Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
In what circumstances would you consider use of IDH inhibitors in high-grade astrocytomas?
Please forgive me for the length and directness of my response, but I believe it is important to first go over the INDIGO trial and explain why, in my opinion, it was a highly questionable study, with multiple significant methodological flaws and dubious evidence of Vorasidenib's efficacy.INDIGO tri...
Are you offering Lutathera for multiple recurrent meningiomas?
Lutathera is currently only FDA-approved for treating somatostatin receptor-positive gastroenteropancreatic neuroendocrine tumors (GEP-NETs). However, research is ongoing to explore its potential use for meningiomas, as many meningiomas express somatostatin receptors, which could make it a promising...
How do you determine when patients can resume their previous activities after a subdural hemorrhage?
First, it depends on the status of the SDH; if surgically removed or with embolization of the middle meningeal artery, then return to activity can be fairly rapid, over 2-3 weeks if gradually increasing, but if no surgery or intravascular procedure, then I would advise more caution. This would mean ...
When should MOG-Ab be tested in patients with suspected autoimmune encephalitis with seizures and normal MRI?
In someone with suspected autoimmune encephalitis with seizures and a normal MRI (presuming done with gadolinium and the optic nerves are well visualized), I would not obtain MOG. MOG testing would have a very low pretest probability (so low that a positive test might well be a false positive). If o...
Do you typically recommend sleep studies for patients with Parkinsonism?
Not necessarily. If there is concern for sleep apnea (i.e., snoring, etc), then it would be worth doing, as a CPAP can be helpful for sleep quality, but I have found most sleep labs (this includes both community and university-based) are not great at otherwise diagnosing/accounting for other sleep a...
What are potential pitfalls in the use of OCT to support a diagnosis of multiple sclerosis?
OCT used to support a diagnosis of MS must be used with care and with substantial knowledge of OCT and its artifacts. OCT shows retinal nerve fiber layer and retinal ganglion cell damage. There are no OCT findings specific for multiple sclerosis. Therefore, OCT must be interpreted in concert with an...
When do you consider pacing in arrhythmogenic epilepsy?
I have seen only rare cases of it. They all had tonic-clonic seizures triggered by profound bradycardia (sinus as well as AV block). In turn, the bradyarrhythmia was triggered by EEG-documented temporal lobe absence seizures. They all resolved long-term with pacing. Regardless of the un...
How do you determine when patients can resume massage therapy, weight lifting, or sports after a spontaneous CSF leak?
I have seen cases where athletes return to intense activity too soon after a blood patch and have a repeat leak. There is guidance from Duke Health that I have used as a guideline when advising patients on resuming activity.
What work-up and treatment do you recommend for exertional headaches?
Primary Exercise Headache Diagnostic Criteria per ICHD-3: At least two headache episodes fulfill criteria B and C Brought on by and occurring only during or after strenuous physical exercise Lasting <48 hours Not better accounted for by another ICHD-3 diagnosis Caveats: Migraine headache worsened o...
How do you approach new-onset idiopathic intracranial hypertension (IIH) with someone who has history of systemic lupus erythematosus?
Since there is not a clinical recurrence of lupus, let's assume the disease is quiescent. The patient may have a clotting tendency so extra care should be taken in MRV interpretation. Does the MRV show the smooth-walled flow-related stenoses of intracranial hypertension or is it more consistent with...