Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
Do you take any special precautions when treating cervical spine metastases?
For each spine met case, it's important to determine whether it's a surgical or radiotherapy case. Spinal instability neoplastic score (SINS) and Bilsky grade (epidural cord compression) are two important parameters to consider. If SINS is 6 or below and if Bilsky grade is 1c or below, surgical inte...
Do you refer all patients with new findings of CNS or epidural mets/tumor to ED for evaluation or are there some that can be managed completely outpatient?
Interesting question: Sending patients to the ED for non-emergent conditions is not advised. Our EDs around the country are struggling for a variety of reasons (e.g., they are often holding patients awaiting placement or admission), thus our society will benefit by us avoiding sending patients to t...
Would you consider DHE for patients with status migrainous with elevated blood pressure at the time of presentation?
No, I would not. DHE is a very potent and non-selective arterial vasoconstrictor and would potentially further increase elevated blood pressure. When a patient who presents with a headache is found to have elevated blood pressure, it should be assumed that the elevated blood pressure is the cause of...
When do you consider stopping anti-seizure medications in seizure-free pediatric epilepsy patients?
Prior to 1988, we would never dare take a patient off seizure medicine if the patient was seizure-free.Callaghan's paper published in the New England Journal of Medicine (Callaghan et al., PMID 3127710) clearly showed that patients who were seizure-free on Tegretol for 3 years had a 90% chance of be...
When would you consider elective hospitalization for parenteral treatment for new daily persistent headache?
New daily persistent headaches can have a tension-type headache phenotype or a migraine phenotype. If presenting with a severe daily headache and a migraine phenotype I will treat it as status migrainosus since there is no consistent way to differentiate migrainous NDPH from a status migrainosus las...
How frequently do you recommend ordering labs to monitor for side effects of disease-modifying therapies for multiple sclerosis?
Yes, the monitoring depends on which DMT the patient is on. For patients on B-cell-depleting therapies, I screen for Hep B and latent TB prior to therapy and check a CBC and CMP every 6 months, with yearly immunoglobulin monitoring. For JCV Ab-negative patients on Tysabri, I check a CBC, CMP, and JC...
How do you distinguish between primary progressive MS versus relapsing remitting MS with superimposed relapses in a newly diagnosed patient that is naive to treatment?
Relapsing versus progressive MS are clinical phenotypes lacking clear objective radiologic or paraclinical distinctions. Recent literature emphasizes commonalities between these phenotypes, largely framing them as a spectrum of one disease rather than discrete disorders. Originally, these clinical p...
What is your approach to management and surveillance in low grade traumatic blunt ICA injury?
For blunt cerebrovascular injury (BCVI), I use the Biffl scale to evaluate the extent of vessel trauma. The extracranial neck vessels, such as the cervical ICA or VA, are most commonly affected. The Biffl classification consists of five categories, with Grade 1 representing a low-grade injury. This ...
How often do you consider lamotrigine in patients with myoclonic epilepsy?
When considering juvenile myoclonic epilepsy, I frequently prescribe lamotrigine, especially if a person of childbearing potential. However, I counsel on the possibility that it may exacerbate or not completely control the myoclonic seizures. When considering progressive myoclonic epilepsies (PMEs),...
How do you approach the psychiatric symptom management of Huntington’s Disease?
The neuropsychiatric features of Huntington's disease are not as consistent as the motor or cognitive features. Still, they can cause substantial disability, be prominent early in the disease, and even occur as initial features. The majority of Huntington’s disease (HD) mutation carriers experience ...