Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
How would you approach the treatment of erosive inflammatory arthritis (RA or SpA) in a patient with multiple sclerosis on ocrelizumab who has failed csDMARD therapy?
This is a challenging situation to confront, however, as more non- rheumatological illnesses are being managed with biologics, we will be facing this issue with greater frequency. Regarding multiple sclerosis (MS), one should be aware that the major metabolite of leflunomide, teriflunomide, is a bra...
When do you obtain head and neck vascular imaging in patients with traumatic brain injury?
When there are skull base fractures that could lead to a dissection, when there is penetrating or blunt neck injury, when it is unclear if the primary event was a brain hemorrhage with secondary TBI, or in the case of imaging that suggests a concomitant ischemic stroke. This is not an exhaustive lis...
Would you recommend a specific workup or change in management for patients with severe, persistent deficits from methotrexate leukoencephalopathy?
In my practice setting, I typically see this as delayed toxicity in adults that is not reversible. In the acute, and particularly pediatric settings, there may be some limited evidence for leucovorin, aminophylline, drugs that modulate NMDA neurotransmission, etc., but usually in adult patients, tre...
When is air travel safe for patients who have developed an intracranial bleed?
I tried to find evidence-based guidance from the literature, but I found only a few pieces of advice. After ICH, unless it was tiny and of clear cause, I would wait at least 4-6 weeks. After SDH, if neurosurgical drainage was performed, then also at least 6 weeks. After SAH, assuming the causative a...
Is there utility for endovascular stenting of severe symptomatic vertebral artery stenosis?
This is a great question and one I remember asking during fellowship. There have been several randomized trials that touched on vertebral stenting (CAVATAS, SAMMPRIS, VISSIT, VAST), but VIST is the only one I recall that focused specifically on vertebral artery stenosis. The earlier trials had mixed...
What outpatient therapies do you recommend for continuous or severe pain from migraine that is refractory to acute therapies?
I assume that what we are dealing with here is what we call a migraine status or status migrainosus. This refers to a migraine headache that has continued well beyond its usual duration, for which we often use the arbitrary three-day mark. We base this mark on the erroneous assumption that migraine ...
At what timepoint do you do an EMG/NCS in patients with suspected GBS?
In general, nerve conduction studies are often normal early in the disease course. However, during the first week, one may find prolonged minimal F-wave latencies (or even absent responses). This would indicate some degree of involvement of proximal nerve trunks. For years, it has been widely accept...
How do pediatric functional neurologic disorders differ from adult disorders in their presentation and diagnosis?
In terms of presentation, PFND often manifests with an abrupt onset of symptoms, commonly including motor (e.g., limb weakness, gait disturbance) and sensory changes, as well as seizure-like episodes (psychogenic non-epileptic seizures) and pain. Children and adolescents may also present with headac...
Is there a role for using an external ventricular drain (EVD) trial in the workup of normal pressure hydrocephalus?
Typically, the work-up of normal pressure hydrocephalus involves either a large volume lumbar puncture or a 48-72 hour lumbar drain trial (and sometimes both). An external ventricular drain would be too invasive.There is an excellent review article that was recently published regarding this topic:Ca...
Would you offer TPO-RAs to a steroid-refractory chronic ITP patient with history of stroke?
Yes, if needed, though with a bit of trepidation, and it probably wouldn't be my first choice. Second-line chronic ITP treatment can include TPO-RA, rituximab, or splenectomy, and no one treatment is clearly better than the others (Neunert et al., PMID 31794604). Both splenectomy and TPO-RAs have in...