Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
What is your approach to the treatment of visual snow syndrome?
Visual snow is not a syndrome. It's a symptom that consists of static vision. I opine that it's origin is retinal (not brain) and that it relates to ongoing activity. In the past I have referred to it as retinal repolarization disorder. It should not be confused with migraine aura status, which is a...
What is the utility and yield of CSF studies for orbital apex syndrome?
"Orbital apex syndrome" is a description of WHERE the problem is. It is a specific pattern of localization - i.e., some combination of CN III, IV, V1, V2, or VI, along with evidence of optic neuropathy (CN II) - that indicates that there is pathology anterior to the cavernous sinus (because the opti...
Have you found FcRn inhibitors effective for weaning off or replacing IVIG for the treatment of refractory seropositive myasthenia gravis?
I think efgartigimod can be considered as an alternative to IVIG in sero-positive generalized MG, especially in patients who experience severe side effects from IVIG or contraindications due to cardiac, renal dysfunction or clotting disorder.One of the proposed mechanisms of IVIG is by overwhelming ...
Do you use sitting vs supine spirometry to consider tracheostomy in a patient with Amyotrophic Lateral Sclerosis?
The decision to pursue tracheostomy is becoming less of a choice altogether in our practice. However, to answer your question once my patients are on NIPPV I don't routinely subject patients to supine spirometry for prognostic follow-up, given the high risk-benefit ratio of transferring a patient wi...
How do you select patients with spontaneous intracerebral hemorrhage for minimally invasive surgical hematoma evacuation, if offered at your institution?
Disclosure - our institution is conservative in its approach to surgical management of ICH, as we don't seem to have the supportive evidence to warrant large-scale application. With that, we take all cerebellar ICH with depressed level of consciousness or NIHSS >4. We consider cortical hemorrhages o...
What is your approach to managing patients who initially present with symptomatic intracranial large vessel occlusion but subsequently experience resolution of symptoms or become non-disabling before any intervention?
If a large vessel occlusion (LVO), such as ICA-terminus, M1, or Basilar, is present, I would treat it even if there has been a significant improvement in symptoms. As mentioned in the prior post, an occlusion in one of these areas will likely exhaust collateral reserves and become symptomatic again....
What factors would influence your decision to use or avoid heparin bridging in patients with mechanical heart valves resuming anticoagulation after intracerebral hemorrhage?
The main conclusion from the publication by Sakusic et al., PMID 39102615 was that withholding anticoagulation for the first seven days after ICH is safe in patients with mechanical heart valves and bridging with intravenous heparin to coumadin upon resumption of anticoagulation should be avoided. T...
How do you adjust dosing of rozanolixizumb for MG patients who deteriorate before the minimum re-dosing period?
First, I make sure the dose is appropriate for weight. If it is, I am comfortable with shortening the dosing interval. Consider checking the IgG level before doing so to make sure the patient does not have hypogammaglobulinemia.
What do you consider when deciding to use a high-efficacy DMT as an initial treatment in multiple sclerosis?
I'd say the question is when would you "not" consider a high-efficacy DMT in MS. High-efficacy therapies (specifically, B-cell depleting therapies) have a good risk profile and are exceptionally effective in treating relapsing MS. Evidence would suggest that you get the largest "bang for your buck" ...
Do you typically consider Botox for patients with TMJ?
I do a fair number of Botox injections for TMJ (only small doses (5 to 7.5 units) when using Botox for migraines. Patients do report that it is helpful.