Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
Has MR spectroscopy ever led you to forego a planned stereotactic biopsy in a patient with a suspected intracranial neoplasm?
I have never had spectroscopy allow me to forego a stereotactic biopsy when I suspected active/progressive neoplasm; however, if I suspected necrosis more than recurrence or tumor and spectroscopy was in accordance with that, then I have been able to save people a biopsy in that situation.
Does persistent focal slowing without epileptiform discharges indicate increased seizure risk in patients without significant structural abnormalities?
Good question! :-) Lateralized rhythmic delta (LRDA), especially temporal (TRDA) certainly does, basically to the same degree as interictal epileptiform discharges (IEDs). Focal polymorphic slowing is of course not technically "epileptiform" but it does indicate some focal dysfunction, so I would sa...
What is your approach to secondary stroke prevention in patients with atrial fibrillation and intracranial stenosis (>70%)?
The patient clearly needs to be on an anticoagulant for stroke prevention with atrial fibrillation and I would choose apixaban. If an antiplatelet is added to the apixaban, the risk of a major bleeding side effect is significantly increased. It is uncertain if apixaban is effective in reducing the r...
Do you recommend normobaric hyperoxia for thrombectomy patients?
Not yet. Below is my take: Trial Summary 120 patients were randomized at two comprehensive stroke centers in China with anterior-circulation LVO presenting 6-24 hours after onset to EVT plus normobaric hyperoxia (NBO) or EVT alone. NBO consisted of 100% oxygen at 10 L/min by face mask for 4 hours, i...
How do you decide when to order an EEG to evaluate for non-convulsive status epilepticus in a patient admitted with acute encephalopathy?
This can be a challenging question to answer given the broad differential of acute encephalopathy and how available EEG is at your hospital. At centers with easily available EEG capabilities, the threshold to obtain an EEG will be lower. I will also assume this question is related to patients who ha...
How do you counsel patients with postural orthostatic tachycardia syndrome (POTS) regarding safe and effective exercise regimens?
It depends on where they're starting from. If they're starting from scratch, I give them two recommendations: first is the Children's Hospital of Philadelphia protocol, and if they live in town, I refer them to our PT facility at Vanderbilt (The Dayani Center) to have our PT folks help them get star...
How do you determine which type of re-vascularization technique is appropriate to treat a patient with Moya Moya disease?
There are 2 types: indirect and direct. The direct bypass involves suturing a branch of the STA to a cortical branch of the MCA. This is by far the best method to treat ADULT cases. In children, the INDIRECT method, which is easier and does not involve direct suturing of arteries together, is usuall...
Do you ever use ocular ultrasound in evaluation of papilledema?
As a neuro-ophthalmologist, I never use ultrasound to make a diagnosis of papilledema. I do use it to reveal optic nerve head drusen that also cause axoplasmic flow stasis and can mimic papilledema. A high quality set of fundus photos is very useful for determining the presence of optic disc edema.
What early clinical findings help in differentiating CIDP vs. POEMS?
I would like to share that I had a very challenging experience last year with a patient ultimately diagnosed with POEMS by myself, after more than one year of treatment as CIDP. There were multiple reasons it was challenging:1.) The patient presented initially with NO systemic features - just the ne...
When do you use greater occipital nerve block to treat acute refractory migraine?
I frequently offer ONBs for patients with acute migraine when they have persistent headache, despite migraine cocktail & other initial ER interventions. Since occipital nerve blocks are safe, effective, and have Level A recommendations from the American Headache Society, I perform them quite frequen...