Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
When do you attribute tremors to lamotrigine?
Not a side effect of LTG, but tremors are common and patients love to attribute everything to medications.
How do you counsel patients with isolated REM behavioral sleep disorder secondary to antidepressant on the risk of developing a neurodegenerative disease?
If I believe the RBD is truly secondary to antidepressant use, then the risk of developing an alpha synucleinopathy should be very low. However, this may not be able to be clearly discerned. In which case, I believe the patient has the right to know and should know about the risk of developing an al...
When should patients be referred for advanced MRI testing to assess for CVS and PRL?
There are many pathways to an MS diagnosis that do not rely on CVS or PRL. As such, I think it is very reasonable to start with a standard brain MRI that we have been using for many years for MS diagnosis. Many patients - maybe most - will meet criteria with a standard MRI and, potentially, CSF evid...
When do you consider tapering tocilizumab in patients with GCA in remission?
This is a timely question and recent data sheds some light on this important topic. The risk of GCA relapse is approximately 50% (Mainbourg et al., PMID 30951256) in all comers. The GIACTA trial (Stone et al., PMID 28745999) utilized a one-year course of TCZ. A recent publication of the extension ph...
What maximum core volume or core-to-penumbra ratio do you use for eligibility for extended window thrombolysis beyond 4.5 hours?
For the CTP, most trials used a core less than 70 mL, a mismatch volume of 10 mL or greater, and a mismatch ratio of > 1.2. Most extended-window thrombolysis trials used these parameters.
Do you obtain an MSLT or start empiric therapy with modafinil in patients with residual excessive daytime sleepiness despite optimal adherence to PAP therapy?
In this situation I would start either modafinil, armodafinil, or solriamfetol for residual EDS if the OSA was appropriately controlled without need for MSLT. We have an FDA label for these medications in this situation to support this practice. If I felt like there was concern for a combination of ...
For stroke patients with ablated paroxysmal atrial fibrillation without known recurrence and ICAD, would you recommend dual antiplatelet therapy or anticoagulation with or without an antiplatelet agent?
Ablation treats cardiopulmonary symptoms, but it has not been adequately tested against anticoagulation for AFib-related stroke. Anecdotally, at least once a month, I will see a patient with an acute embolic-appearing stroke after their cardiologist has stopped their anticoagulation because they wer...
How do you decide on switching to a different preventative anti-CGRP treatment in migraine patients who are experiencing reduced effectiveness with their current treatment?
On occasion, I have found that patients who were diagnosed with chronic migraine actually have EPH or CPH and respond to an indomethacin trial. Alternatively, those with less-than-ideal responses to CGRP antagonists or gepants, Botox injections can offer more relief. These patients tend to have a si...
Do you recommend anticoagulation for stroke prevention in patients with atrial high rate episodes?
In a patient with atrial high-rate episodes (AHREs) detected by a device, I would generally only recommend treatment with anticoagulation if the episodes are confirmed as atrial fibrillation or atrial flutter based on an ECG/rhythm strip. Detecting AHREs is important to alert treating clinicians of ...
How do decide on extending an NCS for a suspected CIDP patient but so-far negative testing?
I agree with @Dr. First Last that testing 2 upper extremities and at least one lower extremity are appropriate (the guidelines make this point). The upper extremities tend to provide more useful information, as the lower extremity amplitudes can be very low and proximal stimulation is limited. Pleas...