Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
Which patients will have earlier diagnosis of multiple sclerosis via the new 2024 McDonald Criteria?
I think the group that will most benefit from the new diagnostic criteria, in terms of earlier diagnosis, is those with a history of optic neuritis. This is because the new criteria expand "typical CNS topographies" from four to 5 to include the optic nerve. In addition, those who present with lesio...
Considering only cerebrovascular indications, are there circumstances in which you would use aspirin along with a DOAC in patients with atrial fibrillation and stroke?
I will use aspirin 81 mg and a DOAC together in patients who "fail" (I hate that term) the DOAC. The combination was used in patients in the original DOAC trials, so it is not unreasonable. Not my first choice, but can be done. It is worth noting that the evidence does not support doing this upfront...
Do 5HT4 agonists such as Metoclopramide actually lead to improvement in symptoms for patients with diabetes related gastroparesis?
Yes, sometimes when the gastroparesis is frequent or the symptoms are tough, I do use Reglan to help. By the time they wind up in the hospital, they are really willing to have me use anything on them that might help. I explain to every patient the side effects of Reglan, including tartive dyskinesia...
How do you counsel patients interested in carotid endarterectomy for asymptomatic carotid disease as a means to reduce dementia risk?
This is a good question. I reviewed the paper by Vitali et al, PMID 40922111 and I would add that previous studies of patients with asymptomatic carotid stenosis have not found a reduction in dementia with the procedures. In this retrospective study, carotid endarterectomy but not carotid stenting r...
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...
How do you decide when to add steroid-sparing immunotherapy for myasthenia gravis after starting prednisone and Mestinon?
My approach is generally to add a steroid-sparing agent if the patient experiences worsening of their symptoms during prednisone wean, such that they cannot tolerate a prednisone dose lower than 7.5 mg/day without functionally limiting symptoms. However, there are many patient-specific consideration...
What is your preferred workup for patients who present with concern for autonomic neuropathy?
When patients report one or more symptoms suggestive of autonomic dysfunction, objective confirmation of impaired autonomic function is required. This may include the standard battery of autonomic tests included in the CASS score (tilt table testing, response of HR and BP to Valsalva maneuver, and ...
How do you workup patients with neuropathy suspected to be secondary to sarcoid?
To answer this question, the attached paper with consensus criteria for the diagnosis of neurosarcoidosis, published in 2018, should be reviewed, Stern et al., PMID 30167654.Based on this paper, a diagnosis of probable or definite neurosarcoidosis requires unequivocal evidence of non-caseating granu...
How safe and effective is carotid stenting in carotid dissection?
Stenting in the setting of carotid dissection can be safe and effective, particularly when performed in the appropriate clinical context. The most common scenario where I consider stenting is during a tandem lesion associated with an LVO, where EVT is already being performed. In this setting, dissec...
How do you assess periprocedural risk for patients with incidental silent ischemic infarcts scheduled for elective surgeries, major or intravascular procedures?
If the infarct is definite, I would initiate some work-up to determine risk, at least a CTA head/neck, and an echocardiogram. If hypertensive lacune, BP control might be all that is needed. If a cryptogenic, cortical/subcortical infarction, the CTA and echo would be more important. A risk estimate o...