Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
How do you treat agitation in progressive supranuclear palsy?
Benzodiazepines are generally avoided due to adverse effects on cognition, the increased risk of falls, and disinhibition.Pharmacologic treatment for agitation is generally reserved for patients with severe agitation, when a patient is a threat to themselves and others, when agitation is the cause o...
Among patients with secured subarachnoid hemorrhage who are receiving daily TCDs, what is the appropriate frequency of post operative neurological assessments?
I think a textbook might state something like "every 1-2 hours in the acute setting." However, in my opinion, the frequency of neurological examinations should be tailored to the individual patient and involves considerable clinical judgement. Factors that might influence this decision include a) se...
What is your approach to tapering anesthetic drips for refractory status epilepticus after achieving burst suppression?
Ensure adequate oral/IV ASMs are on board, targeting the receptors appropriately based on the type of status- generalized, focal (e.g., GABA, Na channel, glutamate, etc.). These would include the first, second, and third line as per status protocols. Check levels to ensure adequacy. At least 24 hou...
What factors do you take into account when deciding the length of adjuvant temozolamide in GBM?
The field is evolving from 12 cycles to 6 for IDH-wildtype GBM in recent years, on the basis of some retrospective studies and notably the prospective Spanish study GEINO 14-01 - there does not seem to be much OS benefit, and there are also toxicity concerns (myelosuppression, hypermutation). Extens...
How often do you perform surveillance brain MRIs in patients with MS on highly effective DMTs?
The so-called guidelines to do MRIs on an annual basis pre-dated the introduction of anti-CD20 drugs. After these drugs were introduced in 2017, the need for MRIs has fallen off a cliff (as it ought to). With 95% or better suppression of new disease activity (inflammatory component and not the iron...
How do you counsel women on anti-CD20 therapy for MS who are planning for pregnancy?
I counsel patients that anti-CD20 therapies are relatively safe in patients with MS who are considering pregnancy. Monoclonal antibodies are not transported across the placenta until the 2nd trimester, and with a half-life of 20-30 days (depending on which anti-CD 20 is used), the amount that crosse...
When would you consider checking JC virus prior to initiating biologic therapy?
JC is a ubiquitous virus with sero-prevalence in the adult population of 60-70% in most studies. The concern is that in those who harbor latent JC are vulnerable to reactivation and ultimately the development of Progressive Multifocal Leukoencephalopathy (PML). The drug natalizumab used to treat MS ...
How do you monitor patients with transverse myelitis after a negative initial work up?
Both clinical and radiological evaluations, at least annually.
How do stroke-risk considerations affect your use of atypical antipsychotics for patients with dementia?
Antipsychotics carry a number of risks, including a warning of sudden death in elderly demented patients. If nothing else works for a behavioral problem, you have to use an antipsychotic. Also, for frank paranoia, which is not only causing distress to parents but also to the environment, treatment w...
How do you decide when to pursue malignancy workup for patients with cryptogenic stroke?
Agree with above. I would also pursue malignancy work-up in this scenario as well: currently on anticoagulation (whether for afib or another medical reason) and has an ischemic stroke on top of that.