Managing Neurological Disorders in Pregnancy

Podcast Transcript

Neuro Pathways Podcast Series

Release Date: January 15, 2024

Expiration Date: January 15, 2025

Estimated Time of Completion: 27 minutes

Managing Neurological Disorders in Pregnancy

Caroline Just, MD

Description

Each podcast in the Neurological Institute series provides a brief, review of management strategies related to the topic.

Learning Objectives

• Review up to date and clinically pertinent topics related to neurological disease
• Discuss advances in the field of neurological diseases
• Describe options for the treatment and care of various neurological disease

Target Audience

Physicians and Advanced Practice providers in Family Practice, Internal Medicine & Subspecialties, Neurology, Nursing, Pediatrics, Psychology/Psychiatry, Radiology as well as Professors, Researchers, and Students.

ACCREDITATION

In support of improving patient care, Cleveland Clinic Center for Continuing Education is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

CREDIT DESIGNATION

• American Medical Association (AMA)

Cleveland Clinic Center for Continuing Education designates this enduring material for a maximum of 0.50 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Participants claiming CME credit from this activity may submit the credit hours to the American Osteopathic Association for Category 2 credit.

• American Nurses Credentialing Center (ANCC)

Cleveland Clinic Center for Continuing Education designates this enduring material for a maximum of 0.50 ANCC contact hours.

• Certificate of Participation

A certificate of participation will be provided to other health care professionals for requesting credits in accordance with their professional boards and/or associations.

• American Board of Surgery (ABS)

Successful completion of this CME activity enables the learner to earn credit toward the CME requirements of the American Board of Surgery’s Continuous Certification program. It is the CME activity provider's responsibility to submit learner completion information to ACCME for the purpose of granting ABS credit.

Credit will be reported within 30 days of claiming credit.

Podcast Series Director

Imad Najm, MD

Epilepsy Center

Additional Planner/Reviewer

Cindy Willis, DNP

Faculty

Caroline Just, MD

Department of Neurology

Host

Glen Stevens, DO, PhD

Cleveland Clinic Brain Tumor and Neuro-Oncology Center

Agenda

Managing Neurological Disorders in Pregnancy

Caroline Just, MD

Disclosures

In accordance with the Standards for Integrity and Independence issued by the Accreditation Council for Continuing Medical Education (ACCME), The Cleveland Clinic Center for Continuing Education mitigates all relevant conflicts of interest to ensure CME activities are free of commercial bias.

The following faculty have indicated that they may have a relationship, which in the context of their presentation(s), could be perceived as a potential conflict of interest:

Caroline Just, MD	QxMD (since acquired by WebMD) Independent Contractor: programming neurologic criteria into mobile app WebMD Independent Contractor: programming neurology section of mobile app
Imad Najm, MD	Eisai Advisor or review panel participant NIH Other activities from which remuneration is received or expected: Research Funding LivaNova, PLC Advisor or review panel participant SK Life Science Inc Advisor or review panel participant Teaching and Speaking
Glen Stevens, DO, PhD	DynaMed  Consulting

 The following faculty have indicated they have no relationship which, in the context of their presentation(s), could be perceived as a potential conflict of interest: Cindy Willis, DNP

CME Disclaimer

The information in this educational activity is provided for general medical education purposes only and is not meant to substitute for the independent medical judgment of a physician relative to diagnostic and treatment options of a specific patient's medical condition. The viewpoints expressed in this CME activity are those of the authors/faculty. They do not represent an endorsement by The Cleveland Clinic Foundation. In no event will The Cleveland Clinic Foundation be liable for any decision made or action taken in reliance upon the information provided through this CME activity.

HOW TO OBTAIN AMA PRA Category 1 Credits™, ANCC Contact Hours, OR CERTIFICATE OF PARTICIPATION:

Go to: Neuro Pathways Podcast Jan 15 2024 to log into myCME and begin the activity evaluation and print your certificate. If you need assistance, contact the CME office at myCME@ccf.org

Copyright © 2024 The Cleveland Clinic Foundation. All Rights Reserved.

Introduction: Neuro Pathways, a Cleveland Clinic podcast exploring the latest research discoveries and clinical advances in the fields of neurology, neurosurgery, neuro rehab, and psychiatry.

Glen Stevens, DO, PhD: The physiologic changes that occur during pregnancy can exacerbate symptoms of existing neurologic disorders and cause a wide range of acute neurologic issues. These conditions pose a unique clinical challenge due to the complexity of the causes and effects, as well as the potential risks of therapeutic interventions. In this episode of Neuro Pathways, we're discussing the management of neurologic disorders during pregnancy and considerations for the preconception and postpartum period.

I'm your host Glen Stevens, neurologist/neuro-oncologist in Cleveland Clinic's Neurological Institute and joining me for today's conversation is Dr. Caroline Just. Dr. Just is a neurologist in the Center for General Neurology within Cleveland Clinic's Neurological Institute.

Caroline, welcome to Neuro Pathways.

Caroline Just, MD: Happy to be here.

Glen Stevens, DO, PhD: Caroline, what I know about you, because I had the pleasure of having you give a talk at a meeting that I ran this past year, is you love Jeopardy.

Caroline Just, MD: This is true.

Glen Stevens, DO, PhD: You do love Jeopardy. So, as we go along, if I can think of a good Jeopardy question, but I'm not sure that I can. I know you love it. Tell the audience a little bit about yourself and how you came to the Cleveland Clinic and how you became interested in women's neurology really.

Caroline Just, MD: I did all my training in Canada and my family, and I found ourselves in Ohio for what we thought was a year and turned into much longer. The clinic job here at Cleveland Clinic came up right as I was looking for a new academic institution to join. I've been here for about a year and a half, and it's been great. My interest in women's neurology and neuro-obstetrics, a little bit something that I enjoyed during my epilepsy fellowship because it's a huge part of that. But came after, unsurprisingly, I had my own child and got some insight into the unique case of the physiology that happens with pregnancy and how it's a unique state that we don't understand very well and certainly a clinical gap that we need to fill within neurology.

Glen Stevens, DO, PhD: Well, I think it's great that you're here and that you have such a strong interest in this. It really is a unique challenge and really a specialty on its own, so it's great to have you here and I'm really so pleased that you're interested in it. When it comes to neurologic disorders and pregnancy, in some ways there's two main groups. Those individuals who have an existing neurologic disorder and become pregnant and then those who develop a new disorder or symptom after becoming pregnant. Let's start with the first group. You have an existing neurologic disorder. What do clinicians need to consider when an individual with an existing disorder becomes or wants to become pregnant?

Caroline Just, MD: One thing that's really important to know is medications can be teratogenic and their half-life for preconception is really important to know, particularly for some of the newer medicines. There are CGRP, antibodies, the injectables in migraine that have very long half-lives, so it's very important that as clinicians we inform our patients that we would like notice if they are planning on having a child or trying to get pregnant. Of course, a large percentage of pregnancies are unplanned, so it's important to still, if a patient is of childbearing potential, to have a conversation about the possibility.

In terms of MS, perfect example of something where there's a bit of a double arrowed pathway. Pregnancy definitely plays a role in MS treatment and MS can really play a role in when people choose to get pregnant, whether they want to be off meds for longer if they are trying to conceive, if they're considering fertility treatment. So, it definitely plays a huge role there.

Another really important consideration comes up with epilepsy. Many anti-seizure medicines, ASMs, are teratogenic, but many are only very slightly teratogenic, and others are much more concerning and knowing the difference between those is highly important. There are very few scenarios, for example, in which a patient of childbearing age should be on Valproate.

Glen Stevens, DO, PhD: And I'm glad you mentioned that because I think that's probably number one on the most wanted list to avoid.

Caroline Just, MD: Indeed, indeed.

Glen Stevens, DO, PhD: So, it's always good to put that out there. What about folic acid use?

Caroline Just, MD: You've brought up a controversy there. Initially, folic acid use, the more the better was felt to be the case for women in general who are trying to become pregnant and for the duration of their pregnancy. However, a study came out a couple years back raising a concern that with higher doses of folate there was a potential for negative cognitive outcomes. So, what we tend to counsel nowadays is the appropriate dose of folic acid is likely one to two milligrams rather than more than that.

Glen Stevens, DO, PhD: And in my reptilian brain, I seem to remember, but I could be wrong, and you can correct me, that women with MS who get pregnant, during the pregnancy, their disease often is quiescent, and then once baby is born, it can kick up again. Is that still the teaching or has that changed?

Caroline Just, MD: That is correct. Overall, interesting historical vignette, it used to be thought that because relapses.

Glen Stevens, DO, PhD: Is this a jeopardy question?

Caroline Just, MD: It used to be thought that because women with MS were so likely to have a postpartum relapse that it was caused by the epidural that they had.

Glen Stevens, DO, PhD: Oh, OK.

Caroline Just, MD: But in fact, your risk of having an MS relapse halves, so becomes half as likely during pregnancy and then doubles during the three to six months postpartum. So, lifetime risk similar.

Glen Stevens, DO, PhD: And you recommend they go off their disease modifying medications during their pregnancy? Or starting before they get pregnant?

Caroline Just, MD: It's definitely a collaborative decision between their MS specialist. I'm happy to be involved. We do have MS specialists here who have an interest in this part of our group. There are some exceptions to that. You certainly could stay on Glatiramer Acetate throughout a pregnancy. There is lots of clinical opinion that being on Natalizumab is reasonable throughout pregnancy, done every six weeks. And then there's another school of thought that for patients, for example on Ocrelizumab, that you just want to make sure that you time it so that their time of being untreated and not pregnant is the least amount of time possible.

Glen Stevens, DO, PhD: And I remember when my wife was pregnant with our first child and she does have migraines, although not bad, bad, but I think they said, "You could take some Tylenol periodically and that's it." What's the teaching now?

Caroline Just, MD: Oh. Yes. Migraines is a nice example where in pregnancy we're really quick to jump to, "Well, there's nothing we can do for you."

Glen Stevens, DO, PhD: We hear that a lot, right?

Caroline Just, MD: So often and there's nowhere else in medicine other than in management of diseases during pregnancy that we say that to people as often. What actually can you do for acute treatments? Tylenol doesn't work particularly well. It also doesn't work outside of pregnancy for migraine. What I usually tend to offer, I really do try to avoid butalbital-based products, even though that is the traditional obstetrics teaching, because they're very addictive, they're sedating. Doing local lidocaine such as an occipital nerve block without steroid is a very reasonable acute treatment. Cyproheptadine, also a very reasonable acute treatment. And Sumatriptan doesn't have randomized evidence for safety, but has a lot of evidence of safe use. So, sumatriptan is something, and other triptans, sumatriptan is just my favorite. They are used regularly during pregnancy by myself and other neuro-obstetrics clinicians, and it's really nice for patients to hear that actually something that worked well for them can still be used.

Glen Stevens, DO, PhD: Excellent. If we look at epilepsy again, just to backtrack for a second, any favorite drugs someone wants? "I have epilepsy, I want to get pregnant." Any particular drugs? We know we got to avoid Depakote, but favorites or drugs that we have data to support less?

Caroline Just, MD: Absolutely. The main two that have the most data and lowest risk of teratogenicity are Levetiracetam and Lamotrigine. Both are just slightly above the regular rate of teratogenicity. In terms of which one, if a patient has a psychiatric history, I'm less likely to want to start Levetiracetam. If they really need control quickly, I'm less likely to start Lamotrigine because you have to titrate it up so slowly. Those are the main two that I tend to use for women of childbearing age, women with epilepsy. If for example, somebody has had a previous Stevens-Johnson episode with Lamotrigine and became psychotic on Levetiracetam, I will consider other options depending on their type of epilepsy. Oxcarbazepine also has relatively good safety data. I really would just caution using Topiramate or Valproate, Valproic Acid if you have other options.

Glen Stevens, DO, PhD: Let's say a different scenario, you have a young woman that's on birth control pills and doesn't want to get pregnant and has a seizure history and on anti-seizure medications, can you talk about some of the medications that are known to influence birth control efficacy?

Caroline Just, MD: Any inducer of ZIP enzymes is likely to do so. Those are generally Phenytoin, Carbamazepine, Oxcarbazepine. Topiramate can do it at higher doses, so that doses we use for epilepsy sometimes, but the doses we use for migraine less likely. The other thing to keep in mind with that is the state of pregnancy or the birth control pill itself. The hormones can actually increase metabolism of Lamotrigine. So, patients may require higher doses of Lamotrigine.

Glen Stevens, DO, PhD: Sounds like you get into a vicious cycle there.

Caroline Just, MD: Indeed, you do.

Glen Stevens, DO, PhD: That brings me to my next question and then that is monitoring of levels during pregnancy.

Caroline Just, MD: Yes.

Glen Stevens, DO, PhD: Talk about that a little bit.

Caroline Just, MD: They should be monitored monthly. Ideally, you get a level that was indicative of good control from prior to pregnancy, like a Levetiracetam or Lamotrigine level, and you try to target that. And you will need to be fairly aggressive with increasing dosing, particularly for Lamotrigine and Levetiracetam. Sometimes you end up with patients on 300 milligrams twice a day of Lamotrigine. That's not uncommon.

Glen Stevens, DO, PhD: You get some calls from the pharmacist?

Caroline Just, MD: Yes, yes. Some very concerned calls. And the other thing to keep in mind is when patients deliver, to ensure that they don't become immediately Lamotrigine toxic.

Glen Stevens, DO, PhD: And the other seizure medications that we need to monitor specifically? I guess any of them, it's a good idea just to check, right?

Caroline Just, MD: Yep. I would still get monthly or every six-week levels. For most cases, you're just more likely to need to adjust Lamotrigine and Levetiracetam more aggressively. Interestingly, some bigger studies have shown that the rate of seizure stays about the same, but the rate of medication changes is much, much higher. Meaning if we're doing a good job, hopefully we're preventing these seizures.

Glen Stevens, DO, PhD: Can you comment on MRI during pregnancy?

Caroline Just, MD: If you need to do an MRI for a new diagnosis, don't do gadolinium, because gadolinium is teratogenic because it has radiation. Most things can probably be avoided. If you're looking, for example, a mesial temporal sclerosis, like a localizing epilepsy study, you're probably not going to operate during that pregnancy, so perhaps you can wait. But doing an MRI during pregnancy is not harmful if you need it. For an elective looking for a specific epileptogenic lesion, maybe delay. But for example, if a patient has a new onset headache and focal findings, that patient should be getting a non-contrast MRI.

Glen Stevens, DO, PhD: Yeah, it's a real issue with us in the tumor field because we have a lot of patients with low grade tumors that decide to get pregnant or don't decide but get pregnant. What we generally tell women is that we try to avoid the MRI in the first trimester, although we tell them we don't have any good data to support that it's going to do anything negative. But since we know the development is during that time, we try to avoid it. And we do the same thing. We recommend not doing a contrasted MRI scan if we can avoid it. If we see something where giving contrast would make a difference, then we'll have that discussion with them separately and we try and do that late in the pregnancy. We'll often do an imaging study depending on the tumor type closer towards the end of when they're going to deliver. And then again, I'm not sure if you want to get into this, but it comes down to can they have a vaginal delivery? Do they have to have a C-section?

Caroline Just, MD: There are very few cases where a C-section results in a better outcome. For example, Chiari malformations. It used to be thought that these patients must have a C-section because the Valsalva necessary during labor will worsen and potentially cause herniation. That is substantially untrue. We don't have randomized studies, but we do have a fairly large cohort study that came out in 2017. We certainly, I think as a result of that, prevented a lot of unnecessary C-sections. There are also very few reasons to avoid an epidural in neurologic disease. Most of them are the same as a patient who's not pregnant. So, a patient on anticoagulation, a patient with a spinal cord tumor, a patient with a local infection. In general, we want to have good evidence for recommending a certain intervention. Another example is AVMs. Is the Valsalva two risky? Should these patients have a C-section? Probably not. They don't necessarily need one. And C-sections do have increased risk of... For example, DVT formation, it's a more controlled delivery, but it's not an easier recovery. It's a more difficult recovery for the patient.

Glen Stevens, DO, PhD: And should these patients all be seeing a high-risk OB?

Caroline Just, MD: Usually, MFM, yeah. There should be collaboration between OB, MFM, and potentially the neuro-obstetrics person involved. There are some great collaborations here between the cerebrovascular clinic and MFM. They have their own stroke and pregnancy-dedicated clinic, and collaboration is absolutely key. Everyone has their area of expertise, but we want to make recommendations based on safety and considering the patient's preferences as well.

Glen Stevens, DO, PhD: What about genetic disorders? A lot of neurologic-genetic disorders, Neurofibromatosis, very common. One in three or 4,000 patients, NF2, Von Hippel-Lindau disease, and even scarier things like Huntington's disease. What do you tell patients? Do you tell everybody, "You need a trip to see medical genetics?" Or genetic counselor?

Caroline Just, MD: I try to have at least a preliminary discussion myself, particularly for some of the specific diseases like Huntington's. We know about genetic anticipation; we know about its transmission. I do recommend that everybody with a clearly transmissible neurologic disease does speak with genetics. Sometimes that happens a bit too late. Sometimes it happens when people are already pregnant or can't make decisions based on that. One interesting thing to note is it comes up in incredibly commonly that women with migraines feel it would be irresponsible for them to become pregnant because they think that their child would be suffering from the same level of migraines, which I think is sad for many levels. Number one, yes, migraines are genetic, but they are highly treatable in most cases. Number two, migraines tend to get better in pregnancy, especially after the first trimester. And number three, it's not a fair thing for someone to make that much of a big life decision without all the information.

Glen Stevens, DO, PhD: I guess the other reason for seeing medical genetics is that, when I used to do a lot of NF work, we would send a lot of, because a lot of young people would come in and be seen regarding their disorder, and we would discuss the fact that it's not autosomal dominant disorder. In my personal experience, those that were minimally affected, more likely to have children, those that were more affected, less likely, although their children may be more or less affected than they are. It doesn't necessarily correlate with them. But we would always recommend they see medical genetics to at least have a discussion of preconception testing that could be done, different ways of enabling or determining if the embryo is going to have the same genetic disorder or not. And depending on what their religious or moral or constitutional decisions were, they could make those themselves. I wasn't here to be the moral police, but there are options in that regard, and I think that it's not a one-stop shop. What someone may choose to do, somebody else may, it's not for them.

Caroline Just, MD: That's a really fundamental principle of neuro-obstetrics. We want to empower patients with the right information to make their own risk-benefit decision. We don't want to assume that the risks always outweigh the benefits.

Glen Stevens, DO, PhD: Yeah, I like that because this is what I deal with all the time. I never want to feel that I push the patient to do something they did not want to do.

Caroline Just, MD: Absolutely.

Glen Stevens, DO, PhD: Even though we tell patients what we recommend, but we don't want to push them to something. We want to make sure that as much as they can, they have free choice. Sometimes all options are difficult options, but at least they understand that.

Caroline Just, MD: And an option one can own and feel empowered to make or choose is the best one.

Glen Stevens, DO, PhD: Let's talk a little bit about postpartum period and what's going on in the postpartum period with patients that have neurologic disorders.

Caroline Just, MD: Absolutely. We can discuss a few different disorders here. Firstly, in the postpartum period, patients with MS are more likely to have a relapse, so that's an important thing to keep in mind. Patients with epilepsy are in a real hotbed of having a seizure due to sleep deprivation, changes in just their sleep patterns, and also that med changes are often being made. Migraines also tend to flare in the postpartum period for similar reasons that seizures tend to be more common. The other reason is the hormone withdrawal that tends to happen around there. For my patients who I see throughout their pregnancy, I tend to do an occipital nerve block around week 37 before they deliver, if I can time it correctly, which sometimes I can, sometimes I really can't, to get them through the postpartum period a little better.

Glen Stevens, DO, PhD: I don't want to jump ahead of you, because you're on a roll, but breastfeeding?

Caroline Just, MD: Oh, excellent point. Breastfeeding really depends on the patient's choice, first of all. And second of all, on the medication. Way too often patients are told, "Well, you have to pump and dump after you take your medication," which is both not evidence-based in most cases and deeply impractical, because many of these infants don't take a bottle and also what are they going to feed their child if they are choosing to do breast milk? Formula is an option, but some people don't want that to be their option. Gadolinium, perfect example. People are always told to pump and dump after Gadolinium. We have no evidence that it crosses in breast milk. The important concept I want to get across here is check the RID, which is the relative infant dose of each medication and if it's less than 10 percent, you're probably okay. There are some exceptions to that. For example, codeine, because it can be metabolized differently by different members of the population. So, codeine should be avoided in the postpartum period if a mother is nursing. But many medications have an RID, relative infant dose, that is negligible. Nortriptyline is a good example of one for migraine prophylaxis.

Glen Stevens, DO, PhD: It sounds like us men need to do a little more heavy lifting in the postpartum period to allow a better sleep, better rest, better relaxation.

Caroline Just, MD: I think that is a really good point. I think having a village is very, very important. Whoever that village is comprised of, if patients are able to financially do it, hiring a postpartum nurse or a doula is something reasonable. It's best to give concrete advice rather than telling people, "Well make sure you sleep." "Okay, well, how do I do that?" If you can get a night nurse every fourth night. Don't carry your baby is something that postpartum women are told due to the risk of seizing while holding their baby. Well, that's impractical advice, right? So, perhaps minimize the time you're holding your baby while walking downstairs. Use a baby carrier if you can.

Glen Stevens, DO, PhD: Yeah, it's amazing. Some of this stuff is so practical, but people just don't think about it.

Caroline Just, MD: Yes. Try to think of something you can tell your patient to do, not just what not to do.

Glen Stevens, DO, PhD: Yeah, I like that. I like that. Let's shift over to acute conditions that are either directly or indirectly associated with pregnancy. Can you go through some of the more common ones? I think a lot of us are familiar with those, but can you go through some of the more common ones?

Caroline Just, MD:Absolutely. New onset headaches in pregnancy are an important thing to look into, and patients can get imaging during pregnancy. We already discussed limiting gadolinium if we can, and potentially limiting some contrast. But if a patient comes in with a new onset subarachnoid sounding headache, they should get a CT scan. It's just the right thing to do. There are other neurologic conditions such as focal neuropathies that can flare during pregnancy or occur during pregnancy. For example, pregnant women are more likely to have carpal tunnel syndrome. They're also more likely to get meralgia paresthetica due to compression of the lateral femoral cutaneous nerve.

Glen Stevens, DO, PhD: What about seizures? Elevated blood pressure, preeclampsia, eclampsia?

Caroline Just, MD: Oh yes. Definitely an area of interest of mine. Preeclampsia doesn't have a clean definition anymore, but in general involves elevated blood pressure beyond someone's baseline, and proteinuria can involve end organ damage. Sometimes that end organ damage is brain related.

What's interesting is that the pathophysiology of preeclampsia and eclampsia are likely the same pathophysiology as PRES, posterior reversible encephalopathy syndrome, and RCVS, reversible cerebral vasoconstriction syndrome, which can occur together, which means two things. Number one, it's common that we're using outside of pregnancy magnesium infusions to treat those conditions. And number two, that we should probably keep in mind that when patients have pre-eclampsia and they develop neurologic symptoms, we need to be a bit more proactive with imaging.

Glen Stevens, DO, PhD: When should somebody see you? When should a family practice person refer to you?

Caroline Just, MD: We're a group, so there's me, I tend to see the general stuff. I see a lot of migraines, but we have somewhat in every center. We get most of our referrals from OB or from MFM. If the question is preconception counseling, that's a great referral. If the question is no known neurologic disease and an early pregnancy with concerns about how this might affect the pregnancy, that's also great. If it's a new neurologic symptom in pregnancy, great referral. We get a lot of Chiari-related counseling because Chiari's are so frequently diagnosed and diagnosed incidentally. So, that's also a very common referral and patients are able to get to the expert that they need to get to.

Glen Stevens, DO, PhD: And one thing we didn't touch on, any thoughts about myasthenia in pregnancy?

Caroline Just, MD:

Oh, excellent question.

There are definitely some considerations. Myasthenia is one of those conditions where it can be safely managed throughout pregnancy in most cases. There is the concern of neonatal myasthenia gravis from transient antibodies, but in most cases, patients are able to be managed carefully. Sometimes they might need IVIG, sometimes they might need more acute treatments, sometimes they might need low dose steroids, but in general, it's very achievable to have myasthenia and to go through multiple pregnancies. You just need to be followed by an expert.

Glen Stevens, DO, PhD: Final takeaway for our listeners?

Caroline Just, MD: The point that I want to get across is that we have to ensure we get risk-benefits straight. So, if we're not sure what should be part of that risk benefit discussion, it's okay to ask, it's okay to refer. If you would like to just touch base, if you have a specific question, please reach out. We're a very collaborative institution and myself and my colleagues are happy to be involved in caring for your patients.

Glen Stevens, DO, PhD: Excellent. Well, Caroline, this was an interesting conversation. I've moved out of the realm of having children, but I have grandchildren, so it's good to stay up on all this. I'd like to thank you for joining me today and look forward to our continued collaboration.

Caroline Just, MD: Thanks for having me.

Conclusion: This concludes this episode of Neuro Pathways. You can find additional podcast episodes on our website, clevelandclinic.org/neuropodcast, or subscribe to the podcast on iTunes, Google Play, Spotify, or wherever you get your podcasts. And don't forget, you can access real-time updates from experts in Cleveland Clinic's Neurological Institute on our Consult QD website. That's consultqd.clevelandclinic.org/neuro, or follow us on Twitter @CleClinicMD, all one word. And thank you for listening.