Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
For patients with hydrocephalus secondary to leptomeningeal disease, how do you determine what type of shunt device to place?
For my small part, please ask neuro-oncology if they plan to use intrathecal chemo (and need a hybrid with Ommaya).
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.
Which imaging features do you use when considering Normal Pressure Hydrocephalus to decide whether to proceed with large-volume LP or lumbar drain trial?
At our center, we follow the approach of the NPH clinic at the Imperial College Hospital in London.See this excellent review article for further details: Carswell, PMID 36162853.
In advanced Parkinson’s disease, how should clinicians assess symptom management and quality of life when patients are no longer able to communicate themselves?
This is challenging and why palliative care professionals are not familiar with neurodegenerative conditions, questions their efficacy in helping our patients. Using validated tools can help such as the ESAS-rPD. This scale can be used to assess response to interventions. Family members may be able ...
How do you decide between the different oral longer acting levodopa medications?
The question would be, why are you changing, and what are you changing from? (i.e., are one of these your initial agent, a change due to Sinemet side effects, or a change because of motor fluctuations?) The current theory on dopamine replacement is "smoother is better," so the longer (and lower) you...
How do you counsel patients and caregivers about the trajectory of cognitive decline in Parkinson’s disease?
I address the subject of cognitive impairment fairly early in PD, since patients may notice mild deficits in multitasking and attention even within the first few years of diagnosis. Strategies such as making lists and breaking down individual tasks are effective in preserving independence. Worsening...
Cost and access aside, when might you prefer to start a patient on a triptan instead of a gepant for acute migraine therapy?
For me, the triptans are first line for migraine abortion. They have been on the market for well over three decades, we have a lot of experience with them, a lot of clinical-trial information is available on them, and also in special populations like teenagers and adolescents, as well as pregnant wo...
For a patient with large volume glioblastoma, what do you do if they are found to have a subdural infection in the middle of chemoRT requiring repeat surgery?
In this scenario, the patient will likely stop the daily treatments for a variable period of time that I would estimate to be measured in weeks while recuperating from surgery and receiving IV antibiotics. When cleared for radiation, I would start by doing a new Simulation using an updated MRI to ac...
How do you counsel patients with postural orthostatic tachycardia syndrome (POTS) regarding safe and effective exercise regimens?
It depends on where they're starting from. If they're starting from scratch, I give them two recommendations: first is the Children's Hospital of Philadelphia protocol, and if they live in town, I refer them to our PT facility at Vanderbilt (The Dayani Center) to have our PT folks help them get star...
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...