Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
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...
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...