Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
What is your approach to the diagnostic workup of small fiber neuropathy in patients with known rheumatic disease?
Small fiber sensory neuropathy (SFN), in general, including in patients with rheumatic diseases, should be suspected based on symptoms (positive more than negative sensory symptoms) and ideally confirmed by clinical examination showing altered temperature and/or pain/pinprick perception in the limbs...
For MS patients already on a higher-efficacy DMT, how do you assess if it is time to switch to a new DMT when they have new clinically-silent MRI brain lesions?
Generally, patients have annual MRIs to screen for new active lesions. If there is still ongoing disease activity, such as new Gad+ lesions or expanding T2 lesions, a DMT switch is often considered. If a patient is already on a high-efficacy DMT, one could consider a lateral switch to another high-e...
Which calculators, nomograms, or other resources, if any, do you use to help advise and prognosticate patients with newly diagnosed glioblastoma or other gliomas?
This is a rather difficult question to answer because prognosis in patients with glioblastoma (GBM) is best estimated by combining several clinical, molecular, radiographic, and treatment-related factors rather than relying on any single variable. Several validated prognostic models exist, but in cl...
What treatments options may be considered in patients with POTS who also need daily diuretics to treat heart failure and are already wearing compression garments?
Given the epidemiology of POTS and congestive heart failure, you are far more likely to see a patient with neurogenic orthostatic hypotension and CHF than POTS and CHF. I have an article on NOH and CHF in Autonomic Neuroscience 2020. The principals are basically the same however because the managem...
When do you consider pacing in arrhythmogenic epilepsy?
I have seen only rare cases of it. They all had tonic-clonic seizures triggered by profound bradycardia (sinus as well as AV block). In turn, the bradyarrhythmia was triggered by EEG-documented temporal lobe absence seizures. They all resolved long-term with pacing. Regardless of the un...
Do you utilize thrombolytic therapy in patients with CRAO?
Yes. The previous trial was negative because patients with CRAO were included after 4.5 hours. There are trials underway in Europe for both tPA and TNK to address that. The retina will irreversibly infarct if the blood flow is not restored within 240 minutes (this is from basic science studies with ...
When do you use seizure prophylaxis in patients on clozapine?
The topic of the use of anticonvulsants for primary prophylaxis of clozapine-induced seizures continues to be debated. The idea of prescribing anticonvulsants prophylactically for patients taking >600 mg/day of clozapine was suggested by Devinksy et al., PMID 2006003 in 1991. Clozapine-induced seizu...
Will OCEANIC-STROKE change your approach to secondary stroke prevention for high-risk TIA and non-cardioembolic stroke?
I would consider the OCEANIC-STROKE study a major contribution to the literature on secondary stroke prevention. The study included only noncardioembolic and nonlacunar strokes, with evidence of intracranial or general atherosclerosis (at least one of the above categories). It showed a significant b...
How do you determine personalized blood pressure targets after ischemic stroke?
This is an excellent question and really takes careful consideration of individual patient characteristics. This also requires detailed discussions with your Neuro-Interventional Radiology Team so that you can best understand what happened during thrombectomy and how successful reperfusion therapy w...
In what cases, if any, do you find the use of naltrexone to augment lifestyle interventions (i.e., cognitive behavioral therapy, graded exercise therapy) for chronic fatigue to be helpful?
Yes