Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
Do you recommend additional spinal MRI’s for an asymptomatic Chiari I malformation?
Age does not matter; the severity of the Chiari does. Although subjective, I would image the spine if I thought the foramen magnum was crowded enough to potentially cause a syrinx. I am not a big believer in "a high incidence" of tethered cord in the Chiari I population, so this concern would play i...
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 manage patients with glossopharyngeal neuralgia?
Glossopharyngeal neuralgia can be managed similar to trigeminal neuralgia (TN). It presents with pain like TN but located in the glossopharyngeal distribution (posterior part of the tongue, tonsillar fossa, pharynx, or angle of the lower jaw and/or in the ear). Note that neuralgia of the superior la...
When do you use GLP-1 receptor agonists for the management of patients with idiopathic intracranial hypertension (IIH)?
I would use GLP-1 agonists in all overweight IIH patients who did not have a contraindication if it wasn't for the cost. In the IIH treatment trial, 6% weight loss over 6 months lowered intracranial pressure by about 50 mm (acetazolamide also lowered ICP by about 50 mm, but of course, it did it much...
How do you treat idiopathic hypersomnia inadequately responding to modafinil?
I agree with @Dr. First Last. I usually start my patients on modafinil or armodafinil. If those do not work, I will try solriamfetol. I will supplement with as needed amphetamines as well. I do not often go straight to sodium oxybate/low-sodium oxybate, as you need the right patient for this medicat...
How have you implemented digital data into your evaluations of Parkinson's patients?
We have not yet. This may change in the near future.
Should a trial of cenobamate (Xcopri) be required before referring a patient for epilepsy surgery?
First, I would like to declare my conflict of interest that I am a speaker for Xcopri/SK Life. That being said, I only speak for things I truly use and believe in. My general teaching to learners is this (not saying there cannot be exceptions): I would not use Xcopri first line because there are bet...
What extended window thrombolysis protocols are your institutions implementing?
Regulatory guidelines set time epochs for IV thrombolysis at 3h (US) and 4.5h (rest of the world). Recent guidelines are similar globally, supporting a 4.5h time window. The Canadian guidelines state that: “Intravenous thrombolysis beyond 4.5 hours may be considered, in consultation with a physician...
What maximum core volume or core-to-penumbra ratio do you use for eligibility for extended window thrombolysis beyond 4.5 hours?
For the CTP, most trials used a core less than 70 mL, a mismatch volume of 10 mL or greater, and a mismatch ratio of > 1.2. Most extended-window thrombolysis trials used these parameters.
Do you wait to treat small asymptomatic brain metastases until they reach a certain size?
I typically treat all lesions on MRI that are found to be concerning for brain metastases. This is after a discussion with our neuroradiologist colleagues. If there is uncertainty that a small lesion may not be a brain metastasis, then I will elect to follow with a surveillance MRI and treat in the ...