Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
Which patients will have earlier diagnosis of multiple sclerosis via the new 2024 McDonald Criteria?
I think the group that will most benefit from the new diagnostic criteria, in terms of earlier diagnosis, is those with a history of optic neuritis. This is because the new criteria expand "typical CNS topographies" from four to 5 to include the optic nerve. In addition, those who present with lesio...
Considering only cerebrovascular indications, are there circumstances in which you would use aspirin along with a DOAC in patients with atrial fibrillation and stroke?
I will use aspirin 81 mg and a DOAC together in patients who "fail" (I hate that term) the DOAC. The combination was used in patients in the original DOAC trials, so it is not unreasonable. Not my first choice, but can be done. It is worth noting that the evidence does not support doing this upfront...
How do you counsel patients interested in carotid endarterectomy for asymptomatic carotid disease as a means to reduce dementia risk?
This is a good question. I reviewed the paper by Vitali et al, PMID 40922111 and I would add that previous studies of patients with asymptomatic carotid stenosis have not found a reduction in dementia with the procedures. In this retrospective study, carotid endarterectomy but not carotid stenting r...
How do you decide when to add steroid-sparing immunotherapy for myasthenia gravis after starting prednisone and Mestinon?
My approach is generally to add a steroid-sparing agent if the patient experiences worsening of their symptoms during prednisone wean, such that they cannot tolerate a prednisone dose lower than 7.5 mg/day without functionally limiting symptoms. However, there are many patient-specific consideration...
How do you workup patients with neuropathy suspected to be secondary to sarcoid?
To answer this question, the attached paper with consensus criteria for the diagnosis of neurosarcoidosis, published in 2018, should be reviewed, Stern et al., PMID 30167654.Based on this paper, a diagnosis of probable or definite neurosarcoidosis requires unequivocal evidence of non-caseating granu...
How do you assess periprocedural risk for patients with incidental silent ischemic infarcts scheduled for elective surgeries, major or intravascular procedures?
If the infarct is definite, I would initiate some work-up to determine risk, at least a CTA head/neck, and an echocardiogram. If hypertensive lacune, BP control might be all that is needed. If a cryptogenic, cortical/subcortical infarction, the CTA and echo would be more important. A risk estimate o...
What is your pharmacologic approach to treating insomnia comorbid with sleep apnea?
I do not usually treat any insomnia, regardless of comorbidities, with any targeted medication for the insomnia itself. If the patient is getting over 5 hours of sleep, then I use CBT-I as this is guideline-recommended (AASM) first-line treatment for insomnia and has efficacy lasting over a year out...
How do you decide if patients who have a multifocal demyelinating polyneuropathy would benefit from surgical treatment of carpal tunnel syndrome?
I would do median nerve ultrasound at the carpal tunnel and see if there is evidence of compression. If so, surgical release is a reasonable option.
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...
What monitoring do you routinely perform on lifelong EDS for epilepsy syndromes?
One of the complications inherent in using AEDs in anybody with epilepsy syndrome or neurotypical people with seizures is bone loss. It is especially important to look at their early loss of bone mass. I check for vitamin D levels even in very young patients. I might even do DEXA scans. I'm very pro...