Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
Do you use acetylcholinesterase inhibitors in patients with cognitive changes in the setting of cerebral amyloid angiopathy?
Many patients with CAA also have cognitive deficits. If so, I use cholinesterase inhibitors, usually donepezil. I would not prescribe these agents if the patient has only microbleeds and no cognitive impairment.
When do you recommend lumbar puncture in patients with concern for memory loss?
Rapidly progressive memory loss/dementia- because you obviously want to exclude diagnoses like CJD, infectious/autoimmune/paraneoplastic encephalitis, lymphoma or other malignancy, etc. When you need to know the patient's "brain amyloid status". E.g. a) Patients with amnestic MCI and atypical cour...
Would you consider AEDs in patients with recurrent TGA?
In the case of recurrent TGA, meaning more than two attacks, I would ask for a focused history on migraine and seizures. If I suspected the latter, I would do a trial of an antiseizure medication, usually levetiracetam.
How frequently do you check CK in patients with Becker's muscular dystrophy?
I do NOT check CK regularly in Becker or other muscular dystrophies after the initial diagnosis. The question is why should we check it regularly when there is no disease-modifying treatment currently FDA approved for the vast majority of muscular dystrophies, and there is no correlation of the leve...
When do you initiate migalastat in female patients with genetic evidence of heterozygous Fabry disease?
Female "carriers" of a Fabry gene mutation should be offered treatment when there is clinical or subclinical evidence of cardiac, neurologic, renal, or GI involvement. This means that all female heterozygotes need a clinical exam, echo, EKG +/- Holter, creatinine, urine protein/creatinine ratio, neu...
What guidance do you provide for anesthesia in patients with incidentally found carotid web?
Terrific question. I would certainly not do an intervention and one may argue aspirin is not indicated. I would ensure all risk factors for stroke are managed appropriately and if aspirin is otherwise indicated based on ASCVD risk, would initiate it. Testing for high risk features (high resolution M...
Is there a preference between the different high-intensity statins for high-risk stroke patients?
Atorvastatin 80 mg daily (studied in secondary stroke prevention in SPARCL) and rosuvastatin 40 mg daily are maximal approved doses for the two potent statins. These have been compared head-to-head in coronary atherosclerosis in SATURN study. The study was an atherosclerosis progression/regression s...
Can bleeding risk when switching from VKA treatment to a NOAC in frail, elderly patients be accurately compared if individual times in therapeutic range while on VKA treatment are not captured?
It has been postulated that, among patients who do not have an INR within therapeutic range, about half have subtherapeutic values and half have supratherapeutic values. Therefore, the latter are at higher risk of bleeding complications. Time in therapeutic range (TTR) ranges around 60-70% in random...
How do you approach treatment of sub-total resected ZFTA fusion ependymoma after radiation therapy in a young adult?
Thank you for asking.ACNS0831 has shown that there is no benefit of adjuvant chemotherapy in patients with incomplete resection. This was based on a comparison between ACNS0121 where patients did not receive any chemo after XRT and ACNS0831 where all patients with residual received adjuvant chemothe...
If you have a patient with isolated CN VII palsy (Bell's Palsy), and straightforward symptoms with no red flags (such as concern for carcinomatous meningitis), do you routinely get an MRI brain or do you just make a clinical diagnosis?
In my practice, I do not order a brain MRI if there are no red flags. I treat with a course of steroids; 60 mg of prednisone for four days, 40 mg for four days, 20 mg for four days and then stop. I see the patient back in six weeks. If they have not made a complete recovery, I perform MRI imaging wi...