Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
How do you counsel patients with GCA on the benefits of steroids who have already experienced vision loss?
I first tell the patient they are at considerable risk for further visual loss in the same eye or the other eye over the next 1-2 weeks. I also let them know that, even though their risk of visual loss has been reduced, their best option for preventing further visual loss is immediately starting hig...
How do you implement antipsychotics in the management of agitation in Alzheimer’s patients?
The answer to how you implement antipsychotic medication in the management of agitation in a patient with Alzheimer's dementia involves several steps, outlined here: Ensure the agitation is not related to an acute medical condition and/or delirium. In this case, it is important to treat the underlyi...
How do you decide on head-of-bed positioning after mechanical thrombectomy for acute stroke?
First, there is some evidence that HOB positioning is related to deterioration/improvement before endovascular thrombectomy (EVT) from the ZODIAC trial. Second, safety comes first. Follow your ABCs. If the airway is ok, the patient does not develop orthopnea with a supine position, and the BP is ok ...
When should CT-guided blood patch be considered for patients with spontaneous intracranial hypotension headache?
First of all, I think the epidural blood patch for Spontaneous Intracranial Hypotension (SIH) should always be CT-guided and not XR-guided or "blind", whenever possible. And, while headache is present almost always, and the vast majority of the time the headache is orthostatic, the SIH syndrome is n...
How might treatments beyond immunomodulating therapies be important for MS?
Current disease-modifying therapies are very effective at controlling inflammatory activity, but they incompletely address other aspects of the underlying pathophysiology of multiple sclerosis (MS), including progression, neurodegeneration, and CNS repair. Future approaches may therefore complement ...
How might CSF protein or other biomarkers be used to help differentiate relapsing vs progressive forms of MS at disease onset?
CSF is an unlikely source for biomarker measurement, except at baseline or at diagnosis, or exceptionally if there is a dramatic change suggesting a disease condition other than MS. Serum biomarkers are more likely a more feasible source for measurement, but to date, there is really no set of biomar...
Do you foresee the blood-brain barrier as a specific target for future MS therapies?
The blood-brain barrier (BBB) plays a crucial role in the pathogenesis of MS. The importance of the BBB has been highlighted by the effect of natalizumab on MS disease activity; the therapy consists of monoclonal antibodies against alpha-4 integrin that inhibit lymphocyte trafficking across the BBB ...
What biomarkers have you found useful to track in patients with MS?
There are several clinically useful biomarkers in body fluids. For diagnostic purposes, I suggest analyzing oligoclonal IgG bands and the kappa free light chain (KFLC) index; if differential diagnoses such as neuromyelitis optica spectrum disorder (NMOSD) or myelin oligodendrocyte glycoprotein-assoc...
What pharmacological management do you consider for self-injurious behavior in patients with autism spectrum disorder?
This is a great question but requires a nuanced answer. It all depends. In short, what I think the clinician needs to know is whether the patient with ASD and self-injury has a treatable condition that is driving self-injury. Perhaps the most critical is whether the patient has a medical problem tha...
How do you approach questions regarding clearance for elective surgery in patients with epilepsy?
I write a letter that gives a sense of how well-controlled the epilepsy is, emphasizes that ASMs should be taken on the morning of surgery as usual, and if hospital admission is needed, that they should be given on schedule during the admission as well. I then give some general tips on seizure first...