Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
How does progression independent of relapse activity (PIRMA) influence your decision to change treatment in relapsing remitting multiple sclerosis?
In a patient who is progressing in the absence of relapse activity, I typically do not change DMT and instead focus on managing the symptoms directly. Such as physical therapy or walking aids, physical worsening, cognitive rehab, OT for fatigue issues, or counseling if mood issues are contributing t...
When do you consider testing autoimmune antibodies for axonal polyneuropathies without clear etiology?
Dr. @Dr. First Last gave an excellent summary of the clinical red flags that should trigger antibody testing in polyneuropathies. I would like to highlight that not all antibodies are pathogenic or cause the same phenotypes/clinical syndromes, therefore, I would like to break it down by antibody gro...
When do you find benefit in sequencing different dopamine receptor blockers for emergency treatment of migraine?
I know that these medications given intravenously have been found effective abortively in randomized, double-blinded, placebo-controlled trials. Prior to the advent of the triptans in the early nineties, I often treated migraine headaches abortively with metoclopramide 10 mg orally, in 15 minutes, f...
When do patients with descending paralysis and suspected botulism require inpatient EMG?
If a health care provider suspects botulism in a patient presenting with descending paralysis (beginning from the cranial/bulbar region) and certain clues such as autonomic nerve involvement with dilated poorly reactive pupils, constipation, etc. can help, then treatment must be administered immedia...
How would you balance the risk of intracranial hemorrhage with thrombosis of mechanical valves in patients with infective endocarditis?
I'm not sure that there is a good answer to this question. If you look at it segmentally, clearly, patients with mechanical valves require anticoagulation, especially in the mitral position. In patients with endocarditis and native valves, whether or not to anticoagulate the patient after or before ...
In older adults with mild cognitive impairment, do you ever prescribe cholinesterase inhibitors and/or memantine?
This is a great question, and of course, "do you ever" will get you in trouble every time! Let me start by saying that, in general, I do not prescribe these drugs for MCI. Cholinesterase inhibitors are clearly indicated for the mild-moderate stage of some kinds of dementia (some people would include...
Cost and access aside, when might you prefer to start a patient on a triptan instead of a gepant for acute migraine therapy?
For me, the triptans are first line for migraine abortion. They have been on the market for well over three decades, we have a lot of experience with them, a lot of clinical-trial information is available on them, and also in special populations like teenagers and adolescents, as well as pregnant wo...
When should we order a DaT scan in patients suspected of Parkinsonism syndrome?
I believe that a good clinical examination can tell you if a patient has parkinsonism or not and that is the same answer one gets from a DaTscan. If the findings are too subtle, then re-examine the patient at intervals. So my answer is it is not necessary. I emphasize "my" answer because not everyon...
What are your recommendations for screening for sleep disorders in patients with IDD?
Sleep disorders are very common for people with IDD. One consideration, in particular, is in patients with Down Syndrome because of the shape of their mouth and large tongue. They have a very high rate of sleep apnea, obstructive sleep apnea in particular, which can be seen even in children. You wo...
Does global brain atrophy increase risk for intracranial bleed after fall in older adults?
It depends on the location of the hemorrhage. Subdural bleeding/hematoma is much more likely in elderly people with brain atrophy and a fall. Epidural hemorrhage is much more common in young patients. Intracerebral hemorrhage is more related to risk factors such as hypertension in middle age and amy...