Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
When do you consider intramuscular indomethacin for the assessment of trigeminal autonomic cephalalgias?
Indomethacin as a preventive treatment should only be considered for paroxysmal hemicrania and hemicrania continua. Both diagnoses are made based on the history. The diagnosis of paroxysmal hemicrania is based on the attack pattern: unilateral headaches lasting 10-30 minutes and occurring multiple t...
When and how do you deviate from efgartigimod (Vyvgart) dosing from the drug label recommendation of weekly infusions for four weeks in patients with myasthenia gravis?
In the landmark ADAPT study, efgartigimod vs placebo was given in patients with MG initially as weekly infusions x4. The timing of the second and subsequent cycles was determined on a case-by-case basis, based on the patient's clinical response and serial measurement of quantitative MG parameters (M...
Would you consider combining tovorafenib and trametinib as dual therapy?
A phase 1/2 study of tovorafenib and the MEK inhibitor selumetinib is planned through the Developmental Therapeutics Committee of the Children's Oncology Group for low-grade gliomas that have failed appropriate prior MAPK blocking therapy and other patients with BRAF/RAF1, RAS, and NF driven maligna...
How do you track objective clinical response to treatment in CIDP?
The EAN/PNS 2021 guidelines address this point. Symptom improvement is not really objective. There is no recommendation to follow NCS/EMG, and I would discourage it. I perform the MRC exam (sum score comes from this), grip test, INCAT (takes 3 seconds), iRODS, and Timed Up and Go at every visit. The...
How do you decide the length of a routine EEG?
A routine EEG, defined by codes 95819 or 95816, typically lasts 20-40 minutes or up to an hour. Studies lasting 1 to 2 hours (code 95813) lack a clear rationale and are not commonly utilized. "Prolonged" EEGs are the newer (2020) codes that depend on duration and whether or not there is video.The ch...
How do you manage headaches in stroke patients?
In general, I treat headaches based on phenotype. If they have associated migraine features then I treat them with migraine medications. If tension type then I address all the headache hygiene components. If cervicogenic then physical therapy for these. Always screen for and counsel on medication ov...
What is your approach to the management of Bell's palsy that has not improved after six months?
My understanding is that 'Bell's palsy' means idiopathic facial palsy. Therefore, I usually evaluate for other causes, depending on the clinical scenario, before calling it Bell's palsy. We see a lot of Lyme disease in PA. Facial palsy may be the initial manifestation of neurosarcoidosis and may res...
How do you approach patients with positive LRP4 antibodies without clinical findings of myasthenia gravis?
This is an interesting question. Another interesting one is what was the ordering physician looking for when they ordered LRP4. Myasthenia gravis is a clinical diagnosis. As a neuro-ophthalmologist, I see a high volume of both ocular and generalized myasthenia. I personally do not base my diagnosis ...
What workup do you recommend for isolated postural and action tremors in a developmentally typical toddler?
Rule out Wilson's Disease. 24-hour urine copper, ceruloplasmin, consider further testing, definitely monitor for progression of other symptoms.
How do you approach interval monitoring of cavernous carotid aneurysms?
Cavernous carotid aneurysms are typically extradural in location. While they carry some rupture risk depending on size and morphology, they are less likely to cause SAH and more likely to hemorrhage into the cavernous sinus (e.g., CCF). Although any intracranial hemorrhage is concerning, bleeding in...