Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
What is your approach to optic neuritis that worsens after weaning steroids?
The most important first step is to confirm that this represents a true relapse. Visual acuity, color vision, and visual fields are helpful, but can be subjective and variable. I would look for objective evidence of recurrent or worsening optic neuritis, such as a new or worsening RAPD, OCT changes,...
Is there any contraindication to the use of ezetimibe in patients with a history of statin-induced necrotizing myopathy?
These types of questions are always great to discuss. The reality is there is a risk-benefit ratio to be considered. On one hand, there is a concern for the need for lipid-lowering to prevent cardiovascular disease, and some situations are more pressing than others. A diabetic with a known cardiovas...
What clinical history or findings make you more concerned for an amyloid-related neuropathy?
Many, including: Presence of a monoclonal IgG or IgA protein on serum or urine protein immunofixation, especially lambda light chain, and especially if kappa to lambda light chain ratio is very low. Unexplained autonomic dysfunction, especially orthostatic hypotension without compensatory tachycard...
What do you recommend to patients when they are having an acute flare of fibromyalgia symptoms?
Great, this is a really important area and unmet need in the field of fibromyalgia management. Unlike other nociplastic disease states (e.g., migraine), there are no rigorously studied abortive therapies to rapidly treat a flare of centralized pain. Indeed, all the therapies we use for FM are intend...
To what extent did device adherence play a role in the clinical endpoints with TRIDENT?
TTFields is a patient-directed therapy, and adherence directly affects how much treatment a patient actually receives. In TRIDENT’s post hoc analysis pooling both treatment arms, patients with at least 50% device usage, averaged over the first three months after TTFields initiation, had longer media...
Do you screen children with sickle cell disease for silent cerebral infarcts?
We screen children with sickle cell disease for SCIs at our center. This is because data suggest that silent cerebral infarcts (SCIs) are much more common than overt stroke and the long-term negative impacts of SCIs are significant. There are also treatments (e.g., chronic transfusion and stem cell ...
How would you approach the workup and management of a young patient with recurrent biannual non-scarring oral ulcers and new onset neurologic symptoms with associated CNS white matter lesions concerning for Behcet’s?
This is a challenging case. It should be noted that oral ulcers in Behcet's typically occur more than twice per year (by ISG criteria should occur at least 3x per year) and without other symptoms of BD it can be very challenging to make a probable diagnosis of BD in this scenario. A careful history ...
Would you consider off-label IV thrombolysis in patients taking a DOAC and presenting with disabling acute ischemic stroke within the window?
In brief, yes, I would and do consider it. I have both treated patients deliberately and inadvertently who were on DOACs (and who took medication in the last 24-hours). When it was inadvertent, I simply did not know and could not know (aphasic patient, no record available, no corroborative informati...
When would you escalate moderate efficacy therapy for MS in a clinically stable patient with a single new clinically silent MRI lesion?
Sure. What is 'moderate efficacy therapy'? How is that defined? And who defines that? Refs? Secondly, a new lesion implies BBB breakdown (supposedly, if it is a T1 gad-enhancing lesion) and so, I would change therapy. My slant is always to use the best data available, so I would use the most efficac...
What extended window thrombolysis protocols are your institutions implementing?
For those with disabling deficits with last known well that is unknown and within 4.5 hours from symptom discovery or wake-up stroke with a non-intervenable LVO or no LVO, we pursue Fast Stroke MRI for IV thrombolysis assessment after CT head non-contrast and CTA head and neck. If there is an interv...