Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
When do you consider starting an antiplatelet in a patient with stoke due to septic emboli?
Hello, This is a very complex question and not a lot of great data are available on the matter. Most experts, myself included, would consider starting a baby aspirin to be relatively safe in an individual with a stroke from suspected septic emboli. This viewpoint may need to be adjusted depending on...
Do you avoid triptans in patients on SSRIs due to the potential risk of serotonin syndrome?
I feel very comfortable using triptans with SSRIs/SNRIs. In 2010, the American Headache Society released a position statement on this very issue:Evans et al., PMID 20618823Their position is that the available evidence does NOT support the claim that triptans should not be used with SSRIs or SNRIs.A ...
When do you consider switching a generic formulation of an antiseizure medication to the brand formulation?
This rarely, if ever, happens. The easiest way to think of the difference is not to think of brand versus generic. Think of brand as the first generic (G1), and all the rest are later generics (G1, G2, etc.). Since the active ingredient is identical amongst all formulations, the only difference is w...
When can EMG be deferred in cases of distal sensory polyneuropathy?
Sensory conduction studies provide information as to whether there is a large fiber disorder of the dorsal root ganglion or the nerve fibers distal to the DRG. The simple answer to the question is that you can defer this study when you don't want or need that information. If the symptoms are very di...
Do you find onabotulinumtoxinA injections effective for the treatment of trigeminal neuralgia?
I use botulinum toxin (off-label) for two face pain conditions, one rare, i.e., trigeminal neuralgia, and one common, i.e., temporomandibular disorder (TMD). For trigeminal neuralgia, I use a tiny needle to inject very small amounts of the toxin into the affected area of the skin and, if involved in...
How would you empirically manage a large sellar/suprasellar mass with encasement of the right cavernous and terminal internal carotid arteries?
Knowing the histology of the mass would really help in creating more accurate treatment recommendations. A biopsy of a sellar mass is usually accomplished by an endonasal-endoscopic transsphenoidal approach utilizing the expertise of an ENT surgeon and a skull-base neurosurgeon. However, in this cas...
How do you explain the use of an AI scribe to patients the first time it is used in their care?
I use an AI scribe in my outpatient clinic, and around 90–95% of my patients agree to it. I obtain consent at the start of each visit and make it clear that it's completely optional—that they can say no at the start or change their mind at any point in the visit, with no impact on their care. I also...
How do concerning TCD trends affect your management of a clinically stable patient with aneurysmal subarachnoid hemorrhage?
I have been relying on TCD to manage clinically stable SAH patients for years. There are several management interventions that I might make in a patient who is showing significant vasospasm on TCD but otherwise seems clinically stable. These interventions include keeping a patient in ICU for frequen...
Would you consider endovascular thrombectomy for acute stroke patients with large vessel occlusion (non-large core) but with poor functional baseline with mRS 3-4?
The Modified Rankin Scale (mRS) is a widely used tool for assessing functional status, ranging from 0 (no symptoms) to 6 (death). It provides a standardized framework for EVT decision-making based on a patient’s functional status and serves as a key criterion in EVT-related RCTs. While invaluable in...
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...