Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
When do you consider starting an anticholinergic in patients with tremor-predominant Parkinson's disease?
Generally, you want to avoid anticholinergics if possible, given the cognitive side effects but they are worth considering in those who have very refractory tremor that does not respond to dopaminergic therapy or amantadine.
How do you treat behavioral disturbances in patients with dementia with Lewy bodies?
The best medication for behavioral symptoms and Lewy body disease is a cholinesterase inhibitor. It reduces hallucinations and dream-like delirium. When more is needed, a small dose of quetiapine at night may be helpful. SSRIs reduce anxiety and can reduce aggression.
Do you recommend endovascular therapy in patients with isolated posterior cerebral artery stroke?
There is limited data on EVT for PCA occlusions. The two studies I am familiar with are the TOPMOST study and the PLATO study, both of which are retrospective. The data from these studies suggest that EVT may improve recovery, including visual outcomes, compared to medical management. However, these...
Should one perform a subsequent screening CTA or MRA head for mycotic aneurysm after cardio-embolic strokes in a setting of endocarditis with initial unremarkable CTA or MRA head/neck?
If the initial CTA is unremarkable and there is no intracranial hemorrhage, I do not routinely obtain follow-up imaging. In my practice, CTA is preferred over MRA due to the lower sensitivity of non-contrast/TOF imaging in detecting small mycotic aneurysms. As mentioned above, CTA may also miss s...
How do you decide on initial and sequential anti-CD20 therapy for patients with multiple sclerosis given the availability of rituximab, ocrelizumab, ublituximab, and ofatumumab?
In my practice, I generally discuss the B cell depleter drug class with patients, as these drugs have similar clinical profiles. I do not have a particular preference for sequencing one anti-CD20 drug over another. Treatment decisions are primarily driven by practical differences for patients, such ...
How do you approach long-term blood pressure parameters in ischemic stroke patients with severe symptomatic intracranial stenosis?
Every patient is unique and I just try to be as low and slow as possible. 4-6 weeks seems to be where most people do well with others tolerating more (I'm able to get them to under 140 or even 120 during their hospitalization over a few days). In the acute setting, I've found it helpful to make sure...
In patients with suspected RCVS, is there a role for preventative CCB if headache has resolved/now asymptomatic?
A number of these patients experience a dull, lingering headache, and I typically maintain them on verapamil, with or without magnesium, until their headache subsides. Afterward, I gradually taper off the medication over 7-10 days. I don't use it as a preventative measure as long as the patient is s...
Do you use alcohol to trigger seizures in patients you suspect to have JME to confirm diagnosis?
In the EMU, I use ETOH as a seizure trigger, if the patient tells me drinking alcohol makes them have a seizure or they have one the next day. I do this regardless of their epilepsy syndrome, not specifically for JME.
How would you manage adjuvant endocrine therapy for a postmenopausal patient with early stage HR+ breast CA who develops an ischemic CVA on an AI?
This is a vexing problem that I myself have had to deal with. My patient developed a TIA on aromatase inhibitor (AI). Work up was negative for predisposing risk factors. The choice was easy in this case. This woman was told by her family friend, who was a doctor, that AIs cause stroke and she refuse...
When can you get a false negative result from RT-QuIC testing?
The current sensitivity of CSF RT-QuIC is thought to be 92%, and the specificity is 100%. The interpretation of the RT-QuIC is affected by the presence of raised CSF red and white cells and elevated total protein concentrations. In VPSPr (Variably Protease-Sensitive Prionopathy), CSF RT-QuIC is posi...