Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
When do you test for myasthenia antibodies beyond AChR and MuSK?
I always check an LRP4 antibody. This is helpful to prognosticate and to determine specific treatments. For example, MuSK Ab (+) MG, as an IgG4 mediated disorder, responds particularly well to B cell therapies and FcRn treatments, but since IgG4 poorly activates complement, a complement inhibitor wo...
What are current strategies to treat severe symptomatic basilar stenosis failing medical therapy?
Thank you so much for asking this question. I really would like to see what experts have to say.In my limited experience, I do not think there is a clear-cut protocol on how to manage these patients. I have seen medical management being ramped up (meaning, decreasing the LDL goal to <50, using Repat...
When do you consider ketamine to treat nonconvulsive status epilepticus?
Ketamine is a fine agent for the management of status epilepticus (SE) and some centers use it first line instead of propofol or midazolam. Mechanistically, it makes more sense as it controls the seizures through NMDA blockade, bypassing GABA receptors, which are downregulated in the setting of SE. ...
In a patient with acute stroke/ICH/SDH/hyperammonemia at risk for rebound edema with new onset renal failure, do you prefer CRRT versus low and slow HD?
In the acute period (first 72-96 hours after ictus), my personal preference is CRRT due to the theoretical advantage of hourly titration of ultrafiltrate. I don't know if it really matters though. As for the frequency of laboratory evaluations, I don't find more frequent than q4 hours to be useful, ...
How do you treat anti-HMGCoA myopathy?
IVIg is a great treatment for anti-HMGCoA antibody necrotizing myopathy. However, traditional treatments like methotrexate, azathioprine, as well as rituximab can be tried. We published a paper on IVIG results on refractory HMGCR and SRP positive patients with excellent results. Kocoloski et al., PM...
When is brain biopsy useful/warranted as part of the diagnostic work-up in patients with suspected primary CNS angiitis?
I have never diagnosed or seen a patient with primary angiitis of the CNS. First, I would ensure that the suspected diagnosis and findings are confined to the CNS and are not associated with a systemic inflammatory disease. If the condition is not confined to the CNS, other areas of the body may be ...
What treatment strategies do you employ in patients with Huntington's disease who have parkinsonian features?
Many HD patients actually have clinically detectable parkinsonism, but it is often masked by other more disabling problems including chorea and psychiatric symptoms. Thus, the use of traditional antiparkinsonian therapies can be hampered by substantial side effects. If a patient is not on any medica...
What is your preferred first-line agent to treat anxiety in patients with Parkinson's disease?
Any standard SSRI/SNRI can be tried. I like to try the SNRIs duloxetine or venlafaxine. If comorbid insomnia is a problem, mirtazapine may be a good choice. Think about talk therapy too. It is important to make sure episodic anxiety is not a non-motor symptom fluctuation related to levodopa or oth...
What is your approach to helping parents manage sleep disturbances in patients with autism spectrum disorder?
At our center, we start with sleep hygiene education, using tools such as the Autism Speaks sleep toolkit which has a printable PDF that is free for parental and clinical use. We also try to do therapy on sleep hygiene and our therapists will often try to find out what factors may exist in the home ...
Is moderate-intensity statin plus ezetimibe just as effective as high-intensity statin monotherapy in preventing major cardiovascular events?
The secondary stroke prevention trial showed that high/moderate-intensity statin therapy combined with ezetimibe and titrated to achieve LDLc <70 were equally effective (compared to goal LDLc <100). Overall, the most important determinant of risk reduction is the achieved LDLc, and so moderate inten...