat similar to aneurysmal SAH rupture. Initial DSA evaluates the AVM’s angioarchitecture and identifies high-risk features, such as intra-nidal or branch feeder aneurysms. These high-risk features are addressed during the acute phase of managem...
How do you manage and adjust Parkinson’s medication if a patient has worsening orthostatic hypotension while being treated with carbidopa/levodopa?
Levodopa is such an important pillar of Parkinson's therapy that it is often necessary to continue this drug despite the worsening of orthostatic intolerance.This is a step-wise approach (i.e., don't go to step 4 if you haven't addressed step 2): Ensure that the patient is getting symptomatic benefi...
How frequently does one see resting tremor in drug-induced Parkinsonism?
I have rarely seen resting tremors in drug-induced Parkinsonism. The exception is when the "inducing" drug is Depakote or Lithium. I have seen this numerous times. Often, the discontinuation of these medications (if possible) can result in resolution of the tremors and other Parkinsonian signs, howe...
Do you typically do genetic testing in patients with progressive supranuclear palsy?
Not routinely unless there is a family history, then would be looking for a PSP mimic through genetic testing. There is an ongoing study looking at PSP genetics that a patient could be referred to through curePSP.
When is it appropriate to use the 10mg-100mg Carbidopa/Levodopa formulation?
The lower dose of carbidopa means that it does not provide a sufficient amount of peripheral dopa decarboxylase inhibition (75 mg is required) especially if prescribed with the TID schedule. 25/100 is the minimal dose that should be used. I don’t see any role for the 10/100. Some practitioners incor...
Is there any clinical benefit in referring patients with SLE or Sjogren's with cognitive impairment for neuropsychological testing?
I have been grappling with this issue more often in fibromyalgia and chronic fatigue syndrome and more recently in patients with Post-acute COVID Syndrome. In FM and CFS I have not found neuropsychological testing helpful to distinguish true cognitive impairment from the confounding effects of sever...
How do different inflammatory markers like CRP and ferritin contribute differently, if at all, to the monitoring of CART neurotoxicity?
These markers are routinely monitored as they are seen in association with CRS (cytokine release syndrome). Not all patients with CRS will also develop neurotoxicity (ICANS), but most patients with ICANS have antecedent CRS, so in an encephalopathic patient post-CART who does not have significant el...
How do you counsel women post-natural menopause who are interested in HRT for reducing dementia risk?
The literature on estrogen replacement and dementia risk is mixed. The Women's Health Study originally found that estrogen replacement was a risk factor for dementia, but later analyses have not confirmed this, and some (as the questionnaire mentions) have suggested a protective effect. Not all stud...