Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
Would you consider intravenous thrombolytics for an acute spinal ischemic stroke?
I would not use thrombolytic therapy for an acute spinal ischemic stroke. There is no good information about the benefits and risks of this therapy in this clinical situation.
When do you consider discontinuing disease modifying therapies for multiple sclerosis?
Certainly, age is increasingly being defined as a factor that influences disease evolution. There are some articles that suggest 55 years might be a 'turning point' to discontinue disease modifying therapies but my preference, particularly when there is no radiological or clinical worsening over the...
What considerations do you take regarding using valproic acid in men who are hoping to conceive with a partner?
This recommendation was based on an analysis of one retrospective study, with data being re-analyzed, in addition to case reports and animal studies. It seems to me that it's too soon to be making rash decisions about treatment, but informing patients of the possibility and uncertainty seems reasona...
When do you usually introduce conversations regarding tracheostomy placement in patients with refractory status epilepticus, or other conditions where one may anticipate delayed awakening?
It depends on the underlying pathology and how long the patient is expected to have impaired airway reflexes requiring prolonged mechanical ventilation. In the Setpoint 2 trial, among patients with severe stroke receiving mechanical ventilation, a strategy of early tracheostomy (</= 5 days), compare...
Does anyone utilize P2Y12 assays to determine if clopidogrel may be ineffective when used for DAPT?
Yes, I use P2Y12 assays in two distinct settings. Medical management: If a patient on clopidogrel mono/dual therapy has disease progression with ICAD or experiences a recurrent ischemic event, I obtain a P2Y12 assay to assess responsiveness. This helps guide the decision to switch to ticagrelor and ...
Have you had success with the Cala Trio device for essential tremor?
I have had a couple of patients who find it useful to calm their hand tremor for about 60-90 minutes after using the device. They may use it before they are going to an event, or before they plan to do an activity that involves the use of their dominant hand. (NOTE: You can only use it for one limb....
What biomarkers best predict the response to B-cell depleting therapies in MS?
We find that ordering a Lymphocyte Subset (specific lab order) is probably the easiest and quickest way to assess the response/efficacy of CD20 therapy and MS patients. Particularly looking at the CD19/precursor to CD20 lymphocytes. It allows us, if the patient relapses on CD20 therapy, to see if we...
What have been your experiences with anti-CGRP therapies for hemiplegic migraine?
I think it is important to point out that true hemiplegic migraine is very rare. Many patients are incorrectly diagnosed with (sporadic) hemiplegic migraine, and actually have sensory aura or *MUMS. These patients can absolutely have CGRP-targeted medications.In terms of true hemiplegic migraine, I ...
What is the role of skin biopsy for evaluating small fiber neuropathy in patients with rheumatic disease who have treatment recalcitrant pain?
I have a shared decision-making discussion with the patient, especially alluding to the fact that the result would not change my therapy (i.e., use neuropathic analgesics for treatment) for small fiber neuropathy (SFN). Where I find it especially useful is in a patient with systemic lupus (SLE) or S...
How do you approach the management of poorly controlled migraines during pregnancy?
This is an excellent question and area of frequent discussion. You can start with Lidocaine nerve blocks: occipital, supra-orbital, and temporal. Sometimes, just IV fluids will help for acute migraines. Other options include Reglan, caffeine, and APAP. If in the second trimester, I will do steroid t...