Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
What is your approach to Tardive Dyskinesia when VMAT2 inhibitors are ineffective or unaffordable?
In established cases of tardive dyskinesia, in which withdrawal-emergent dyskinesia has been ruled out, and dyskinesia has persisted despite a sufficient washout interval after removal of the offending agent, VAM2 inhibitors such as valbenazine and deutetrabenazine are used for pharmacotherapy. If t...
How will your approach to screening and diagnosis of early dementia change given newly available therapies for early Alzheimer's disease?
As it stands, it is not recommended to screen asymptomatic patients for the proteins seen in Alzheimer’s disease outside of clinical trials (i.e., AHEAD 3-45). However, with the emergence of new treatment options in the clinic, I foresee an influx of patients with cognitive symptoms who need a preci...
When do you consider prescribing memantine for migraine treatment?
Memantine is well-tolerated and shows excellent efficacy for prevention in both chronic and high-frequency episodic migraine. The main limitation is that it is not FDA-approved, and payors use this as an excuse to deny coverage in favor of less-well-tolerated, and often less efficacious but cheaper ...
How do you approach a patient with both a resting and action tremor, suggestive of PD and essential tremor together?
This is a wonderful question. To answer this question, we first have to look at the underlying etiology that leads to action tremor in PD. The hallmark of Parkinson's Disease (PD) is rest tremor, and about 75% of patients with PD have rest tremor at some point in their disease course (typically more...
Where in your treatment approach to fibromyalgia will you recommend sublingual cyclobenzaprine?
The choice of medication for any given patient is based on a lot of factors and, realistically, is often highly dependent on affordability and insurance coverage across different pharmacy plans. Despite other FDA-approved options, oral cyclobenzaprine is usually the medication I reach for first with...
How does the presence of 1-3 microbleeds on MRI influence your choice of anti-amyloid therapies for patients with MCI or mild AD?
1-3 microbleeds is a small number, and the question does not specify that to be suspicious for amyloid angiopathy, the microbleeds should be cortical/subcortical, not deep (as seen in hypertensive individuals). This number, assuming that there are no signs of a larger hemorrhage nor superficial side...
Would you start cholinesterase inhibitors for a patient with MCI or mild dementia based on MoCA testing, when there is concern for frontotemporal dementia?
No, there is no benefit of cholinesterase inhibitors and even a risk of harm from them in FTD.
At what degree of lymphopenia do you switch/discontinue dimethyl fumarate in patients with multiple sclerosis?
I do not check the JC index status for my patients on fumarates. While I do not have recent data, to my knowledge, there are only a handful of PML cases attributed to fumarates used in MS. Even when including fumarates used in treating psoriasis, the PML numbers are small. Since the prognostic value...
What clinical or imaging features help distinguish intracranial atherosclerotic disease from intracranial dissection in the setting of an LVO?
This is a great question and very difficult to answer. I think the first thing I look for is whether there is significant atherosclerosis elsewhere. Lack of significant atherosclerosis elsewhere with a single significantly stenotic intracranial lesion in a young person or someone without significant...
In an older adult hospitalized with recurrent falls, weight loss, without clear injuries, but with an inconsistent or difficult-to-reach caregiver, what findings would make you formally report suspected elder neglect and/or abuse?
I'm so glad that you're thinking about the possibility of abuse/neglect in this scenario! It's important to have it on our differential, or we'll always miss this diagnosis. First, it would be good to see if the patient can explain what is happening and provide contextual information that veers us a...