Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
Would you use bupropion for mood disorder or substance use in an adult patient with previous childhood seizures that resolved?
The short answer is maybe, though it would not be my first choice. Bupropion is known to lower the seizure threshold, thus the basis of the question. Selection of an antidepressant depends on multiple factors including response to prior medications, side-effect profile, cost, presence of comorbid sy...
Do you ever use amantadine or modafinil to aid in the rehabilitation of patients with ischemic strokes?
No randomized controlled trials of amantadine or modafinil for the treatment of disorders of consciousness (DoC) after ischemic strokes have been completed. A retrospective study of ICU patients with DoC after ischemic stroke found that amantadine, modafinil, or a combination may be useful in improv...
How would you approach antithrombotic therapy in patients with acute ischemic infarcts and a non-occlusive intracranial thrombus?
I agree with the previous answer and can expand on a few key management nuances involving stroke size, symptom severity, and etiology. For stroke size, I typically initiate anticoagulation (heparin drip) if less than one-third of the affected territory is involved, extrapolating from tPA guidelines....
How clinically meaningful are the differences in the primary outcome between treatment and placebo groups in the CENTAUR trial?
Defining the term "clinically meaningful" proves challenging. Patients involved in the three positive and approved drug trials are unable to detect a slowdown in the progression rate. Attempts were made to gauge ALS providers' opinions regarding a meaningful change in the ALSFRS-R scale, suggesting ...
Would you offer adjuvant radiotherapy for a gross totally resected WHO grade 2 hemangiopericytoma/MFT of the brain in a patient with active multiple sclerosis?
This is a tough question to answer, as there are risks associated with either recommending post-operative radiotherapy or not. Hemangiopericytomas are rare intracranial tumors that arise from pericytes, support cells found in the wall of meningeal capillaries. They are part of a larger spectrum of m...
For patients with newly diagnosed brain metastases without a history of seizure activity, do you routinely start anti-seizure medication?
This is a common clinical question that has been repeatedly explored in meta-analyses and clinical guidelines. Consistently, there's no evidence to support primary prophylaxis for seizures in patients with brain tumors including brain metastases. In summary, the data does not support the routine use...
Would you recommend anticoagulation in a pediatric patient with metastases in a dural venous sinus?
For an adult patient would consider if there is evidence of tumor-associated thrombus on initial imaging or follow-up, but not usually from a prophylactic perspective. This may be different in a pediatric patient and also might depend on the primary malignancy or hematologic, or neurologic comorbidi...
What are your preferred anti-seizure medications for Doose syndrome?
Meds are not listed in any necessary order: valproic acid, clobazam (any other benzo), ketogenic diet, and felbamate. The ketogenic diet and felbamate are the most effective.
What is your hemoglobin target for PRBC transfusion in cases of acute brain injury?
At our institution, our hemoglobin goal has always been 7 except for TBI patients, in which the goal has been 8.5. The TBI goal was a bit arbitrary and really just split the difference between 7 and 10 given some of the contradictory data. Given the new HEMOTION and TRAIN trials, we are revisiting o...
What workup do you recommend for otherwise healthy migraine patients that develop dizziness with episodes?
The workup should exclude other potential causes of vertigo including CNS disorders, and Meniere's disease, with neurology examination, MRI brain, videonystagmography, or electronystagmography. An article also evaluated vestibular migraine versus migraine without vertigo and found in several studies...