Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
How do you approach evaluating the hemorrhage risk of restarting anticoagulation in a patient with ischemic stroke and infective endocarditis without access to DSA?
This is a really excellent question. First of all, if the patient has infective endocarditis, they really should undergo appropriate antibiotic treatment prior to initiating anticoagulation. I have seen several patients have significant (and in some cases fatal) hemorrhages because anticoagulation w...
How do you decide on the speed and target of blood pressure reduction for spontaneous intracranial hemorrhage?
I think the target and speed of blood pressure reduction in ICH depend on several variables, including initial SBP, clinical stability, hematoma size, and renal function. For patients presenting with SBP >220, I typically aim to lower the pressure to around SBP 160 over the first 12 hours, then grad...
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...
How do you decide between FcRn inhibitors and complement inhibitors for treatment-refractory AChR-positive myasthenia gravis?
UPDATE (02/2025):In the last two years, there have been few real-world comparative efficacy studies published to address this question. I have attached a selection of them below. Overall the conclusion is that equipoise remains- there is no clear evidence of the superiority of complement inhibitors ...
When can EMG be deferred in cases of distal sensory polyneuropathy?
Sensory conduction studies provide information as to whether there is a large fiber disorder of the dorsal root ganglion or the nerve fibers distal to the DRG. The simple answer to the question is that you can defer this study when you don't want or need that information. If the symptoms are very di...
How do you navigate C-2 refills in patients who are stable in their treatment and do not otherwise need to be clinically seen monthly?
This practice is routine in child psychiatry. We fill stimulant prescriptions electronically at the phone request of the family as long as they are keeping quarterly appointments. We do not charge for that service. We do document it in the medical record. Your question begs another question, however...
What is your approach for LINAC based radiosurgery when dealing with benign perioptic lesions very close to the optics apparatus?
It all starts with the consideration of what I consider an effective dose of SRS or SRT (hypo-fractionated SRS). The minimum effective dose to achieve local control of a metastatic lesion is usually 18 Gy for single fraction, 27 Gy for 3 fractions, and 30 Gy in 5 fractions.I then consider the histol...
Are there any contraindications using nurtec in patients with headaches in the setting of recent RCVS?
I would be comfortable using Nurtec in a patient with a recent RCVS diagnosis. I am comfortable using triptans in patients with a prior stroke or MI with proper patient counseling unless they have critical/severe artery stenosis. I have had cluster headache patients who continue sumatriptan injectio...
How do you make the decision to empirically treat for GCA when a patient is referred but cannot be immediately seen in clinic?
This is an important question because referrals for possible GCA are common scenarios when a rheumatologist may be asked to recommend a treatment before seeing the patient which are often challenging scenarior. The factors I typically rely on to rate the probability of GCA include: - Specific sympto...
Do you make any dose adjustments for patients with ESKD who are on apixaban and do not otherwise meet criteria for reduced dosing?
I do most of the time but it depends on the indication and patient's weight and age. For soft indications, I usually give 2.5 mg bid, but if there is a significant risk (stroke, clots, etc), I will give a full dose of 5 mg bid.