Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
How do you determine which type of re-vascularization technique is appropriate to treat a patient with Moya Moya disease?
There are 2 types: indirect and direct. The direct bypass involves suturing a branch of the STA to a cortical branch of the MCA. This is by far the best method to treat ADULT cases. In children, the INDIRECT method, which is easier and does not involve direct suturing of arteries together, is usuall...
Do you ever use ocular ultrasound in evaluation of papilledema?
As a neuro-ophthalmologist, I never use ultrasound to make a diagnosis of papilledema. I do use it to reveal optic nerve head drusen that also cause axoplasmic flow stasis and can mimic papilledema. A high quality set of fundus photos is very useful for determining the presence of optic disc edema.
When do you use greater occipital nerve block to treat acute refractory migraine?
I frequently offer ONBs for patients with acute migraine when they have persistent headache, despite migraine cocktail & other initial ER interventions. Since occipital nerve blocks are safe, effective, and have Level A recommendations from the American Headache Society, I perform them quite frequen...
Which molecular pathology findings make an oligodendroglioma too risky for upfront vorasidenib, or which other clinical characteristics do?
I still predominantly use grade/proliferation/presence of enhancement (would be more likely to use vorasidenib in a grade 2 nonenhancing tumor) as well as clinical criteria similar to those used in Pignatti et al., PMID 11956268, or large trials like RTOG 9802 (size at diagnosis, spread across midli...
When do you consider starting short-term DAPT in patients who present more than 24 hours after the onset of a high-risk TIA or minor stroke syndrome?
The literature states that DAPT is most effective when started within the first 24 hours after such an event, but is still effective as far as 72 hours later. So if the patient presents more than 24 hours later, but not later than 72 hours, I would still start it then but would want a CT scan first.
How do you determine the timeline for healing after craniotomy prior to starting chemotherapy and radiation?
I typically wait at least 10-14 days post-op, always after neurosurgery has re-evaluated the craniotomy site for appropriate healing and has already removed staples or sutures.
How do you approach short term antithrombotic regimen, antiplatelets or anticoagulation, after Watchman device placement in ischemic stroke patients with atrial fibrillation and cerebral amyloid angiopathy who are at high risk for intracranial hemorrhage?
This is a good question. Our group published a paper on a series of patients with CAA who underwent placement of Watchman devices for atrial fib (Schrag et al., PMID 32770310). We usually did not anticoagulate patients at all, and we saw only one very minor stroke. I think that it would also be reas...
When would you consider elective hospitalization for parenteral treatment for new daily persistent headache?
New daily persistent headaches can have a tension-type headache phenotype or a migraine phenotype. If presenting with a severe daily headache and a migraine phenotype I will treat it as status migrainosus since there is no consistent way to differentiate migrainous NDPH from a status migrainosus las...
At what stage of the neuropathy workup do you screen for B6 toxicity?
In my experience, vitamin B6 deficiency due to poor oral intake is very uncommon. However, toxicity may occur with supplementation typically more than 2 gm/day, although chronic use of 50 mg/d may also be a cause. Vitamin B6 is present in many supplements and toxicity may cause direct damage to the ...
What factors would influence your decision to use or avoid heparin bridging in patients with mechanical heart valves resuming anticoagulation after intracerebral hemorrhage?
The main conclusion from the publication by Sakusic et al., PMID 39102615 was that withholding anticoagulation for the first seven days after ICH is safe in patients with mechanical heart valves and bridging with intravenous heparin to coumadin upon resumption of anticoagulation should be avoided. T...