Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
Which clinical or imaging features of cerebral amyloid angiopathy aid in predicting future risk of intracerebral hemorrhage?
Hemorrhagic imaging features of cerebral amyloid angiopathy can help understand the future risk of intracerebral hemorrhage (ICH). Observational studies have found that patients with cortical microbleeds without lobar hemorrhage have an ~5% risk of future ICH. In those with prior lobar ICH, this ris...
What would prompt discontinuing treatment versus switching or sequencing treatment in patients treated with an anti-amyloid therapy for Alzheimer's?
To be sure, there is virtually no evidence of outcomes on switching from one antibody to another. If treatment discontinuation occurred due to ARIA, I would strongly discourage rechallenge with another agent. There is no rationale for discontinuing lecanemab or donanemab for lack of efficacy on clin...
When do you recommend neuropsychiatric testing in patients with post-concussive syndrome?
I typically ask the patient what scenarios they experience cognitive issues. The various examples they provide usually relate to difficulty following conversations, forgetfulness within their working memory, and concentration/focus. In the post-concussion patient, they typically have developed adjus...
How are you using CYP2C19 genotyping for determining dual antiplatelet therapy for stroke?
In my practice, P2Y12 assays are the primary tool I rely on for guiding dual antiplatelet decisions. They are more widely available across clinical settings, whereas CYP2C19 genotyping requires infrastructure that is not always accessible outside of large academic and tertiary centers. CYP2C19 ident...
How do you counsel B cell-depleted multiple sclerosis patients on the benefits of regular COVID-19 vaccinations?
The fact that B cell-depleted patients render a blunted antibody response is not unexpected, but antibodies do not protect from viral infections - cells do. To measure a proper vaccine response, one wants to test T cells from patients to see if they are able to kill viral infected cells. This is wha...
What primary and secondary stroke prevention strategies do you use for patients with a pulmonary AVM (PAVM)?
This is not a common problem in stroke neurology. I have been involved in this problem for a patient with HHT (also known as Osler-Weber-Rendu syndrome). Sporadic or post-surgical AVMs may also arise but they are uncommon. In general, the treatment in both scenarios (primary and secondary prevention...
When would you start antiepileptic drugs in a critically ill patient who develops myoclonic jerks but has not yet had an EEG?
Treatment depends on the setting in which these myoclonic jerks are seen. In a non-cardiac arrest patient, such myoclonic jerks are often due to medications, organ dysfunction (e.g., uremia, etc), electrolyte imbalance, or non-convulsive seizures, etc, and workup for this is recommended with labs, h...
When would you consider GLP-1 receptor agonists for IIH in patients at a healthy weight and BMI?
Randomized clinical trial data demonstrate that exenatide (exendin-4), a GLP-1 receptor agonist, reduces ICP in women with active IIH, with reductions of approximately 5–6 cm water of CSF and no serious side effects; this result is both statistically and clinically significant. This pressure-lowerin...
How do you approach treatment of 1p19q non-codeleted high grade gliomas?
The question focuses on the management of 1p19q non-codeleted high-grade gliomas, which for all practical purposes translates roughly to the entity that by legacy terminology has been referred to as anaplastic astrocytoma. This question has come into focus with the recent publication of results of t...
What do you recommend as a first-line antidepressant in patients with major depressive disorder and migraines?
In my clinical practice, I have found SNRI medication, particularly extended-release venlafaxine (dosed from 37.5 mg to 225 mg), to be helpful for patients with both comorbidities. Other medication classes I have seen used to good effect include TCAs (amitriptyline, nortriptyline) and some SSRIs (se...