Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
Do you give TNK to patients presenting with transient global amnesia like symptoms within 4.5 hours?
This is a very interesting clinical question that does not come up practically very often. There is next to no study data available on the matter, so most of what I will propose here can be classified as an expert take. I think that the most direct, and clinically relevant way of approaching such a ...
Would you consider giving platelet transfusion in a patient with spontaneous intracerebral hemorrhage who is on an irreversible antiplatelet agent such as prasugrel?
This question seems logical, but in fact, there has been a clinical trial, the PATCH trial, that found no benefit of platelet transfusion; in fact, both deaths and poor outcomes were more prevalent in the platelet transfusion group than in the control group.
What outpatient therapies do you recommend for continuous or severe pain from migraine that is refractory to acute therapies?
I assume that what we are dealing with here is what we call a migraine status or status migrainosus. This refers to a migraine headache that has continued well beyond its usual duration, for which we often use the arbitrary three-day mark. We base this mark on the erroneous assumption that migraine ...
What are best practices to avoid misdiagnosis of multiple sclerosis in patients over 50 years old?
The onset of MS in patients over 50 years old is unusual. At the same time, there are a greater number of conditions, many of them quite common (i.e., chronic microvascular disease), that cause white matter disease that can mimic MS in patients over 50 years. Given that MS incidence is less and MS m...
How do you approach treatment of aceruloplasminemia with biallelic CP mutations and brain iron deposition?
These are difficult. If the hemoglobin is high enough, you can try phlebotomy, but anemia will often restrict this. Chelation is the only other treatment. The neurological decline is often relentless despite these efforts.
How do you work with patients to establish reasonable treatment goals for the management of fibromyalgia-related pain?
Great question. I explicitly tell my patients that I have no magic-bullet– no penicillin or prednisone-adjacent pill – that will swiftly and reliably alleviate their pain. This expectation, that a pill will eradicate disease, makes sense in the wake of the infectious disease revolution, where target...
What are your preferred beta blockers for migraine prevention treatment?
Beta blockers, originally developed for cardiovascular disease, were serendipitously discovered to reduce the frequency and severity of migraine attacks in the late 1960s. They remain the most widely used class of prescription preventive medications for migraine. Among beta-blockers, only propranolo...
What is your preferred treatment for rhinorrhea in patients with Parkinson's disease?
According to a recent meta-analysis, rhinorrhea is common in people with PD; present in almost half of patients. I have only prescribed it a few times, but to the best of my knowledge, intranasal ipratropium is what is most commonly tried. Efficacy is variable. And there are no PD-specific studies o...
Do you switch from Eliquis to Pradaxa in patients who experience a recurrent ischemic stroke while on Eliquis, considering their different mechanisms of action?
I tend not to switch patients from Eliquis/apixaban to Pradaxa/dabigratan. There is no good data to support this and while the mechanistic argument may make sense, especially since dabigatran, a direct thrombin inhibitor, was the only DOAC to reduce ischemic stroke events in a statistically signific...
What factors do you take into account when deciding the length of adjuvant temozolamide in GBM?
The field is evolving from 12 cycles to 6 for IDH-wildtype GBM in recent years, on the basis of some retrospective studies and notably the prospective Spanish study GEINO 14-01 - there does not seem to be much OS benefit, and there are also toxicity concerns (myelosuppression, hypermutation). Extens...