Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
What are the key factors that you seek to uncover in order to land on the most effective DMT choice for patients with MS?
While generally the degree of activity (clinical and MRI lesion burden) is an important consideration in choosing DMT, the current landscape is such that the bulk of patients are either started on or switched to B-cell suppressor therapies. While there is minimal data on the utility of B-cell suppre...
How do you navigate conversations with patients who are reluctant to start high-efficacy DMTs due to infection risk?
I usually frame the discussion around the balance between the risk of infection and the risk of undertreating MS. In younger patients with relapsing MS, particularly those with active disease or other features associated with a higher risk of future disability, I favor early use of high-efficacy the...
Do you add antiplatelet medications to patients already on anticoagulation for atrial fibrillation if they have a stroke due to a competing etiology?
Adding antiplatelet therapy to anticoagulation in patients with atrial fibrillation and a noncardioembolic stroke has not shown a clear benefit and definitely increases bleeding risk. Okazaki et al., PMID 41051787 did not find a benefit and increased bleeding risk. An exception might be in acute MI ...
Have you changed your practice in treating CRAO with IV thrombolysis?
The recent THEIA trial had a limited sample size to draw conclusions, even though there was a non-significant trend of improved visual acuity initially in the thrombolysis group. Even the TenCRAOS trial had a small sample size with recruitment challenges, where subtle small differences cannot be acc...
In ischemic stroke patients with low LDL levels (<30-50 mg/dl), would you consider lowering LDL levels to lower values without concern for any side effects?
If LDL levels are already below 70, I don’t target a lower goal. The SPARCL trial showed that reducing LDL to this range has an NNT of about 45 to prevent one stroke, which I find to be modest at best. From my perspective, lowering LDL further (<30-50 range) shifts the focus to treating a number rat...
How do you manage patients with atrial fibrillation having a thromboembolic infarct despite being on adequate anticoagulation?
This scenario is always challenging. In terms of anticoagulation, the efficacy of DOACs in preventing embolic events in AF patients is around 70%, which is impressive compared to warfarin but not foolproof. In cases of a second embolic event while on anticoagulation, two reasonable approaches are of...
How to approach reversal of TNK in hemorrhagic conversion of ischemic stroke?
There is no specific "reversal agent" for tenecteplase. Once administered, the thrombolytic effect will persist until the drug is fully metabolized and any residual plasmin has been cleared by alpha-2-antiplasmin. So, perhaps the first question is what can you do if there is an acute bleeding event ...
Should mRS be incorporated into determining eligibility for extended window thrombolysis?
Key thrombolysis trials (WAKE UP, OPTION, EXTEND, TIMELESS, ECASS-4, HOPE, EXTEND IA) excluded patients with mRS of 2 or greater. The reason for this was the outcome of functional independence at 90 days. Hence, for trial purposes, to look at the outcome, it was necessary to exclude patients with di...
How do you decide when to intervene directly on a feeder artery aneurysm of an AVM?
In a ruptured AVM, we treat the feeding artery aneurysm as a priority and emergently. Either surgery or embolization is warranted. I prefer embolization in the hyperacute setting. In unruptured AVMs with a feeding artery aneurysm that have angioarchitecture amenable to catheterization, I prefer to e...
Do you treat migraine with aura if there is not an associated headache/pain?
I do if it interferes with quality of life. I do not recommend abortive medications for aura. There is no evidence that migraine abortive treatments shorten the duration of aura. I do not think that they do. Anecdotally, I have had some patients report that taking NSAIDs or a triptan at the aura ons...