Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
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 ...
When do you send AChR+ ocular myasthenia gravis patients for thymectomy?
Patients with ocular myasthenia gravis and thymoma should be referred for thymectomy. The data regarding thymectomy in non-thymomatous ocular myasthenia is more limited; thymectomy can be considered in patients who cannot tolerate, or have refractory symptoms despite, immunosuppressive therapy when ...
Is it reasonable to delay radiation therapy following surgical decompression for a patient with spinal cord compression if systemic therapy must be started as soon as possible?
I think it's unwise to delay RT for the usual solid tumor. 1) Surgical decompression seldom removes much tumor. 2) Most of these pts have already received significant chemo decreasing the chances of a meaningful response. 3) A rapid hypofractionated course of RT can usually be given resulting in onl...
Do you screen children with sickle cell disease for silent cerebral infarcts?
We screen children with sickle cell disease for SCIs at our center. This is because data suggest that silent cerebral infarcts (SCIs) are much more common than overt stroke and the long-term negative impacts of SCIs are significant. There are also treatments (e.g., chronic transfusion and stem cell ...
What are the differential and workup for a patient with findings suggestive of idiopathic intracranial hypertension without papilledema on examination?
I agree with Dr. @Dr. First Last, and find it less difficult to "justify" a lumbar puncture than Dr. @Dr. First Last, although admittedly very sympathetic to his approach. I would perform an LP. Lumbar puncture is a very low-risk procedure and in this setting, it isn't all about visual loss, althoug...
Do you use dual anti-platelet therapy inpatients with low NIHSS who have had bilateral brainstem strokes?
I usually look at the stroke mechanism in making my decisions about DAPT rather than just relying on the NIHSS alone. If the mechanism is ICAD, branch atherosclerotic disease, SVD (with infarct extension), embolism from the aortic arch plaque, subclavian artery heterogenous plaque, extra-cranial ver...
What leads you to suspect that a foot drop is secondary to a myopathy rather than a neuropathic process?
Factors suggesting that a foot drop is due to a myopathy include: Clinical factors (slow progression (myopathy but also seen in CMT) versus acute or sub-acute onset (usually neurogenic), absence of sensory findings, absence of pes cavus, signs of facial or shoulder girdle weakness (FSHD can cause f...
How do you approach workup for patients with suspected muscular dystrophy?
I would like to put a couple of notes of caution regarding the approach of starting with sponsored (free) next-gen sequencing for muscular dystrophies before any other tests are done: One has to recognize the phenotypes of certain MDs that can NOT be diagnosed with Next-Gen sequencing, because they...