Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
What is your approach for LINAC based radiosurgery when dealing with benign perioptic lesions very close to the optics apparatus?
It all starts with the consideration of what I consider an effective dose of SRS or SRT (hypo-fractionated SRS). The minimum effective dose to achieve local control of a metastatic lesion is usually 18 Gy for single fraction, 27 Gy for 3 fractions, and 30 Gy in 5 fractions.I then consider the histol...
Are there any contraindications using nurtec in patients with headaches in the setting of recent RCVS?
I would be comfortable using Nurtec in a patient with a recent RCVS diagnosis. I am comfortable using triptans in patients with a prior stroke or MI with proper patient counseling unless they have critical/severe artery stenosis. I have had cluster headache patients who continue sumatriptan injectio...
How do you make the decision to empirically treat for GCA when a patient is referred but cannot be immediately seen in clinic?
This is an important question because referrals for possible GCA are common scenarios when a rheumatologist may be asked to recommend a treatment before seeing the patient which are often challenging scenarior. The factors I typically rely on to rate the probability of GCA include: - Specific sympto...
Do you make any dose adjustments for patients with ESKD who are on apixaban and do not otherwise meet criteria for reduced dosing?
I do most of the time but it depends on the indication and patient's weight and age. For soft indications, I usually give 2.5 mg bid, but if there is a significant risk (stroke, clots, etc), I will give a full dose of 5 mg bid.
When should patients be referred for advanced MRI testing to assess for CVS and PRL?
There are many pathways to an MS diagnosis that do not rely on CVS or PRL. As such, I think it is very reasonable to start with a standard brain MRI that we have been using for many years for MS diagnosis. Many patients - maybe most - will meet criteria with a standard MRI and, potentially, CSF evid...
What makes a patient a good candidate for treatments targeting amyloid such as lecanemab or donanemab?
All the amyloid antibody trials were conducted in patients without the burden of cerebrovascular disease we often see in clinic populations. Many individuals with cognitive impairment have both vascular and neurogenerative contributions to their decline. We don’t yet know from real-world experience ...
What is your clinical threshold for treating a potential monoclonal gammopathy of thrombotic significance?
I strongly advise against routine screening for monoclonal gammopathy in patients with thrombosis. The incidence of MGUS, particularly in older patients, is relatively high and so the signal-to-noise ratio in this setting will be very low. In a patient with recurrent thrombosis and thrombocytopenia ...
How do you manage high-risk MDS IB2 patients on HMA and venetoclax who develop an acute stroke requiring antiplatelet therapy?
Not sure of the current platelet count? Not sure of the age of the patient.Will still use antiplatelet therapy for acute stroke as advised.Support with platelet transfusion as needed for platelet count <20. Hopefully patient responds to HMA and venetoclax, and platelet counts improve.If in CR by mar...
What are best practices to avoid misdiagnosis of multiple sclerosis in patients over 50 years old?
The onset of MS in patients over 50 years old is unusual. At the same time, there are a greater number of conditions, many of them quite common (i.e., chronic microvascular disease), that cause white matter disease that can mimic MS in patients over 50 years. Given that MS incidence is less and MS m...
Do you perform EMG and repetitive nerve stimulation in patients with ocular myasthenia gravis, particularly those who are AChR-positive, to assess for electrophysiological evidence of generalized disease?
There is already quite some literature about this question. I have included a recent reference that identified the predictors of generalization of ocular MG in 122 patients evaluated over 24 years in Malaysia. To summarize, in multivariate analysis, positive anti-AChR antibodies, positive RNS (OR 4....