Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
When do you restart anticoagulation in patients with atrial fibrillation who just had an ischemic stroke?
The recent ELAN trial (Fischer et al., PMID 37222476) and now the published CATALYST meta-analysis (Dehbi et al., PMID 40570866) all support the concept that early anticoagulation (within 4 days of stroke) with a DOAC is safe and effective. There appears to be no interaction with clinical factors su...
How do you evaluate and manage patients with recurrent multifocal subcortical ischemic infarcts of unclear etiology?
Presuming the search for a large vessel or cardiac source was negative, I would assume the cause is small vessel disease. To reduce the risk of recurrence, vascular risk factors such as hypertension and elevated cholesterol should be maximally controlled. An antiplatelet drug should also be used, ei...
Which multiple sclerosis DMTs would you consider in patients with concurrent Crohn's disease and elevated JCV Ab titers?
This may depend on the course/activity of both the MS and Chron's. S1P inhibitors, specifically ozanimod, have minimal risk of PML and are FDA-approved for both UC/Crohn's and MS. While the treatment landscape continues to shift, S1P inhibitors are generally considered either moderate or high-effica...
How do you counsel eligible patients on how to decide between lecanemab vs donanemab?
Donanemab is not yet offered at my institution, though we expect it to be soon. With that caveat, it is my view that lecanemab will almost always be my recommendation because of the lower rate of ARIA, especially in e4 carriers. While the Q4W dosing regimen of donanemab is an attractive feature for ...
How do you approach patients considering Leqembi therapy for Alzheimer’s disease who cannot get MRIs?
They are excluded.
Do you prescribe prophylactic steroids to patients receiving radiosurgery for AVMs?
I do not use prophylactic steroids when treating AVMs with stereotactic radiosurgery. In fact, usually SRS of AVMs is rarely associated with edema and these patients rarely require steroids in the observation period after SRS.
What laboratory biomarkers are most helpful for predicting TBI severity?
GFAP level.
In patients with low grade gliomas that are older than 40 y/o or have subtotal resections, do you ever withhold upfront RT off protocol?
Yes. We should be humble about the data supporting RT in this scenario (that is, for IDH-mutant tumors). I would suggest that for IDH wild-type tumors (i.e., molecular GBMs) RCTs in the '70s established an OS benefit for RT and that withholding of RT is not supported.For IDH-mutant tumors, data from...
What do you recommend for a commercial driver's license holder who experiences migraine with visual aura?
My answer is similar to my answer for driving and epilepsy. The most important issue to understand is what the rules are for a CDL. What is medically appropriate may not follow the CDL rules. However, my gestalt is whether a visual aura impacts driving. Some visual auras are quite mild and do not im...
What dose/duration of corticosteroids do you use for patients with intractable episodic cluster headaches?
Best evidence for oral steroids from a large randomized controlled trial: Prednisone 100 mg for 5 days, then taper by 20 mg every 3 days until off (the largest study available). Obermann et al., PMID 33245858Occipital nerve block: In addition to oral steroids, there is also evidence of the occipital...