Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
Are there instances where tracheostomy alone without mechanical ventilation can be sufficient to manage neuromuscular respiratory failure?
This is a very rare circumstance in our assisted ventilation clinic. This situation usually arises because a patient underwent tracheostomy during an acute illness while they were requiring invasive ventilatory support, and were able to wean from the ventilator but had dyspnea or hypercarbia while t...
Do you always initiate hypercoagulable work up in a patient with recurrent stroke?
As always, this is a more complex problem than it appears. A history of both prior other thrombosis and family history of thrombosis is essential. Are there good reasons for the stroke and/or has it been worked out in past including carotid disease, atrial fibrillation, underlying malignancy, valvul...
How will you treat a young man with recurrent cryptogenic strokes with no identifiable cause, with MTHFR A1298C homozygous mutation and normal homocysteine level?
The genetic variant you report seems to be a SNP that, while it has been reported to be statistically associated with various diseases in GWAS studies, is not pathogenic. SNPs that are significant in GWAS studies have very small effect sizes that can be measured when considered in thousands of peopl...
What is your preferred imaging modality for determining infarct core when evaluating acute stroke cases?
I agree with prior responses. In most cases, a combination of CT & CTA with ASPECTS scoring & collateral assessment is sufficient to determine infarct core burden. I don't routinely rely on MRI for EVT or thrombolysis assessment due to logistical and/or time constraints. CTP can be hit or miss, but ...
How do you decide between the gene silencing drugs for familial amyloidosis with polyneuropathy?
The data to answer this question are very limited to non-existent, exactly because there have been no studies with a head-to-head comparison of the efficacy of different agents. Ultimately, it's a shared decision between the patient and the physician, which should take into account factors such as p...
How do you use optical coherence tomography in the diagnosis and management of patients with multiple sclerosis and related diseases?
Personally, I do not routinely obtain OCTs, but I always find them helpful. Most of my patients who have had optic neuritis tend to have them yearly under the care of their ophthalmologist and I review them for stability. One could argue that these should be done annually along with MRIs for all pat...
Which methods of tracking response to treatment in myasthenia gravis do you find most helpful?
To me, it is still a combination of history and clinical examination supplemented by MG-specific scales. Thus, it is the global impression of how a patient is doing rather than any one metric. Amongst the MG-specific scales, I use the MG activities of daily living (MG-ADL) and MG Composite (MGC) sco...
What is the stepwise investigation of patients suspected of inflammatory myopathy?
I have published an algorithmic approach to suspected inflammatory myopathy in Continuum Lifelong Learning in Neurology from AAN (Manousakis, PMID 36537973). Unfortunately, the article is not free, and I can't attach the algorithm in this response, because it's a PPT file. Happy to provide it upon r...
In what clinical situation would you consider using benzodiazepines in patients with dementia?
When a dementia patient is in the moderately severe or severe stages of the disease and has palliative goals of care, they would be eligible for palliative care FAST 6 or hospice FAST 7. Caregivers are no longer trying to maximize independence. The patient has 24/7 supervision. The caregiver is at r...
Would you recommend PFO closure in patients >60 years old with presumed paradoxical embolism as their mechanism of stroke?
Technically, based on the available clinical trial evidence, PFO closure is not indicated for patients over age 60 or for patients whose stroke was > 6 months ago. However, we frequently need to extrapolate from clinical trial populations to manage the patients we see in practice. Also, presumably, ...