Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
Do you require a lumbar puncture to evaluate for infectious etiologies before starting steroids for possible transverse myelitis seen on MRI?
Yes, I would perform a lumbar puncture alongside an MRI of the brain and cervical/thoracic spine with contrast to evaluate for potential infectious and inflammatory etiologies prior to starting steroids. LP is especially important if the patient has a fever, other symptoms of infection, or is immuno...
In which subset of patients with concussion do you recommend further brain imaging?
I recommend further imaging of a concussion patient in a subset of patients. If the patient had a seizure with the head injury or any sign of declining mentation within the first few hours, they should have a CT head emergently. If it is within 1 week from injury and they report steadily worsening e...
How do you counsel patients who experience diarrhea from mycophenolate mofetil (Cellcept)?
I have them stop the drug, and when their bowels are back to normal (usually just a couple of days), I resume with 1 tablet bid of mycophenolate mofetil (MMF, CellCept), then a few days later go up to 1 tab tid, a few days later 2 tabs bid... etc. I instruct them to go down to the most recent dose ...
How do you decide when to obtain a brain CT and/or MRI in hospitalized patients with altered mental status?
Always, unless the patient can be quickly awakened by glucose, etc., or it DNR, so I guess this means often.
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 ...
Has MR spectroscopy ever led you to forego a planned stereotactic biopsy in a patient with a suspected intracranial neoplasm?
I have never had spectroscopy allow me to forego a stereotactic biopsy when I suspected active/progressive neoplasm; however, if I suspected necrosis more than recurrence or tumor and spectroscopy was in accordance with that, then I have been able to save people a biopsy in that situation.
Does persistent focal slowing without epileptiform discharges indicate increased seizure risk in patients without significant structural abnormalities?
Good question! :-) Lateralized rhythmic delta (LRDA), especially temporal (TRDA) certainly does, basically to the same degree as interictal epileptiform discharges (IEDs). Focal polymorphic slowing is of course not technically "epileptiform" but it does indicate some focal dysfunction, so I would sa...
Do you recommend normobaric hyperoxia for thrombectomy patients?
Not yet. Below is my take: Trial Summary 120 patients were randomized at two comprehensive stroke centers in China with anterior-circulation LVO presenting 6-24 hours after onset to EVT plus normobaric hyperoxia (NBO) or EVT alone. NBO consisted of 100% oxygen at 10 L/min by face mask for 4 hours, i...
How do you decide when to order an EEG to evaluate for non-convulsive status epilepticus in a patient admitted with acute encephalopathy?
This can be a challenging question to answer given the broad differential of acute encephalopathy and how available EEG is at your hospital. At centers with easily available EEG capabilities, the threshold to obtain an EEG will be lower. I will also assume this question is related to patients who ha...
How do you counsel patients with postural orthostatic tachycardia syndrome (POTS) regarding safe and effective exercise regimens?
It depends on where they're starting from. If they're starting from scratch, I give them two recommendations: first is the Children's Hospital of Philadelphia protocol, and if they live in town, I refer them to our PT facility at Vanderbilt (The Dayani Center) to have our PT folks help them get star...