Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
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...
What is your pharmacologic approach to treating insomnia comorbid with sleep apnea?
I do not usually treat any insomnia, regardless of comorbidities, with any targeted medication for the insomnia itself. If the patient is getting over 5 hours of sleep, then I use CBT-I as this is guideline-recommended (AASM) first-line treatment for insomnia and has efficacy lasting over a year out...
How do you decide if patients who have a multifocal demyelinating polyneuropathy would benefit from surgical treatment of carpal tunnel syndrome?
I would do median nerve ultrasound at the carpal tunnel and see if there is evidence of compression. If so, surgical release is a reasonable option.
Can you clinically distinguish TIAs from transient focal neurologic episodes (TFNEs) of cerebral amyloid?
It may be difficult to distinguish between those two types of episodes. The first issue would be does a patient has anyloid. If they do, I would err on the side of caution and presume transient focal neurological symptoms were caused by a vascular episode unrelated to amyloid and appropriately explo...
What monitoring do you routinely perform on lifelong EDS for epilepsy syndromes?
One of the complications inherent in using AEDs in anybody with epilepsy syndrome or neurotypical people with seizures is bone loss. It is especially important to look at their early loss of bone mass. I check for vitamin D levels even in very young patients. I might even do DEXA scans. I'm very pro...
How do you decide between the different oral longer acting levodopa medications?
The question would be, why are you changing, and what are you changing from? (i.e., are one of these your initial agent, a change due to Sinemet side effects, or a change because of motor fluctuations?) The current theory on dopamine replacement is "smoother is better," so the longer (and lower) you...
For which stroke patients, if any, do you recommend implantable loop recorder for long-term cardiac monitoring and why?
Fantastic and pertinent question! I won't pretend that I have an answer, but do have a few thoughts that may help frame further discussion: We derive our evidence for the efficacy of anticoagulation in stroke prevention from older trials designed to answer that specific question (SPAF, etc.). In the...
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 ...
Do you maintain a strict platelet threshold of >50k when performing a lumbar puncture, or are there situations in which you feel comfortable with a lower threshold?
Our institution still uses 50k as a best practice guideline, though many of our proceduralists are comfortable performing the procedure with platelets slightly lower than 50k, and will have a risk/benefit discussion with the patient/team about the bleeding risk prior to proceeding; I myself would be...
How does comorbid epilepsy influence your decision on antipsychotic medications?
In general, epilepsy is not a contraindication to the use of antipsychotic medications if they are needed despite the known risk of lowering the seizure threshold. In general, the risk of seizures for most antipsychotics is low, though some antipsychotics, such as clozapine, olanzapine, and quetiapi...