Neurology
Questions discussed in this category
Do you distinguish between primary and secondary prevention? Wilson et al., PMID 31130428 is helpful, but curious how people apply this data in practi...
Do all malignant posterior fossa infarcts need sub-occipital craniectomy or are there a subset of cases that can be managed with EVD?
Also how would you manage this perioperatively?
How do you differentiate symptoms related to centralized pain syndrome from possible cognitive dysfunction?
In a patient who is already on a standing regimen of baclofen, tizanidine, trihexyphenidyl, clonidine, and diazepam and who is taking additional diaze...
If so, what is the recommended maximum dose of clozapine for PD patients?
Is there a role in adjusting the medication doses to levels in patients who are seizure free; or is it sufficient to just monitor patients clinically?
Do you attempt to taper fully or maintain at a low dose?
This applies to using EVD either in addition to or instead of a large volume lumbar puncture.
Anecdotally, the diagnostic yield in these patients seems quite low, yet autoimmune encephalitis is often invoked in such patients, particularly in th...
Which tests do you typically order?
What do you recommend for surveillance and when to start the “three R’s” (riluzole, radicava/edaravone, and relyvrio (sodium PB/TUDC...
Are higher levels of exercise in patients with PD potentially even more beneficial to brain health?
What are the diagnosis and treatment for hypnagogic shooting headache?
If a patient has a metastatic lesion in close proximity to one hippocampus, would you offer sparing of the contralateral hippocampus? Do your dose con...
If the patient is in burst-suppression once EEG is connected, how long do you keep patient in burst-suppression before weaning sedation?
If a patient has classic TM symptoms but a normal MRI, are there specific causes you look for?
Should perfusion imaging be standard of care in cases of a severe symptomatic intracranial stenosis?
If yes, is there a preference with MRI or CT technique?
Is your approach different than that to a primary essential tremor?
Regimen currently 25 mg lenalidomide D1-21 of D28 day cycles, Daratumumab 16 mg/kg every 2 weeks.
History of 4th ventricle choroid plexus papilloma s/p GTR, now with recurrent disease in the 4th ventricle and the left lateral ventricle (7 nodules i...
For patients who are unable to have complete brain stem testing, would you recommend apnea testing prior to ancillary tests in case of suspected brain...
How would you educate Parkinson's patients about the benefits of exercise based off of this study?
For patients undergoing outpatient MR imaging for other indications who have instantly found acute stroke, do you typically recommend the patient be a...
How does 1p/19q co-deletion and IDH mutation status influence your decision?
Do you offer this person a vascular intervention (i.e. CEA or stenting)?
Or love to share personal experiences/articles?
For example, patients with spasticity due to hypoxic or anoxic brain injury.
In what ways, if any, does the timing of perfusion imaging from onset of stroke symptoms affect its utility in informing quality of distal perfusion?
For instance, if the patient doesn’t tolerate apnea testing, is too unstable to go for ancillary testing outside the ICU, and TCDs/EEG are unava...
Are there variations with different patient populations?
Do you charge for it? Do you bring them in to complete the paperwork? Or do you send them to PT for Functional Capacity Evaluation?
Are there any diagnostic tests or imaging that you recommend?
Do you switch MG patients from Soliris to Vyzvart due to cost, and with switching do you have a recommended wash out period?
When do you consider observation?
How about a distal occlusion? The patient was initially symptomatic but symptoms improved or mostly resolved.
Do you wait 12 weeks for confirmation to begin treatment if patient is declining?
Would you consider empiric SRS if biopsy/resection is not feasible?
When would you consider liquid biopsy?
See Benbadis, AAN Commentary February 2023; 13 (1).
Are there any protocols in place? Aside from telling patients to use ice packs or bags or immerse hands/feet in ice water baths from 15" before to 15"...
Is there any role for a surgical intervention in patients with distal weakness, who has marked peripheral neuropathy but also lumbosacral radiculopath...
What is the best way to treat late onset myasthenia gravis (in this case, age >90)? Would the newer complement inhibitors be safe? Steroids in this...
How do you account for a normal EMG/NCS in the setting of prolonged clinical symptoms suggestive of a radiculopathy? How do you explain this to patien...
Are there any environmental exposures you ask about for newly diagnosed ALS patients?
Do you see improvement with treatment such as IVIG?
If so, how long do you continue medication and when do you discontinue?
Does treatment with surgical resection versus radiation alone change your man...
For example a 1 or 2 mm brain metastasis? Would you consider waiting for these to enlarge slightly for reasons such as more certainty they are real, l...
The patient has no known history of autoimmune disease.
In patients with hx of metastatic cancer, presenting with unilateral proximal arm weakness. No checkpoint inhibitors use.
Which CSF lab...
Particularly when ondansetron and taking it with food are not beneficial.
What is your preferred dose/fractionation following a previous course of radiotherapy?
How do you recommend titration?
Will these results change your practice?
For example, a patient with 2 Hz GPDs with hepatic or uremic encephalopathy.
In patients with chronic migraine and possible medication overuse headache due to chronic narcotic use, what’s your strategy for those patients?...
Does timing relative to initiation of antibiotics matter?
What are some high-yield instances where triphasic waves on electroencephalogram (EEG) are more than just harmless markers of gross toxic-metabolic en...
How do you approach low IgG levels on these medications?
Assouline et al., PMID 24411632 recommend delivering 500cGy x 4 fractions = 2000cGy on days 1, 3, 8, 10. Do you follow this schedule, treat every othe...
What modality do you prefer?
Should one restart lamotrigine or look for an alternative? If no other alternative available, is slow titration vs regular titration preferred?
What would be your next treatment for a young adult patient with medulloblastoma refractory to repeat resection, craniospinal irradiation, and initial...
If so, for how long?
Would the checkpoint inhibitor still work if blocking only that portion of the inflammatory cascade as opposed to more global blockade with steroids?
Is there any data supporting this?
In patients with suspected CIDP, does the use of imaging—MRI (thickening or abnormal enhancement of cervical/lumbar nerve roots or brachial/lumb...
Are VDRL titers useful?
B5 deficiency can be seen in patients with burning feet syndrome, do you typically screen for this when assessing for neuropathy?
Do you just use antibiotic prophylaxis if therapy is started prior to meningococcal vaccination?
Based on this review (Melamed and Lee, PMID 31998289), patients with MS on several DMTs may be at higher risk for certain cancers. How does this play ...
Is there data for CGRP inhibitors?
How do you treat medically refractory sleep related movement disorder in patients who has failed medical management with dopamine agonists, gabapentin...
Do you order any imaging beforehand? Are there other studies that you order?
If patients are asymptomatic, what work up do you typically proceed with?
What is your preferred approach to a pregnant patient who is in status migrainosus that is refractory to first line treatments?
Do EMG studies such as myoclonus or tremor studies change your management?
Is there a clinical scenario in which using the 10mg/100mg Carbidopa/Levodopa formulation is preferred to or more beneficial than using the more commo...
When do you consider a blood patch?
Especially forms of non-pharmacologic treatment, such as physical therapy or special devices.
While it is an excellent score for objectively assessing concerning EEG features, there are pathologies where it can be argued that long-term monitori...
When should we consider getting DaT scan in patient suspecting of Parkinsonism syndrome?
We often use abdominal binders and compression stockings, in addition to hydration and midodrine/fludricortisone. However, are there more targeted the...
How does pravastatin differ in advantage from other high-intensity statins?
Do we prophylactically place patients on anticoagulation after one episode?
Besides MRI/MRV brain, are there other diagnostic imaging that should b...
With studies showing rare risk of developing epilepsy after PRES do you just taper medications over the following weeks-months? Any need for outpatien...
(e.g. Alzheimer's disease)?
If not, then what is your preferred treatment and would you integrate SRS into it?
Do you have a particular cutoff?
Although probably more familiar to ophthalmologists, orbital apex syndrome refers to the consequence of any kind of swelling or mass effect within the...
Do you ever recommend any specific sequences on MRA?
For example, a GAD65 Ab of 0.07 when the cut-off is 0.02. Does this answer change if you consider adult vs pediatric populations?
Instead of waiting for the antibody test to result, if you have a high suspicion for NMDAR encephalitis, is there a role for giving rituximab alongsid...
Is there a role for using a trial of pyridostigmine as a diagnostic aid in a patient with suspected (but not confirmed) myasthenia gravis?
For patients clinically presenting with Transient Global Amnesia and no other focal neurologic deficits, do you always pursue work up to rule out stro...
Do you prophylactically start all patients on B12, B-complex, and/or omega-3? If so, what dose? What about ice mittens and booties?
Do you ever add prophylactic Keppra (levetiracetam) for glioblastoma patients without a seizure history based on data such as this study (nature.com) ...
Which triptans are safer in stroke induced migraines?
Does your management change in any way?
What is the cost and accessibility of CYP2C19 gene testing? Does the limited availability of rapid genotyping techniques limit the clinical applicabil...
In patients presenting with likely statin-induced myopathy versus statin-induced autoimmune necrotizing myopathy - how do you approach the decision re...
How often are you scanning the brain and what is your trigger to treat?
How do you counsel young adults with antibody-negative necrotizing myopathy on prognosis, risk of recurrence, and long-term monitoring/treatment?
How do you plan to incorporate the results of the CHANCE-2 trial (Wang et al., PMID 34708996) in your own practice?
What is the etiology/pathology for tinnitus in Intracranial hypotension? How often is this symptom encountered in patients with intracranial hypotensi...
No thrombus detected on echocardiogram and no evidence of atrial fibrillation is present.
Do you perform routine screening for coronary artery disease in aging patients already taking these therapies?
For patients who present with elevated myoglobin in the setting of normal creatinine kinase and exercise intolerance, what work up process do you typi...
If so, what would you consider ordering?
What are your thoughts on the ethics of inpatient use of sedatives in these patients to help with agitation to “protect themselves from harm and...
Is there role for IVIG? Would you alter the dose or time course of steroid therapy?
Which holistic treatments for migraine without aura do you recommend for patients who are refractory to standard treatments?
Occasionally, patients referred for dedicated epilepsy management for "medication refractory epilepsy" are found to have purely non-epileptic spells. ...
What referrals do you recommend/imaging orders?
In the setting of no personal or family history and no other risk factors for thrombosis, is systemic anticoagulation warranted if local treatments (e...
Since these patients or their caregivers may not know the symptoms related to sleep disorders and the negative effects on their already compromised ne...
This question is intended to include consideration of cardiac diagnostic screening, as well as initiation & maintenance of lamotrigine, in epileps...
What effective modalities have you found for acute exacerbations of trigeminal neuralgia including in patients who present to the ED?
How can one safely taper off and stop clonazepam in a woman of reproductive age with epilepsy who is taking it chronically for epilepsy and is plannin...
While some have the practice of 90 days per SAMMPRIS, the lower rates of ischemic stroke in the medical therapy group were driven by events within the...
If so, what percent likelihood do you quote patients for this risk with SRS, SRT and fully fractionated therapy?
Do you routinely discontinue the device or continue if they are otherwise tolerating the treatment well?
What is the diagnostic yield and complication rate in your experience?
How do you decide if and when to send patients with AChR+ ocular myasthenia gravis for thymectomy?
How do you approach secondary stroke prevention for patients with ischemic stroke, atrial fibrillation, and signs of cerebral amyloid angiopathy/micro...
What factors influence your thinking?
Do you wait for a second clinical event or start immunomodulatory therapy right away?
How do you manage botulinum toxin injections in a patient with cervical dystonia after getting implanted with DBS?
Do you require neurosurgical evaluation first? Do you require any patients to wear a neck brace?
How do you treat dangerous behavioral disturbances (aggression, nighttime wandering) in patients with dementia with Lewy bodies (DLB)?
If you have significant side effects, GI and/or cardiac with one of the cholinesterase inhibitors, would you try using another medication or would you...
The most frequently taught cause of asterixis is hepatopathy and of course hepatic encephalopathy, and has other close associations (ie, uremia), I ha...
How do you manage freezing of gait in Parkinson disease when dopaminergic therapy worsens the freezing phenomenon?
I teach my students/residents that they should hardly ever get routine X-rays in patients presenting with radicular symptoms. MRI far better for seein...
Specifically, what do you do if there is minimal improvement with IV steroids and/or IVIG?
NCCN lists PCV as category 1 (and now with analysis in Abstract 2002 from ASCO 2019 showing benefit in IDH mutated), and temozolomide as 2B, yet temoz...
For what duration do you use therapy?
Is there any benefit to starting hyperosmolar therapy prior to the development of depressed level of consciousness or midline shift?
Are there contraindications to drugs like oxaliplatin or abraxane?
Does chronicity or severity of the patient's underlying symptoms play a role in yo...
Do you just see if the tremors are more associated with action versus static tremors? What are other clinical characteristics that can be helpful to c...
The thought being, if no clearly defined lesion exists on available neuroimaging, how do we balance the benefits, risks, and uncertainty in choosing w...
In patients diagnosed with pseudotumor cerebri, is vaginal delivery safe? How do you manage this condition during the pregnancy?
Are there any specific patient populations that you are no longer routinely recommending to start B-cell depleting medications? For example, are you l...
e.g. DITP from eptifibatide after a cardiac intervention
What would be the next steps in these cases?
Based on the results of the recent longitudinal analysis linking EBV infection and MS (Bjornevik et al., PMID 35025605), can negative EBV antibodies (...
For medical oncologists, would you offer a PD-1/L1 inhibitor? For other subspecialties, how would you counsel the oncologist regarding the risk of usi...
For example, a clinically stable patient on eculizumab, do you continue it indefinitely?
By completely unremarkable, I mean zero clinical events AND zero interictal abnormalities despite full withdrawal of medications. Assume, for the sake...
What testing do you typically proceed with?
Do you typically recommend MRI or CT?
How do you treat refractory focal status epilepticus in an adult with history of alcoholism and traumatic bilateral subdural hematomas who is failing ...
Additionally, what is the current role for temporal artery ultrasound in workup for GCA?
What is the your preferred loading (and maintenance) dose for use of Perampanel in the treatment of refractory status epilepticus?
What would be your preferred technique and dose/fractionation?
Specifically, how do you treat the delayed headache, not the headache that develops during the infusion where pre-hydration and slowing down the rate ...
How does presence of intraventricular hemorrhage change your recommendations?
The question is broad and is meant to include patients who have healthy BMD, osteopenia, and osteoporosis, as well as exposure to first generation AED...
For stroke-like migraine attacks after radiation therapy (SMART syndrome), does your management of these patient's change with recurrent episodes? How...
Can intrathecal methotrexate be continued with close neurologic observation vs switch in treatment now due to findings?
If so, when do you consider this?
Is there a role for immunomodulatory therapy?
Do you biopsy immediately, stop treatment, biopsy at a later time, or depend solely on the data you already have?
What modality do you prefer?
How do you approach treatment?
At what point do you consider genetic testing?
Are there any reasons you avoid therapy?
When would you consider treatment with steroids in patients with diabetic radiculoplexus neuropathy?
Are there any alternative treatments?
Is there any additional benefit to radiation in addition to steroids in a patient who is not a surgical candidate?
Given the bleak prognosis in HD, how do you decide which patients will benefit from DBS to treat the chorea?
In what clinical scenario would you refer a patient for embolization? Are there any contraindications?
Can you expand on this by sharing exactly what this routine workup should include? What additional tests outside of evaluating for POEMS and amyloidos...
How long do you wait (from onset of symptoms) to do a EMG/NCS in a patient with GBS?
It seems clear that longer monitoring yields more AF detected. What is less clear to me is whether all ILR-detected AF is relevant and merits anticoag...
What other workup/clinical examination findings do you look for?
Is there is a particular pattern of extraocular motility restriction in Miller Fisher syndrome?
What is the best way to determine if patients with new PCA territory infarct can drive? Upon discharge from the hospital, do you routinely refer them ...
Thoughts on sarilumab vs methotrexate, or just treat with steroids alone
How would you treat patients with symptoms of AIS who have an allergic reaction to TPA with no evidence of large vessel occlusion on imaging? What nex...
Small study in pediatric PACNS have evaluated this as a potential marker (Cellucci et al., PMID 22740622)
For a relatively young, medically compliant patient with HFrEF (EF<35%) and h/o embolic stroke, what is the consensus of starting AC for secondary ...
How do you manage ADHD in patients with Tourette syndrome in order to prevent exacerbating the tics such as with medications like Aderall?
Is there an AED of choice?
For patients with ischemic stroke status-post decompressive hemi-craniectomy, when should they start aspirin for secondary stroke prevention? POD 5? P...
Presuming that work-up for cardioembolic sources is negative, how would you proceed?
Does this add any value?
Has the recently published interim analysis of the CATNON trial altered your utilization of temozolomide?
Does IDH status change your treatment appro...
Do you consider the small, but statistically significant, improvement in OS to outweigh the side effects of treatment?
Length of temozolomide course when given with adjuvant radiotherapy
If not, how often do you repeat pelvic imaging?
In patients undergoing continuous EEG monitoring in the ICU, we often encounter EEG patterns that lie along the inter-ictal continuum (IIC). In such c...
What are common side effects to look out for with Eteplirsen?
Ie through electrodiagnostic, imaging, and otherwise?
Are there contra-indications while breast-feeding?
At what point could starting AEDs be considered for patients with recurrent simple febrile seizures?
What steps should be taken to wean them off?
For example, with a Watchman device? What is the evidence behind this?
Do you approach things differently if a rare variant like this is suspected? Is the Balo's subtype more similar to RRMS or PPMS?
What factors play into your decision whether to re-treat the brain with craniospinal radiotherapy vs irradiation of the spine only vs other measures (...
Specifically, do you reach for Rituximab or cyclophosphamide?
Patients can develop sensory and motor symptoms such as paresthesias, jaw/facial pain and stiffness, cramping and twitching, ptosis and vision changes...
If so, how do you decide when to restart anticoagulants?
When would you consider stenting or CEA even if there is less than 50 obstruction when no other etiology has been found?
E.g. The case in question is for a patient planned for thoracic RT for LS-SCLC. Any medications that may help or just give much bigger expansions to c...
When do you favor RT? What is your preferred dose/fractionation?
How does length of time from prior chemoradiotherapy influence your management?
Given the slow recovery of nerve damage, what would you expect to see on a repeat EMG after treatment? Continued denervation or just sequelae of past ...
In a palliative setting, how long would you wait to initiate WBRT?
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International journal of radiation oncology, biology, physics, 2018-03-15
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