Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
When do you consider ultrahigh-dose methylcobalamin injections for ALS?
I have noted that several ALS experts are offering this option nowadays to patients. I will analyze herein why I am NOT in favor of this approach, and, if I would offer methylcobalamin to any of my ALS patients, I would prefer to offer the oral form:1) The reason it is offered is a positive randomiz...
What is your approach to using intra-arterial or intrathecal vasodilators in patients with vasospasm in subarachnoid hemorrhage despite usage of oral nimodipine?
Bottom line up front: The 2023 AHA/ASA focused update on aSAH recommends IA vasodilator infusion or mechanical angioplasty in clinically significant vasospasm refractory to medical therapy (Class IIa, Level B) and states that intraventricular nicardipine “may be considered” in selected patients (Cla...
Does CEA still have a role instead of stenting for surgical management of asymptomatic carotid artery disease?
In most patients with asymptomatic high-grade stenosis, stenting is preferable to endarterectomy based on the results of CREST-2. In a small percentage of such patients, stenting may not be technically feasible. Also, some patients may not want to take the medications usually prescribed after stenti...
What are your ACTRIMS 2026 top takeaways?
1. Abstract and presentation CE2.2 from Dr. Dalia Rotstein in Toronto (Rotstein et al., ACTRIMS 2026). With so much press on the role of EBV in MS and data strongly suggesting that exposure is nearly an absolute requirement for having the disease, some people were actually advocating testing a patie...
How do you determine the timeline for healing after craniotomy prior to starting chemotherapy and radiation?
I typically wait at least 10-14 days post-op, always after neurosurgery has re-evaluated the craniotomy site for appropriate healing and has already removed staples or sutures.
How do you conduct follow-up on patients with brain mets who have undergone GammaTile placement?
For patients with high-grade gliomas, they get an immediate post-implant CT and MRI for dose calculation, then I schedule serial follow up CE-MRI every 9-10 weeks for at least a year; if stable at the one-year mark, I "graduate" the patient to get MRIs every 12 weeks for the second year of follow-up...
How would you manage a rare presentation of an older adult after gross total resection of an "infant-type hemispheric glioma" of the left frontal lobe, IDH1 negative and negative for MYB fusions?
Infant-type hemispheric gliomas (IHGs) are rare high-grade astrocytic tumors characterized by giant size and abundant vascularity, often with regions of cystic transformation. They are aggressive brain tumors that occur during early infancy, usually between 0 and 12 months of age. They are often ver...
How do you approach selecting optimal muscle biopsy site when evaluating a patient for suspected inflammatory myopathy?
There are a few things to consider when formulating your approach to this, which include 1) the clinical exam, 2) ease of biopsy of muscle, and 3) potential confounders of diagnosis. The goal is to get a specimen from a muscle that is undergoing active inflammation. These muscles will generally be w...
For trigeminal neuralgia in patients with multiple sclerosis, do you consider microvascular decompression or stereotactic radiosurgery as treatment options?
Secondary trigeminal neuralgia attributed to multiple sclerosis occurs when there is an "MS plaque at the trigeminal root entry zone or in the pons affecting the intrapontine primary afferents" according to ICHD-3. Note that according to ICHD-3 "Pontine lesions affecting the second order neurones of...
Do you routinely check CSF cell counts and cultures on patients with external ventricular drains to monitor for infection?
I think protocols still vary widely by institution, but we only check CSF cell counts and cultures from an EVD if there is a clinical concern for hospital-acquired meningitis/ventriculitis. It is clear that the more times you access the EVD setup for CSF collection, you are increasing the risk for i...