Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
What leads you to suspect that a foot drop is secondary to a myopathy rather than a neuropathic process?
Factors suggesting that a foot drop is due to a myopathy include: Clinical factors (slow progression (myopathy but also seen in CMT) versus acute or sub-acute onset (usually neurogenic), absence of sensory findings, absence of pes cavus, signs of facial or shoulder girdle weakness (FSHD can cause f...
Does performing peripheral nerve (greater occipital, auriculotemporal, or supraorbital) blocks at the same visit as Botox injections for migraine treatment provide greater benefit than at different visits?
To my knowledge, there has never been a study to provide an answer to this question, so it remains unknown. I have performed nerve blocks and Botox injections in the same visit. I administer nerve blocks to most patients at a frequency of every 4-6 weeks. When a nerve block is scheduled within a few...
Can you clinically distinguish TIAs from transient focal neurologic episodes (TFNEs) of cerebral amyloid?
It may be difficult to distinguish between those two types of episodes. The first issue would be does a patient has anyloid. If they do, I would err on the side of caution and presume transient focal neurological symptoms were caused by a vascular episode unrelated to amyloid and appropriately explo...
When do you consider switching a generic formulation of an antiseizure medication to the brand formulation?
This rarely, if ever, happens. The easiest way to think of the difference is not to think of brand versus generic. Think of brand as the first generic (G1), and all the rest are later generics (G1, G2, etc.). Since the active ingredient is identical amongst all formulations, the only difference is w...
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...
Do you find onabotulinumtoxinA injections effective for the treatment of trigeminal neuralgia?
I use botulinum toxin (off-label) for two face pain conditions, one rare, i.e., trigeminal neuralgia, and one common, i.e., temporomandibular disorder (TMD). For trigeminal neuralgia, I use a tiny needle to inject very small amounts of the toxin into the affected area of the skin and, if involved in...
How would you empirically manage a large sellar/suprasellar mass with encasement of the right cavernous and terminal internal carotid arteries?
Knowing the histology of the mass would really help in creating more accurate treatment recommendations. A biopsy of a sellar mass is usually accomplished by an endonasal-endoscopic transsphenoidal approach utilizing the expertise of an ENT surgeon and a skull-base neurosurgeon. However, in this cas...
How do concerning TCD trends affect your management of a clinically stable patient with aneurysmal subarachnoid hemorrhage?
I have been relying on TCD to manage clinically stable SAH patients for years. There are several management interventions that I might make in a patient who is showing significant vasospasm on TCD but otherwise seems clinically stable. These interventions include keeping a patient in ICU for frequen...
Would you consider endovascular thrombectomy for acute stroke patients with large vessel occlusion (non-large core) but with poor functional baseline with mRS 3-4?
The Modified Rankin Scale (mRS) is a widely used tool for assessing functional status, ranging from 0 (no symptoms) to 6 (death). It provides a standardized framework for EVT decision-making based on a patient’s functional status and serves as a key criterion in EVT-related RCTs. While invaluable in...
What factors predispose patients who undergo thrombectomy to repeatedly embolize to the same artery despite successful recanalization, other than ICAD?
Intracranial atherosclerotic disease is a well-recognized cause of recurrent ischemic stroke through repeated in situ thrombosis and distal artery-to-artery embolization, predisposing patients to recurrent infarction within the same vascular territory. Likewise, high-risk extracranial atheroscleroti...