Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
What are the best practices for centers interested in providing anti-amyloid therapies for early Alzheimer's to ensure treatment delivery success?
I would use the same criteria for AAA treatment as those required for entering AAA clinical trials. Overall, our center has not had difficulty with ensuring that patients have timely MRIs before treatments. I enlist caregivers and patients to remind me when they are scheduled for their next infusion...
When do you consider hemispherectomy for patients with Rasmussen encephalitis with stable epilepsy and preserved function of the affected half of body?
Depends on several factors. First, how debilitating are the seizures? If the person cannot function, like going to school for children or adult activities, then surgery to stop the seizures should be considered. Also, age is a factor. Children under the age of 5 years should be considered to make us...
What do you do for a patient with Parkinson's Disease and orthostatic hypotension who has failed midodrine, fludrocortisone, droxidopa, pyridostigmine, and atomoxetine?
I would not recommend using amantadine in this situation as it is known to worsen orthostatic hypotension (Perez-Lloret et al., PMID 22336566). This is a tricky situation, and if the patient has failed all of these medications, I would consider an alternate diagnosis, specifically MSA, especially if...
What is the most updated consensus regarding the use of pill in the pocket oral anticoagulation in paroxysmal atrial fibrillation, and populations of patients who are most likely to be considered for enrollment in clinical trials?
I'm not sure that there is a consensus. The best available large trial data would recommend anticoagulation based on a CHADS2Vasc score of 2 or higher, while a score of 0 patients could be off anticoagulation, and if the score is 1, patients would benefit from shared decision-making. For the CHADS2V...
Which clinical or imaging features of cerebral amyloid angiopathy aid in predicting future risk of intracerebral hemorrhage?
Hemorrhagic imaging features of cerebral amyloid angiopathy can help understand the future risk of intracerebral hemorrhage (ICH). Observational studies have found that patients with cortical microbleeds without lobar hemorrhage have an ~5% risk of future ICH. In those with prior lobar ICH, this ris...
What would prompt discontinuing treatment versus switching or sequencing treatment in patients treated with an anti-amyloid therapy for Alzheimer's?
There are guidelines to stop the medication due to ARIA. In my practice, we only discontinued treatment once, and it was due to the personal choice of the patient and family. I do not see a reason to switch from one medication to the other based on the data we currently have.
When do you recommend neuropsychiatric testing in patients with post-concussive syndrome?
I typically ask the patient what scenarios they experience cognitive issues. The various examples they provide usually relate to difficulty following conversations, forgetfulness within their working memory, and concentration/focus. In the post-concussion patient, they typically have developed adjus...
How are you using CYP2C19 genotyping for determining dual antiplatelet therapy for stroke?
In my practice, P2Y12 assays are the primary tool I rely on for guiding dual antiplatelet decisions. They are more widely available across clinical settings, whereas CYP2C19 genotyping requires infrastructure that is not always accessible outside of large academic and tertiary centers. CYP2C19 ident...
What is the role for inpatient limited-montage EEG recording?
Unequivocal YES! For purposes of detecting severe seizures that cause brain injury (i.e., high seizure burden, status epilepticus), a reduced montage EEG is more than adequate, performs equivalently, and in fact BETTER because of the Clarity AI algorithm which continuously monitors, interprets, and ...
How do you counsel B cell-depleted multiple sclerosis patients on the benefits of regular COVID-19 vaccinations?
The fact that B cell-depleted patients render a blunted antibody response is not unexpected, but antibodies do not protect from viral infections - cells do. To measure a proper vaccine response, one wants to test T cells from patients to see if they are able to kill viral infected cells. This is wha...