Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
Do you recommend thiamine for patients presenting with acute symptoms of TGA?
Thiamine might be considered, especially if the patient has features of Wernicke-Korsakoff syndrome. However, if the patient has TGA, no drug treatment is needed since the amnesia resolves on its own.
What adjustments do you make to a hemodialysis prescription for a patient with a recent stroke?
There are multiple considerations in the setting of a CVA in a patient requiring hemodialysis. One is addressing potentially high intracerebral pressure (ICP). A slow reduction in BUN to avoid osmotic-related brain cell swelling and an associated rise in ICP may be addressed in a variety of ways. Lo...
What blood pressure targets do you enforce in the first 24-48 hours in a patient who develops an intracranial hemorrhage after mechanical thrombectomy?
Typically post-thrombectomy you encounter hemorrhagic transformation of an ischemic infarct. In this setting, I adjust the SBP goal to the classification of hemorrhagic transformation (HI-1, HI-2, PH-1 or PH-2). HI-1: No specific parameter; SBP goal adjusted according to TICI score. HI-2: SBP 120-...
How do you discontinue ketogenic diets previously used as a treatment for epilepsy?
The caveat in my answer is that I use ketogenic diets (mostly MAD) in adults with medically refractory epilepsy. We typically advise patients to discontinue gradually by adding back ~5 gm carbs/week until they are eating more "normally." Sometimes these patients never go back to their previous Stand...
What criteria are used to choose a specific dose of aspirin in ischemic stroke?
In my training and current practice, most stroke specialists have adjusted from the standard 81 mg aspirin dose (one-size-fits-all) to weight-based dosing. A meta-analysis of RCTs (Rothwell et al., PMID 30017552) suggests that low-dose aspirin may not suffice for stroke prophylaxis for patients who ...
How do you approach managing nausea and GI side effects when initiating methotrexate?
There are several strategies to minimize nausea and gastrointestinal symptoms with the use of methotrexate. The medication can be taken with food, just not with caffeine. The dose can be split throughout the day it is taken such as half the dose in the morning and the other half in the evening. The ...
When starting a patient with MS on a DMT, how frequently should MRIs be ordered to assess whether the treatment is effective?
I typically obtain an MRI brain around 6 months after initiation of a new DMT and then monitor MRIs yearly thereafter, unless new clinical symptoms develop.
Does IVIG or subcutaneous Ig interfere with monoclonal antibody therapy (i.e. dupilumab, infliximab, rituximab, etc)?
I definitely agree with Dr. @Dr. First Last concerns. For what it’s worth, I use a lot of IVIG in combination with monoclonal medications in my myositis clinic, and have anecdotally noted multiple instances in which I feel that the efficacy of one of those monoclonals seems to have been worse when t...
What workup do you consider for a developmentally typical child with multiple large café au lait macules but no other signs of neurofibromatosis?
The likelihood that this is NF1 depends somewhat in part on the age of the child in question. In infants and toddlers, cafe-au-lait macules are usually the first and only clinical sign of NF1. Most children with NF1 will develop skin fold freckling in early childhood, and the majority (probably 60-7...
Would you consider using DOACs as a bridge to warfarin instead of heparin or LMWH?
I would feel very comfortable bridging with apixaban, given its relatively short half-life and fairly quick absorption. I think it is very similar to bridging with Lovenox. More importantly, it usually takes at least 24 hours until heparin IV gets to therapeutic levels - it is often too high or too ...