Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
How effective have you found acupuncture for treatment of chronic migraine?
I would prefer to educate a patient interested in acupuncture for severe headaches about all the other treatments that are available. However, if they would still like to pursue acupuncture, I would support them, just like Dr. @Dr. First Last would say. Some patients can get better, although it is n...
How has the utilization of mobile stroke units changed the landscape of in-hospital stroke management?
Mobile stroke units shift CT-based diagnosis, thrombolysis, and LVO triage into the prehospital setting, enabling earlier hospital activation and direct-to-angiography workflows. In BEST-MSU, onset-to-thrombolysis fell from 108 to 72 minutes, treatment rates rose from 79.5% to 97.1%, and 90-day mRS ...
What are the key factors that you seek to uncover in order to land on the most effective DMT choice for patients with MS?
I generally consider three major domains when selecting a DMT: patient-specific factors, clinical disease characteristics, and radiographic disease characteristics. From a disease perspective, I look for clinical and MRI features associated with a higher risk of future disability. For example, signi...
Do you add antiplatelet medications to patients already on anticoagulation for atrial fibrillation if they have a stroke due to a competing etiology?
Adding antiplatelet therapy to anticoagulation in patients with atrial fibrillation and a noncardioembolic stroke has not shown a clear benefit and definitely increases bleeding risk. Okazaki et al., PMID 41051787 did not find a benefit and increased bleeding risk. An exception might be in acute MI ...
Have you changed your practice in treating CRAO with IV thrombolysis?
The recent THEIA trial had a limited sample size to draw conclusions, even though there was a non-significant trend of improved visual acuity initially in the thrombolysis group. Even the TenCRAOS trial had a small sample size with recruitment challenges, where subtle small differences cannot be acc...
How to approach reversal of TNK in hemorrhagic conversion of ischemic stroke?
There is no specific "reversal agent" for tenecteplase. Once administered, the thrombolytic effect will persist until the drug is fully metabolized and any residual plasmin has been cleared by alpha-2-antiplasmin. So, perhaps the first question is what can you do if there is an acute bleeding event ...
Should mRS be incorporated into determining eligibility for extended window thrombolysis?
Key thrombolysis trials (WAKE UP, OPTION, EXTEND, TIMELESS, ECASS-4, HOPE, EXTEND IA) excluded patients with mRS of 2 or greater. The reason for this was the outcome of functional independence at 90 days. Hence, for trial purposes, to look at the outcome, it was necessary to exclude patients with di...
How do you decide when to intervene directly on a feeder artery aneurysm of an AVM?
In a ruptured AVM, we treat the feeding artery aneurysm as a priority and emergently. Either surgery or embolization is warranted. I prefer embolization in the hyperacute setting. In unruptured AVMs with a feeding artery aneurysm that have angioarchitecture amenable to catheterization, I prefer to e...
Do you treat migraine with aura if there is not an associated headache/pain?
I do if it interferes with quality of life. I do not recommend abortive medications for aura. There is no evidence that migraine abortive treatments shorten the duration of aura. I do not think that they do. Anecdotally, I have had some patients report that taking NSAIDs or a triptan at the aura ons...
How do you navigate C-2 refills in patients who are stable in their treatment and do not otherwise need to be clinically seen monthly?
This practice is routine in child psychiatry. We fill stimulant prescriptions electronically at the phone request of the family as long as they are keeping quarterly appointments. We do not charge for that service. We do document it in the medical record. Your question begs another question, however...