Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
For stroke patients with ablated paroxysmal atrial fibrillation without known recurrence and ICAD, would you recommend dual antiplatelet therapy or anticoagulation with or without an antiplatelet agent?
Ablation treats cardiopulmonary symptoms, but it has not been adequately tested against anticoagulation for AFib-related stroke. Anecdotally, at least once a month, I will see a patient with an acute embolic-appearing stroke after their cardiologist has stopped their anticoagulation because they wer...
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 ...
How does LV non-compaction on TTE change your secondary stroke prevention management?
Left ventricular non-compaction is a rare condition where the L atrial wall is thick and irregular and can contain areas of clot. I would favor anticoagulation in this situation, rather than antiplatelet therapy, but of course there are no clinical trials regarding this uncommon finding.
How would you advise a younger patient with residual/recurrent optic nerve meningioma, proceeding with radiotherapy, about the risks of malignant transformation or induction of other brain malignancies because of radiation?
The risk of malignant transformation of an optic nerve sheath meningioma (ONSM) after RT appears to be remarkably low, much lower than the risk of blindness from an untreated, progressive ONSM. In a younger patient, I would lean toward RT for patients with imaging progression or early visual loss, ...
What leads you to suspect that a foot drop is secondary to a myopathy rather than a neuropathic process?
Factors suggesting that a foot drop is due to a myopathy include: Clinical factors (slow progression (myopathy but also seen in CMT) versus acute or sub-acute onset (usually neurogenic), absence of sensory findings, absence of pes cavus, signs of facial or shoulder girdle weakness (FSHD can cause f...
When do you find benefit in sequencing different dopamine receptor blockers for emergency treatment of migraine?
I know that these medications given intravenously have been found effective abortively in randomized, double-blinded, placebo-controlled trials. Prior to the advent of the triptans in the early nineties, I often treated migraine headaches abortively with metoclopramide 10 mg orally, in 15 minutes, f...
What is your approach to REM behavior disorder not adequately treated with melatonin and clonazepam?
Rule out comorbidities like sleep apnea or medications causing RBD. Optimize doses for melatonin and clonazepam, and consider dual therapy with these. Other options are gabapentin or pramipexole. Thanks,Sam Morkous
Does performing peripheral nerve (greater occipital, auriculotemporal, or supraorbital) blocks at the same visit as Botox injections for migraine treatment provide greater benefit than at different visits?
To my knowledge, there has never been a study to provide an answer to this question, so it remains unknown. I have performed nerve blocks and Botox injections in the same visit. I administer nerve blocks to most patients at a frequency of every 4-6 weeks. When a nerve block is scheduled within a few...
Do you recommend a workup for POEMS and/or amyloidosis for IgM monoclonal gammopathies associated with neuropathy?
While IgM monoclonal disorders, amyloidosis, and POEMS syndrome may all be associated with peripheral neuropathy, they are not often confused with one another. A patient with a peripheral neuropathy can be diagnosed most simply by a serum protein electrophoresis. The presence of a monoclonal IgM spi...
Can you clinically distinguish TIAs from transient focal neurologic episodes (TFNEs) of cerebral amyloid?
It may be difficult to distinguish between those two types of episodes. The first issue would be does a patient has anyloid. If they do, I would err on the side of caution and presume transient focal neurological symptoms were caused by a vascular episode unrelated to amyloid and appropriately explo...