Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
When might you soften the post-thrombolysis monitoring requirements for patients receiving TPA for acute stroke?
The recent study by Anderson et al., PMID 40412428, suggests that a pattern of reduced monitoring after tPA was noninferior to standard monitoring in patients with initial NIHSS < 10, treated within 2 hours of symptom onset. This is suggestive that the reduced monitoring protocol is safe in patients...
How long do you typically wait before starting anticoagulation after holding Leqembi/Kisunla in patients with cognitive impairment?
Lecanemab's half-life is about 5-7 days. This means wait for about 3 to 4 weeks before starting anticoagulation. The half-life of Donanemab (Kisnula) is about 12 days, which means waiting for anti-coagulation for about 6 to 8 weeks. These are not hard and fast rules; it is done out of an abundance o...
When do you start cyclophosphamide for the treatment of anti-NMDA receptor encephalitis?
First-line immunotherapy for anti-NMDA receptor encephalitis includes high-dose steroids, intravenous immunoglobulin (IVIg), and plasma exchange (PLEX), sequentially or concurrently. Second-line immunotherapy includes a trial of rituximab first and then cyclophosphamide due to the serious side effec...
What is the effectiveness of transmagnetic stimulation for patients with chronic pain, including chronic headaches?
In addition to repetitive TMS (rTMS) discussed helpfully by Dr. @Dr. First Last, single pulse TMS (sTMS) is an FDA-approved treatment for migraine. In contrast with rTMS administered in a clinical setting, sTMS is administered at home with a lightweight device designed for home administration. Effic...
How do you decide when to pursue genetic testing for cerebral palsy?
Unless there is a very obvious cause that has a very low likelihood of a genetic etiology (e.g., neonatal meningitis, embolic stroke from a discovered source, etc.), I almost always perform genetic testing. Even cases of presumed HIE can have an underlying genetic contributor that increased the risk...
What is your management approach for CAR-T induced motor neurologic deficits (cyclophosphamide/IVIG/steroids, etc.) and any prophylactic approach to an early, rapid rise in absolute lymphocyte count post CAR-T infusion?
Specifically, this seems to be a question around cilta-cel. There has been some recent guidance to consider pre-emptively starting dexamethasone if the absolute lymphocyte count rises above 3,000 in the period following CAR T administration. This partially stems from the observation that many of the...
How do you counsel patients with dermatomyositis on sun protection?
We make sure patients know that sun exposure can trigger flares, so we strongly recommend staying out of direct sunlight between 10 AM and 4 PM, using broad spectrum, SPF30+ sunscreen daily even when indoors (as UVA can penetrate through windows), and wearing sun protective clothing (ideally UPF-rat...
Do you recommend getting a muscle biopsy in a patient with suspected IMNM with statin exposure, weakness, elevated CK, and positive HMGCR antibody?
A patient with a typical clinical presentation of IMNM (muscle weakness, high levels of CPK) and positive anti-HMGCR antibodies leaves no question regarding the diagnosis, and muscle biopsy would not change management. I would reserve muscle biopsy for atypical cases (for example, positive anti-HMGC...
What is the optimal BP target for patients with diabetes and hypertension to reduce their risk of MI/stroke?
From the 2025 ADA Standards of Care, section 10 discusses Cardiovascular Disease and Risk Management. With proper blood pressure technique, the recommended blood pressure treatment goal is less than 130/80 mmHg if this can be achieved safely. Several randomized controlled trials are referenced with ...
In which subset of patients with concussion do you recommend further brain imaging?
I recommend further imaging of a concussion patient in a subset of patients. If the patient had a seizure with the head injury or any sign of declining mentation within the first few hours, they should have a CT head emergently. If it is within 1 week from injury and they report steadily worsening e...