Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
What biomarkers best predict the response to B-cell depleting therapies in MS?
I would say that checking CD19 counts is helpful to monitor response to B-cell therapy, but it is not useful in predicting response. I used to check this before and after starting B-cell therapies, but ultimately did not find it useful. I now only check it if someone has breakthrough disease activit...
What have been your experiences with anti-CGRP therapies for hemiplegic migraine?
I think it is important to point out that true hemiplegic migraine is very rare. Many patients are incorrectly diagnosed with (sporadic) hemiplegic migraine, and actually have sensory aura or *MUMS. These patients can absolutely have CGRP-targeted medications.In terms of true hemiplegic migraine, I ...
What is the role of skin biopsy for evaluating small fiber neuropathy in patients with rheumatic disease who have treatment recalcitrant pain?
I have a shared decision-making discussion with the patient, especially alluding to the fact that the result would not change my therapy (i.e., use neuropathic analgesics for treatment) for small fiber neuropathy (SFN). Where I find it especially useful is in a patient with systemic lupus (SLE) or S...
How do you approach the management of poorly controlled migraines during pregnancy?
This is an excellent question and area of frequent discussion. You can start with Lidocaine nerve blocks: occipital, supra-orbital, and temporal. Sometimes, just IV fluids will help for acute migraines. Other options include Reglan, caffeine, and APAP. If in the second trimester, I will do steroid t...
In which clinical scenarios do you find medial and lateral plantar sensory or mixed nerve conduction studies to be valuable?
I agree with Dr. @Dr. First Last. I would just add that I frequently do these when patients are complaining of numbness, paresthesias, or pain in the plantar aspect of their feet. If normal, you can be more clear about whether a large fiber neuropathy is present. If the symptoms are just in the toes...
Do you treat cerebral vein thrombosis with parenchymal hemorrhage using full dose heparin protocol rather than the high risk protocol?
I just want to clarify the question a bit. I will assume that you mean cerebral venous sinus thrombosis with cerebral vein thrombosis here. IV heparin is considered a standard treatment for cerebral venous sinus thrombus, but not necessarily cerebral vein thrombosis. Heparin for isolated cortical ve...
What is your strategy for treating persistent headaches in the aftermath of subarachnoid hemorrhage?
In the immediate aftermath of a subarachnoid hemorrhage, regardless of whether the aneurysm has been secured or not, the following strategies can be employed to manage headaches: Headache Cocktail: This may consist of magnesium infusions, Benadryl, and an antiemetic like Compazine. Magnesium infusi...
How do you manage pregnant individuals with newly diagnosed idiopathic intracranial hypertension?
Pregnancy in IIH is managed the same as if the patient did not have IIH with one caveat. IIH patients should stay within the recommended weight gain their obstetrician targets. Pregnancy is not a cause of IIH, but the excessive weight gain that can occur can trigger or worsen IIH. Labor and delivery...
When might you soften the post-thrombolysis monitoring requirements for patients receiving TPA for acute stroke?
The recent study by Anderson et al., PMID 40412428, suggests that a pattern of reduced monitoring after tPA was noninferior to standard monitoring in patients with initial NIHSS < 10, treated within 2 hours of symptom onset. This is suggestive that the reduced monitoring protocol is safe in patients...
How long do you typically wait before starting anticoagulation after holding Leqembi/Kisunla in patients with cognitive impairment?
Lecanemab's half-life is about 5-7 days. This means wait for about 3 to 4 weeks before starting anticoagulation. The half-life of Donanemab (Kisnula) is about 12 days, which means waiting for anti-coagulation for about 6 to 8 weeks. These are not hard and fast rules; it is done out of an abundance o...