Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
Do you treat migraine with aura if there is not an associated headache/pain?
I do if it interferes with quality of life. I do not recommend abortive medications for aura. There is no evidence that migraine abortive treatments shorten the duration of aura. I do not think that they do. Anecdotally, I have had some patients report that taking NSAIDs or a triptan at the aura ons...
How do you manage patients with atrial fibrillation having a thromboembolic infarct despite being on adequate anticoagulation?
This scenario is always challenging. In terms of anticoagulation, the efficacy of DOACs in preventing embolic events in AF patients is around 70%, which is impressive compared to warfarin but not foolproof. In cases of a second embolic event while on anticoagulation, two reasonable approaches are of...
What pharmacological management do you consider in patients with Autism Spectrum Disorder whose primary behavior is aggression?
As with all of my child patients, my approach is never to medicate behavior but rather to medicate suffering. This means that I view “aggression” of all forms as a kind of communication that something is wrong inside and that other means of effective communicating or managing that discomfort or what...
How do you approach treatment of a glioblastoma in pregnancy?
Glioblastoma during pregnancy could be treated safely (to mother and fetus) with certain precautions and modifications. Collaboration and consultation with the patient’s obstetrician are essential. External shielding over the patient’s abdomen during treatment will decrease the external scatter radi...
When is air travel safe for patients with recent diagnosis of ischemic stroke?
Air travel on a modern commercial jet includes full pressurization and oxygenation, such that I see minimal or no risk to air travel. Flying on a small, private plane would have higher risk, so I would wait longer for that, perhaps even a month. During helicopter flights for acute stroke patients, o...
How do you treat steroid-refractory MS flares when PLEX is unavailable?
There is limited evidence on the efficacy of IVIG for MS relapses. A repeat course of IV methylprednisolone within 2-3 weeks could be considered. If the patient is not already on high-efficacy DMT, then I would also promptly initiate anti-CD20 therapy.
Should mRS be incorporated into determining eligibility for extended window thrombolysis?
Key thrombolysis trials (WAKE UP, OPTION, EXTEND, TIMELESS, ECASS-4, HOPE, EXTEND IA) excluded patients with mRS of 2 or greater. The reason for this was the outcome of functional independence at 90 days. Hence, for trial purposes, to look at the outcome, it was necessary to exclude patients with di...
What clinical history or findings make you more concerned for an amyloid-related neuropathy?
Many, including: Presence of a monoclonal IgG or IgA protein on serum or urine protein immunofixation, especially lambda light chain, and especially if kappa to lambda light chain ratio is very low. Unexplained autonomic dysfunction, especially orthostatic hypotension without compensatory tachycard...
When would you prescribe pharmacologic DVT prophylaxis in bedbound neuromuscular patients?
Short answer: I would still not prescribe pharmacologic DVT prophylaxis routinely for all my bedbound neuromuscular patients in the outpatient setting. The point raised by the question is more than reasonable. Ideally, a randomized trial of prophylaxis vs. placebo should occur before we change our p...
When is it useful to test for multiple amyloid-related biomarkers for patients undergoing work-up for cognitive impairment?
If a patient has a presentation consistent with MCI or early dementia due to AD (slow progressive decline, STM loss, no hallucinations, no neuro deficits), I will get an MRI and amyloid blood-based biomarkers. If the goal is just a diagnosis, I stop there. If they are interested in “mab” therapy, I ...