Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
Is there a difference in treatment of status epilepticus from alcohol withdrawal vs other causes?
Alcohol status is best managed by using short half-life like Ativan (lorazepam) and valium (diazepam) with long half-life benzos like Librium (chlordiazepoxide) unlike other status which responds to Phosphynition/levetiracetam and lorazepam.
Do you routinely recommend a sleep study in patients with clinical history of REM-sleep behavior disorder?
I do routinely recommend and perform in lab sleep testing for patients with suspected REM behavior disorder (RBD). The finding of REM sleep without atonia (RSWA) is supportive of a diagnosis of RBD, as atonia is normally presented in individuals (without RBD) during REM sleep. RBD can be a tricky di...
How would you manage a patient with LGI-1 encephalitis with faciobracial dystonic seizures who has not improved with 3 days of intravenous steroids?
I typically treat with five days of IV steroids. In patients with autoimmune encephalitis, including LGI-1, who do not improve after five days of IV steroids, I would then move to IVIG or plasmapheresis (depending on patient comorbidities, availability of plasmapheresis, and severity of symptoms). I...
How do you mitigate the risk of rebound disease activity when discontinuing S1p inhibitors or Tysabri in patients with multiple sclerosis?
While there is no ideal method as determined by well-designed randomized studies, two options would be: (a) steroid bridge between therapies and (b) minimize wash-out period between switches. For many DMTs, a wash-out period between drugs is not needed. If the question regarding the S1p inhibitor wa...
How do you implement antipsychotics in the management of agitation in Alzheimer’s patients?
The answer to how you implement antipsychotic medication in the management of agitation in a patient with Alzheimer's dementia involves several steps, outlined here: Ensure the agitation is not related to an acute medical condition and/or delirium. In this case, it is important to treat the underlyi...
What nutritional supplements do you recommend for patients with ALS?
I do not recommend specific supplements. If the question relates to the PEG formula, we use basic formulas and higher caloric versions if needed.
In what clinical situations do you switch to Vyalev in patients with Parkinson's disease?
Vyalev (foscarbidopa/foslevodopa) administered by subcutaneous infusion with an external battery-operated pump, was recently FDA-approved. Conceptually, it offers the prospect of continuous levodopa administration which should improve dyskinesia and motor fluctuations. Skin reactions can be problema...
Would you add immunosuppression in ocular myasthenia gravis patients who are symptomatically well-controlled on pyridostigmine?
This requires a shared decision-making approach with the patient because there is no right or wrong answer/choice. Although it has never been demonstrated in a placebo-controlled blinded study, I do believe (for years now) that low-dose prednisone can reduce the risk of generalization of ocular MG.A...
What treatments options may be considered in patients with POTS who also need daily diuretics to treat heart failure and are already wearing compression garments?
Given the epidemiology of POTS and congestive heart failure, you are far more likely to see a patient with neurogenic orthostatic hypotension and CHF than POTS and CHF. I have an article on NOH and CHF in Autonomic Neuroscience 2020. The principals are basically the same however because the managem...
What are preferred sleep aids in elderly patients with dementia?
Melatonin 3-6 mg because of their loss of melatonin-secreting potency with age. Doxepin 10 mg because of the cost of 3 and 6 mg versions. If restless legs or limb movements during sleep, gabapentin or pregabalin. Pregabalin can be better tolerated with less next-day sedation (also can be an issue wi...