Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
When would you consider checking JC virus prior to initiating biologic therapy?
JC is a ubiquitous virus with sero-prevalence in the adult population of 60-70% in most studies. The concern is that in those who harbor latent JC are vulnerable to reactivation and ultimately the development of Progressive Multifocal Leukoencephalopathy (PML). The drug natalizumab used to treat MS ...
How do you monitor patients with transverse myelitis after a negative initial work up?
Both clinical and radiological evaluations, at least annually.
How do stroke-risk considerations affect your use of atypical antipsychotics for patients with dementia?
Antipsychotics carry a number of risks, including a warning of sudden death in elderly demented patients. If nothing else works for a behavioral problem, you have to use an antipsychotic. Also, for frank paranoia, which is not only causing distress to parents but also to the environment, treatment w...
What is your approach to management of patients with cerebral edema in the setting of hypoxic-ischemic injury?
Depends on the clinical status of the patient. Obviously, if the neurological exam is modestly good, i.e., purposeful movement or better, then follow the exam for signs of worsening edema. If the exam is not so good (flexion or less), we tend to use continuous EEG and serial imaging to monitor. As f...
Is there a role for routine EEG in the diagnostic evaluation of critically ill comatose patients or should these patients always receive long-term continuous video EEG monitoring?
We looked into this and found that in a non-comatose patient with no history of clinical seizures, the lack of epileptiform abnormalities on initial 30 minutes of EEG recording is associated with <5% risk for electrographic seizures suggesting that a routine EEG can be sufficient in that group (Stru...
Do you think repeated routine EEG is sufficient for cardiac arrest patients or should we be always using continuous EEG?
For most patients with cardiac arrest, cEEG has not been shown to offer improved outcomes over serial routine EEGs. In cases where there are EEG patterns that suggest seizures may be occurring, such as rhythmic or periodic patterns other than low-frequency GPDs, or repetitive evolving patterns, we t...
Do you routinely use pupillometry for serial neurologic examinations in the ICU, especially for patients at risk for transtentorial herniation?
We frequently do pupillometry assessments on patients at high risk of ICP crisis. It gets rid of observer subjectivity as it is often an issue in ICUs. We have a protocol with the following indications for q1h pupillary assessments. It is not based on particular guidelines but serves as a good marke...
How do you adjust chronic outpatient steroid therapy when myasthenia gravis patients are admitted for crisis?
1.) It is important to figure out what triggered the crisis. If it was triggered by a recent, active infection (especially bacterial), it is not a good idea to increase the steroid dose. I would actually attempt to taper the prednisone slowly after IVIG or PLEX is initiated for treatment of the MG c...
How do you manage anxiety for patients who are experiencing a myasthenic crisis?
For a long time, we have been taught that we should avoid benzodiazepines in this setting (also applies to patients with ALS, myositis, etc.) because of their suppressive effect on the CNS respiratory drive and the risk of exacerbating hypercarbic respiratory failure. Based on recent conversations w...
How would you approach a patient with recurrent grade 3 oligodendroglioma (MGMT-methylated, IDH mutant, 1p/19q co-deleted) 1 year after gross total resection and adjuvant chemotherapy and radiation?
There are multiple options to consider for the recurrence of grade 3 gliomas after prior chemotherapy or radiation. Regardless of whether or not the recurrence overlaps completely or partially with the prior treatment fields, options include systemic therapy (including IDH-targeted therapies for IDH...