Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
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...
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 ...