Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
Would you use a lumbar drain in a patient with spinal stroke from fibrocartilagenous embolism?
There are no clinical trials to suggest any benefit. Smaller studies - particularly case series have shown some benefit with the use of lumbar drain in the first 48 hours and keeping the pressure around 10 mmHg. These include mostly patients post a cardiovascular surgical procedure as a cause in the...
Is there a role for using an external ventricular drain (EVD) trial in the workup of normal pressure hydrocephalus?
Typically, the work-up of normal pressure hydrocephalus involves either a large volume lumbar puncture or a 48-72 hour lumbar drain trial (and sometimes both). An external ventricular drain would be too invasive.There is an excellent review article that was recently published regarding this topic:Ca...
What medications are preferred and contraindicated for insomnia in patients with a recent stroke or traumatic brain injury?
In acute brain injury (ABI), which includes stroke and traumatic brain injury the focus is often on neurorehabilitation. The presumption here is that the patient is medically and neurologically stable. For example, not having a stroke in evolution, uncontrolled gastrointestinal bleeding, or similar....
Is Migraine with Unilateral Motor Symptoms (MUMS) a diagnostic entity worth considering in patients with migraine and other associated symptoms?
I do not think so. It is not a part of the ICHD-3 criteria. If a patient with migraine disorder presents with weakness, it is possible that the weakness/motor symptoms are symptoms of migraine disorder. There is a diagnostic classification for such a patient already in the ICHD-3 criteria, which wou...
Do you recommend a "washout" period for anti-CGRP medications before conception?
Wise advice from Dr. @Dr. First Last. We are presenting a talk at AHS demonstrating that women who conceive on monoclonal antibodies have an elevated risk of spontaneous abortion in the first trimester. Remember that 50% of pregnancies are unplanned. I advise women on CGRP-targeted therapies to be o...
When have you used suzetrigine for acute migraine treatment?
I have never used suzetrigine in migraine disorder. There are no studies or even case reports of its use in migraine disorder. It is not FDA-approved for migraine disorder indication. It is ~$500 for a month's supply. It would not be covered by insurance for a migraine disorder indication. I would n...
When do you offer TNK for ischemic stroke patients with a large vessel occlusion presenting outside the 4.5-hour window?
I agree with Dr. @Dr. First Last. Generally, I do not treat with TNK if EVT is available, but I do treat if no EVT is available, assuming favorable imaging as per the TRACE-III trial. However, as with all decisions, there are nuances. Since the benefit and risk ratio of TNK was only slightly favorab...
What is your approach to determining eligibility for hospice in persons with Alzheimer's disease?
We strongly recommend early hospice enrollment for patients with dementia as soon as they meet eligibility criteria. In our approach, we carefully evaluate both functional and cognitive decline. One area that is often overlooked, however, is nutrition. When a patient with Alzheimer’s disease begins ...
When do you restart anticoagulation in patients with atrial fibrillation who just had an ischemic stroke?
The recent ELAN trial (Fischer et al., PMID 37222476) and now the published CATALYST meta-analysis (Dehbi et al., PMID 40570866) all support the concept that early anticoagulation (within 4 days of stroke) with a DOAC is safe and effective. There appears to be no interaction with clinical factors su...
How do structural and functional findings on echocardiogram influence your decision to anticogulate ESUS cases?
This is a great but very difficult question. It is important to remember that currently, there is NO randomized controlled trial data that provides evidence for anticoagulating patients with ESUS, and the ad hoc analysis of the Arcadia trial you mention simply does not change this. Arcadia specifica...