Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
For patients with generalized tonic-clonic seizures lasting > 2 minutes without IV access, what alternative medications can be used?
You can use intranasal midazolam (Nayzilam), intranasal diazepam (Valtoco) or rectal diazepam (Diastat). Other options are buccal or intramuscular midazolam using the IV solution.
How do you acutely manage a free-floating thrombus in a major artery in a patient with a stroke as a result of it?
There is no clear guidance from trials. My own practice has been to anticoagulate for 72 hours, then repeat the CTA. If the thrombus is no longer visible, I switch to dual anti-platelet Rx; if still there switch to DOAC for 30 days and reimage.
How do you approach the management of a large vessel stroke if you anticipate the development of malignant cerebral edema?
In ischemic strokes with anticipated malignant cerebral edema, I would base some initial management decisions for prevention of edema on the labs obtained at admission. If the sodium is less than 130, I would start hyperosmolar therapy to bring levels into a normal range. If less than 135, normal sa...
In women of childbearing age with NMDA encephalitis and normal pelvic imaging, is there a role for oophorectomy for possible microteratoma?
Pelvic imaging of female patients with anti-NMDA-receptor encephalitis for ovarian teratoma should consist of MRI of pelvis or ultrasound of pelvis with transvaginal views. If this testing is unrevealing, the recommendation, in general, is not to proceed with oophorectomy. There have been reports of...
What is your decision process on decreasing the sodium goal for patients with cerebral edema?
In my practice, when treating an adult patient with cerebral edema, we avoid hyponatremia but do not set a specific sodium goal. Rather, we titrate therapies (e.g., mannitol, hypertonic saline) to achieve a specific ICP goal (e.g., ICP < 22 mmHg). We stop administering mannitol if the osmolar gap > ...
How do you approach management of cerebral venous sinus thrombosis in a patient with severe thrombocytopenia?
Many patients with thrombocytopenia have abnormally functioning platelets, and as such still benefit from anticoagulation treatment. In patients with cerebral venous sinus thrombosis and counts <50K, I recommend involving hematology to help determine the appropriate regimen, which may involve a hepa...
When do you consider starting hypertonic saline solution in patients with an acute ischemic stroke?
Hypertonic (3%) saline is infrequently used, and mainly applies to patients who have signs of significant midline shift or cerebral edema on CT or MRI with a depressed loss of consciousness. In stroke patients in the awake/alert state with a large stroke and risk for edema development in the next 24...
In patients with recurrent ischemic infarcts on the same side as an internal carotid artery lesion, is intervention warranted even if there is less than 50% obstruction?
If a carotid web is found, it would be reasonable to consider intervention to prevent thrombus formation and embolization. Grory et al., PMID 30621527
Is an EMG/NCS required to clinically diagnose Guillain barre syndrome?
GBS remains a primarily clinical diagnosis, characterized by rapidly progressive large fiber sensorimotor deficits with early arreflexia, supported by albuminocytologic dissociation in cerebrospinal fluid. EMG/NCS can be normal or non-specific in up to half of the patients in the first week and only...
How do you determine the timing of anticoagulation for patients with large MCA strokes secondary to atrial fibrillation?
Timing for anticoagulation initiation depends on the size of the stroke and whether a thrombus is present outside the cerebral vasculature. In general, between 4-14 days is standard practice, with early initiation in smaller strokes (to prevent recurrent stroke) and later in larger strokes (to preve...