Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
How do you counsel patients with isolated REM behavioral sleep disorder secondary to antidepressant on the risk of developing a neurodegenerative disease?
I start by reviewing the different causes of RBD. With isolated RBD (iRBD), there is a risk of neurodegeneration over several years, but if it is truly antidepressant induced RBD, the risk is not clear. There have been cases of neurodegenerative disease but it does not appear that the risk is the sa...
When should patients be referred for advanced MRI testing to assess for CVS and PRL?
There are many pathways to an MS diagnosis that do not rely on CVS or PRL. As such, I think it is very reasonable to start with a standard brain MRI that we have been using for many years for MS diagnosis. Many patients - maybe most - will meet criteria with a standard MRI and, potentially, CSF evid...
When do you consider tapering tocilizumab in patients with GCA in remission?
This is a timely question and recent data sheds some light on this important topic. The risk of GCA relapse is approximately 50% (Mainbourg et al., PMID 30951256) in all comers. The GIACTA trial (Stone et al., PMID 28745999) utilized a one-year course of TCZ. A recent publication of the extension ph...
In a young patient with recurrent low-grade glioma s/p gross total resection, is there any role for further observation instead of radiation and chemotherapy?
As simple as this question seems to be on the surface, it is actually a very difficult clinical scenario to opine with certainty, primarily because of a lack of data. So, let us address this with each option in mind, weighing the pros and cons: Observation: We do know that in resected patients, radi...
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 obtain an MSLT or start empiric therapy with modafinil in patients with residual excessive daytime sleepiness despite optimal adherence to PAP therapy?
In this situation I would start either modafinil, armodafinil, or solriamfetol for residual EDS if the OSA was appropriately controlled without need for MSLT. We have an FDA label for these medications in this situation to support this practice. If I felt like there was concern for a combination of ...
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...
For stroke patients with ablated paroxysmal atrial fibrillation without known recurrence and ICAD, would you recommend dual antiplatelet therapy or anticoagulation with or without an antiplatelet agent?
Ablation treats cardiopulmonary symptoms, but it has not been adequately tested against anticoagulation for AFib-related stroke. Anecdotally, at least once a month, I will see a patient with an acute embolic-appearing stroke after their cardiologist has stopped their anticoagulation because they wer...
What treatments, after appropriate dose reductions/delays, do you offer for patients with oxaliplatin-induced cold allodynia/dysesthesia?
The primary treatments that I use for cold-induced oxaliplatin neurotoxicity are reducing the oxaliplatin dose and limiting the duration of oxaliplatin treatment (usually not more than 16 weeks of oxaliplatin-containing therapy in the initial line of treatment). Medications that are effective for pa...
How do you decide on switching to a different preventative anti-CGRP treatment in migraine patients who are experiencing reduced effectiveness with their current treatment?
On occasion, I have found that patients who were diagnosed with chronic migraine actually have EPH or CPH and respond to an indomethacin trial. Alternatively, those with less-than-ideal responses to CGRP antagonists or gepants, Botox injections can offer more relief. These patients tend to have a si...