Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
How do you decide on the treatment target of burst suppression pattern vs seizure cessation for patients with status epilepticus?
There is no high-level data to support burst suppression as superior to electrographic seizure cessation, with data largely coming from case series. In general, those who reach burst suppression seem to have better seizure control, but at the expense of more side effects from the meds. Accordingly, ...
What approach do you use when treating adult diffuse gliomas with H3-G34 mutations, now classified into their own category under the 2021 glioma guidelines?
Although DHG H3G34-mutant diffuse gliomas are more commonly associated with pediatric patients, they can occur in young adults as well. In a recent paper describing 17 patients harboring this rare mutation, the median age at diagnosis was 25 years (range: 19–33). All tumors were hemispheric. All cas...
How do you use muscle MRI in the diagnosis and management of muscular dystrophies?
A similar question about the utility of MRI in muscle diseases has been asked previously and replied to. I do not routinely use MRI in the diagnosis and management of muscular dystrophies. To diagnose muscular dystrophy, I usually rely on history and exam, analysis of family history/pedigree to clar...
How do you taper phenobarbital in a patient with epilepsy?
Since the risk of withdrawal seizures is high, it's best to administer clobazam. The dose depends on the dose of phenobarbital. After a week, clobazam can be discontinued gradually, tapering off without the risk of withdrawal.
How do you dose gabapentin in patients with renal failure?
There are many algorithms available online about the renal dosing of gabapentin. However, it should be emphasized that the recommendations are not based on large patient studies; therefore, the efficacy of the reduced doses for neuropathic pain is not certain (Raouf et al., PMID 28184168).
Do you ever start a ketogenic diet in patients who present with status epilepticus admitted to the ICU?
A ketogenic diet can be considered in super-refractory status epilepticus. There are a handful of small studies and case series that are mostly pediatric, but also a few adult papers (Camões et al., PMID 35081248, Katz et al., PMID 33671485, and Cai et al., Acta Epileptologica 2022), which suggest t...
How frequently do you check lab work in patients with stable myasthenia gravis?
It depends on what medications they are on! If patients are on pyridostigmine only (some mild ocular MG cases), none. If patients are on monotherapy with eculizumab or ravulizumab, I check none. On steroids: at least twice a year A1c, BMP, annual DEXA scan for osteoporosis, annual eye exam. On azat...
When do you consider genetic testing in patients with suspected hereditary brachial plexopathy?
There are two hereditary disorders associated with brachial plexopathy: 1) Hereditary neuralgic amyotrophy (HNA), which is caused by SEPT9 mutations ~70% of cases, and 2) Hereditary neuropathy with liability to pressure palsies (HNPP), which can manifest as a painless brachial plexopathy especially ...
When is the best time to consider left atrial appendage closure for secondary stroke prevention in patients with atrial fibrillation?
There is equipoise about the timing of left atrial appendage closure following ischemic stroke. Due to the need to temporarily treat a patient with either dual antiplatelet or anticoagulation therapy, it is reasonable to wait until after the acute stroke period has passed to allow for healing of inf...
How significant are the cardiovascular side effects, such as hypertension, associated with valproate?
I do not routinely think of cardiovascular side effects, especially HTN, as being a major factor with valproate. I think of things like cardiac conduction changes are associated with sodium channel blockers much more frequently, such as lacosamide.However, as a result of this question, I found this ...