Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
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...
Would you consider giving thrombolytic therapy for patients with acute vision loss concerning for CRAO based on history and within the window before any ophthalmological assessment and confirmation?
We have utilized a prior study to give tPA or tenecteplase within 4.5 hours of onset for CRAO. I would not do so, however, without an ophthalmology evaluation to confirm the likely diagnosis and to exclude an alternative diagnosis such as a retinal detachment.
When do you find ultrasound guidance to be most helpful for botulinum toxin injection?
I occasionally use ultrasound to survey the target muscle and neighboring structures such as blood vessels. I find this most helpful in the groin area or abdomen. The main difficulties with ultrasound relate to maintaining aseptic technique and needing an extra hand to control the probe in some situ...
How do you decide between Vyalev and Onapgo for patients who would benefit from continuous dopaminergic stimulation?
Either is fine.
Is there a role for bevacizimab (IV or IA) for steroid refractory radionecrosis for AVM?
Radiation necrosis (RN) following SRS can occur at variable intervals of time following treatment, usually occurring 9-18 months later. The preferred first line of approach is usually steroids, as done in this case. I usually look at the MRI-Flair images and determine the dose of dexamethasone depen...
Will you incorporate the use of tirzepatide in the management of patients with OSA?
Yes! However, the best methods to incorporate GLP-1s into the practice of Sleep Medicine have yet to be determined. Hopefully, our professional organizations can provide us with clinical practice guidelines to better direct our practice in this area.For those that have not had a chance to review, SU...
Do you utilize tumor treating fields in patients with anaplastic pleomorphic xanthoastrocytoma (PXA) III?
I would, but I haven't actually had the opportunity. With more information appearing that TTF is effective in brain metastases, mesothelioma, and pancreatic cancer, why wouldn't you use it if you didn't have a better option? The only real risk is financial.
How do you approach the medical evaluation of new onset psychosis in elderly patients?
The medical evaluation of new-onset psychosis begins with a thorough history (medical, neurologic, and psychiatric history), including a history of the present illness, medications, as well as the use of alcohol and recreational drugs. Obtaining information from family or others who know the patient...