Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
How do you counsel patients to reduce post-procedure side effects with onabotulinumtoxinA (Botox) for chronic migraine?
I caution them to not rub/itch the injection sites especially around the corrugators and frontalis sites for the rest of the day. Some people will recommend for 24 hours, but honestly while sleeping they could roll onto their face or rub their face anyway. I also do not recommend they do significant...
Is there any contraindication to the use of ezetimibe in patients with a history of statin-induced necrotizing myopathy?
These types of questions are always great to discuss. The reality is there is a risk-benefit ratio to be considered. On one hand, there is a concern for the need for lipid-lowering to prevent cardiovascular disease, and some situations are more pressing than others. A diabetic with a known cardiovas...
When do you offer TNK for ischemic stroke patients with a large vessel occlusion presenting outside the 4.5-hour window?
I agree with Dr. @Dr. First Last. Generally, I do not treat with TNK if EVT is available, but I do treat if no EVT is available, assuming favorable imaging as per the TRACE-III trial. However, as with all decisions, there are nuances. Since the benefit and risk ratio of TNK was only slightly favorab...
How do you manage the developmental and behavioral regression seen in Down Syndrome Disintegrative Disorder (DSDD)?
Thank you for this important question. One of the keys is to ensure that the change and regression being seen is DSDD or something else. Sometimes, this is confused with Alzheimer's seen in older individuals with Down syndrome. DSDD is seen in much younger people, late teens, and 20's as a more rapi...
When would you consider intra-arterial thrombolysis for acute ischemic stroke?
The prior answer brings up several valid scenarios where IA thrombolysis may be applicable. I can offer some nuanced perspective based on current practice. Device technology has advanced significantly since the landmark EVT trials of 2015. Today, EVT is increasingly feasible in distal-segment occlus...
How do you utilize FDG PET in the evaluation of dementias?
FDG PET is a regional map of glucose utilization in the brain. It tends to show reduced activity in specific areas in early Alzheimer's disease. It can complement MRI, which shows patterns of atrophy, rules out strokes, etc. Neither test is biologically specific for AD, which would require an amyloi...
What is your approach to secondary stroke prevention in patients with atrial fibrillation and intracranial stenosis (>70%)?
The patient clearly needs to be on an anticoagulant for stroke prevention with atrial fibrillation and I would choose apixaban. If an antiplatelet is added to the apixaban, the risk of a major bleeding side effect is significantly increased. It is uncertain if apixaban is effective in reducing the r...
How do you manage patients with glossopharyngeal neuralgia?
Glossopharyngeal neuralgia can be managed similar to trigeminal neuralgia (TN). It presents with pain like TN but located in the glossopharyngeal distribution (posterior part of the tongue, tonsillar fossa, pharynx, or angle of the lower jaw and/or in the ear). Note that neuralgia of the superior la...
How do you decide between using nuclear medicine scanning versus computed tomographic angiography (CTA) for ancillary brain death testing?
I would NEVER use CTA as an ancillary test when determining brain death.The American Academy of Neurology guidelines specifically classify CT angiography as an unacceptable ancillary test for brain death determination.The acceptable ancillary tests for adults include digital subtraction angiography ...
Would you avoid triptans in patients with CADASIL?
Most patients with CADASIL have migraines with aura (including hemiplegic migraine and the severe form known as CADASIL encephalopathy). There is no evidence contradicting the use of triptans in CADASIL specifically. However, smaller studies and systematic reviews, and meta-analyses have shown that ...