Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
What is the most appropriate adjuvant treatment for a GBM in a young patient <50 with a poor performance status (ECOG 3-4)?
In general, for a young patient with poor performance status, I would like to know whether the poor performance status is potentially reversible, such as from edema, mass effect, seizures, hydrocephalus, or a recovering post-op deficit, versus fixed or disease-driven. If performance status improves,...
How do you factor in projected procedure time into borderline decisions for EVT for acute stroke?
The decision to intervene on a patient with an NIHSS less than 6 is challenging on its own. It is about the clinical picture, the occlusion site, and the risk-benefit of intervention versus medical management. A proximal M1 with robust collateral flow is a very different case than a distal M2, even ...
When do you consider IV ketamine for status migrainosus?
Given that the current evidence for IV ketamine is of low quality and primarily limited to retrospective studies - with the American Headache Society 2025 ED guidelines assigning it a level U (no recommendation) - I would consider it in the inpatient setting only after standard abortive therapies ha...
Which patients are you most likely to use cenobamate adjunctively in super-refractory status epilepticus?
This is a good question and the recent study from Campos-Fernandez et al., 42956387 tried to answer this question, though this is a small cohort with patients on a number of ASMs (IQR 4-5) already, so this needs to be kept in mind if one is considering cenobamate in SRSE.In the hospital, we typicall...
What is your approach to REM behavior disorder not adequately treated with melatonin and clonazepam?
Rule out comorbidities like sleep apnea or medications causing RBD. Optimize doses for melatonin and clonazepam, and consider dual therapy with these. Other options are gabapentin or pramipexole. Thanks,Sam Morkous
In what clinical scenarios do you utilize opioids in patients with restless leg syndrome?
I would say in refractory RLS, i.e., the patient has failed all the options below: Iron supplementation if ferritin <50, Gabapentin/pregabalin, Dopamine agonists, and Non-pharmacological options (like the vibrating pad). *I don't love carbidopa/levodopa for RLS. It very often causes augmentation.
Do you ever use amantadine or modafinil to aid in the rehabilitation of patients with ischemic strokes?
No randomized controlled trials of amantadine or modafinil for the treatment of disorders of consciousness (DoC) after ischemic strokes have been completed. A retrospective study of ICU patients with DoC after ischemic stroke found that amantadine, modafinil, or a combination may be useful in improv...
What are your go-to options for managing ICU delirium in patients with contraindications to antipsychotics?
Evidence for Ramelteon (Yu et al., PMID 36726202)Delirium with behavioral disturbances Depakote Clonidine Propranolol, especially with TBI Non pharmacological Make sure they're closer to the nursing station. Constant re-orientation. Shades open during the day and close at night. Bring anything they ...
What is your management approach for CAR-T induced motor neurologic deficits (cyclophosphamide/IVIG/steroids, etc.) and any prophylactic approach to an early, rapid rise in absolute lymphocyte count post CAR-T infusion?
Specifically, this seems to be a question around cilta-cel. There has been some recent guidance to consider pre-emptively starting dexamethasone if the absolute lymphocyte count rises above 3,000 in the period following CAR T administration. This partially stems from the observation that many of the...
How do the results of CREST-2 influence your recommendations on screening for asymptomatic carotid stenosis?
Agree with the prior comment. One important nuance is what “medical management” actually meant in CREST-2. This was centralized, protocol-driven care with structured lifestyle counseling and medication escalation, including access to PCSK9 inhibitors with costs covered. Even in that highly organized...