Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
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...
Do you discontinue or adjust azathioprine when a patient develops elevated MCV after starting it?
Great question, with practical implications for the clinic: Azathioprine (AZA) is a prodrug that likely exerts its immunosuppressive effects against B- and T-cell function by interfering with purine metabolism through its metabolites (including 6-MP). Logically, many of the "classic" AZA side effect...
What autonomic symptoms do you encounter in patients with ALS?
In my experience, autonomic symptoms are not typical in ALS and we do not routinely ask screening questions for dysautonomia. A recent study from Europe (see below) suggests that the only sign of autonomic dysfunction is mildly increased heart rate at rest (which may also be attributed to other fact...
What duration of dual antiplatelet therapy do you use for secondary prevention of ischemic stroke due to intracranial atherosclerotic disease?
It is a fair question that we don't have a solid evidence-based answer for. I agree that the SAMMPRIS trial was driven by events within the first 30 days, although this was primarily driven by procedure-related events in the stented group. We do know that intracranial athero (ICAS) risk of stroke re...
How do you modify TNBC neoadjuvant chemotherapy in patients with multiple sclerosis?
This is a good, but tough question with unfortunately no great data to support the safety of immunotherapy combinations in patients with active autoimmune diseases including multiple sclerosis. While the significant improvement in pathologic complete responses with the addition of pembrolizumab to c...
If memantine were started 6 weeks after completion of radiation to base of skull, would you expect any potential benefit?
There is currently no credible high-quality data to support the use of memantine in focal brain RT for primary or metastatic brain tumors, regardless of whether the hippocampus is in the radiation field. Therefore, I would not prescribe memantine during or after RT in such a clinical setting. In my ...
Do you use vitamin B6 to help with Keppra irritability?
I am an adult epileptologist and do not routinely prescribe pyridoxine for neuropsychiatric adverse effects of levetiracetam. I do see this done a lot more in the pediatric population, where there is more data than is available in the adult population (though still not of very high quality). Anecdot...
How will you counsel patients regarding ARIA?
It is possible that with real-life experience and further study, blood biomarkers will be validated as early detection signs of ARIA, but right now we are left with MRI. I believe that we need a lot more real-world data about these drugs before we consider alternative ways to diagnose and screen for...