Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
What is your approach to tapering anesthetic drips for refractory status epilepticus after achieving burst suppression?
Ensure adequate oral/IV ASMs are on board, targeting the receptors appropriately based on the type of status- generalized, focal (e.g., GABA, Na channel, glutamate, etc.). These would include the first, second, and third line as per status protocols. Check levels to ensure adequacy. At least 24 hou...
How often do you perform surveillance brain MRIs in patients with MS on highly effective DMTs?
The so-called guidelines to do MRIs on an annual basis pre-dated the introduction of anti-CD20 drugs. After these drugs were introduced in 2017, the need for MRIs has fallen off a cliff (as it ought to). With 95% or better suppression of new disease activity (inflammatory component and not the iron...
How do you counsel women on anti-CD20 therapy for MS who are planning for pregnancy?
I counsel patients that anti-CD20 therapies are relatively safe in patients with MS who are considering pregnancy. Monoclonal antibodies are not transported across the placenta until the 2nd trimester, and with a half-life of 20-30 days (depending on which anti-CD 20 is used), the amount that crosse...
When would you consider checking JC virus prior to initiating biologic therapy?
JC is a ubiquitous virus with sero-prevalence in the adult population of 60-70% in most studies. The concern is that in those who harbor latent JC are vulnerable to reactivation and ultimately the development of Progressive Multifocal Leukoencephalopathy (PML). The drug natalizumab used to treat MS ...
How do you monitor patients with transverse myelitis after a negative initial work up?
Both clinical and radiological evaluations, at least annually.
How do stroke-risk considerations affect your use of atypical antipsychotics for patients with dementia?
Antipsychotics carry a number of risks, including a warning of sudden death in elderly demented patients. If nothing else works for a behavioral problem, you have to use an antipsychotic. Also, for frank paranoia, which is not only causing distress to parents but also to the environment, treatment w...
What is your approach to management of patients with cerebral edema in the setting of hypoxic-ischemic injury?
Depends on the clinical status of the patient. Obviously, if the neurological exam is modestly good, i.e., purposeful movement or better, then follow the exam for signs of worsening edema. If the exam is not so good (flexion or less), we tend to use continuous EEG and serial imaging to monitor. As f...
Is there a role for routine EEG in the diagnostic evaluation of critically ill comatose patients or should these patients always receive long-term continuous video EEG monitoring?
We looked into this and found that in a non-comatose patient with no history of clinical seizures, the lack of epileptiform abnormalities on initial 30 minutes of EEG recording is associated with <5% risk for electrographic seizures suggesting that a routine EEG can be sufficient in that group (Stru...
Do you think repeated routine EEG is sufficient for cardiac arrest patients or should we be always using continuous EEG?
For most patients with cardiac arrest, cEEG has not been shown to offer improved outcomes over serial routine EEGs. In cases where there are EEG patterns that suggest seizures may be occurring, such as rhythmic or periodic patterns other than low-frequency GPDs, or repetitive evolving patterns, we t...
Do you routinely use pupillometry for serial neurologic examinations in the ICU, especially for patients at risk for transtentorial herniation?
We frequently do pupillometry assessments on patients at high risk of ICP crisis. It gets rid of observer subjectivity as it is often an issue in ICUs. We have a protocol with the following indications for q1h pupillary assessments. It is not based on particular guidelines but serves as a good marke...