Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
How do you approach weaning treatments for CIDP in remission?
I usually treat CIDP patients with IVIG first, unless there is a contraindication (e.g., history of anaphylactic reaction, very recent thrombotic event, or worsening kidney function in a person who is not yet on dialysis). I use the regimen proposed by the ICE trial, with a loading dose of 2 g/kg fo...
Would you consider IV thrombolytics in patients with acute ischemic stroke, with or without a large vessel occlusion, if they have a history of von Willebrand disease (VWD), regardless of its type?
I would still consider it unless the INR >1.7 or they are on anticoagulation for some clinical reason.
Do you recommend surveillance lumbar punctures for patients with Mollaret's meningitis after diagnosis or in between clinical episodes?
No. My focus with these patients is to establish the diagnosis, which is often difficult, with false-negative CSF PCR tests, and then do everything I can to prevent and alleviate the attacks. I see no role for surveillance LPs because either the patient is better clinically or they are not, and CSF ...
How do you approach sequentially tapering combination therapy (i.e., IVIG, mycophenolate, rituximab) for dermatomyositis that is in remission?
This process involves trial and error and requires collaboration between the physician and the patient to determine the most appropriate tapering strategy. My personal preference is to begin tapering medications with the highest risk of side effects. Among IVIG, mycophenolate, and rituximab, I would...
How do you approach the decision of when to perform left heart catheterization in a patient with an NSTEMI who recently had an acute ischemic stroke?
This is a complicated question. Most acute CVA patients have non-MI troponin elevations, and I generally treat them medically. If there is a true NSTEMI associated with CVA, it requires a thoughtful approach. I generally divide my NSTEMI patients into high-risk and non-high-risk. I will perform a di...
How do you manage patients with atrial fibrillation having a thromboembolic infarct despite being on adequate anticoagulation?
This scenario is always challenging. In terms of anticoagulation, the efficacy of DOACs in preventing embolic events in AF patients is around 70%, which is impressive compared to warfarin but not foolproof. In cases of a second embolic event while on anticoagulation, two reasonable approaches are of...
How do you sequence pharmacologic treatments for primary insomnia?
First, be sure you have already addressed deficiencies in sleep hygiene: Room at 65 degrees F Wearing earplugs Complete darkness (no visible hand in front of face) No clock Golden hour before bed ETOH, nicotine, and caffeine reduction with cessation of 4 hours before bed Writing a list of worries B...
How do you manage patients with good relief but intolerable chest tightness with sumatriptan?
An abstract I collaborated on was accepted by the European Society of Cardiology reported that patients with angina diagnosed with migraine have a higher prevalence of vasospastic angina, otherwise known as angina and non-obstructive coronary artery disease (ANOCA). We are recommending that these pa...
Which factors help you choose between intermittent phenobarbital dosing versus continuous pentobarbital infusion for pharmacological burst suppression in refractory status epilepticus?
I am not aware of any guidelines or data that recommend the use of phenobarbital over pentobarbital for burst suppression in refractory status epilepticus. In fact, guidelines tend to favor pentobarbital in patients who have failed propofol and midazolam. Phenobarbital can certainly be used for seiz...
How do you identify patients with false positive AcHR antibodies?
First of all, of course, one should look for the clinical correlation. Even a weakly positive AchR binding antibody is likely to be "real" (true positive) if accompanied by unequivocal clinical signs of MG, e.g., fatigable ptosis with positive ice pack test, or fatigable bulbar/limb weakness. Ideall...