Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
What do you do when headache appears clinically attributed to intracranial hypotension but imaging and opening pressure are normal or not obtainable?
Regarding the IHS classification and diagnostic criteria, it is important to remember the following: The initiative came from Glaxo Pharmaceuticals in order to make it possible for the company to pursue the development of sumatriptan for migraine abortion globally. The company also paid for the fir...
How do you decide on the timing of carotid stenting after thrombectomy for an intracranial large vessel occlusion with ipsilateral carotid stenosis?
There are ongoing randomized trials that are attempting to tackle this question. So, a data-driven status will be available soon. In the meantime, clinical considerations apply: Sometimes one has to stent to gain access to the intracranial circulation, perhaps due to a very tight extracranial carot...
What is your approach to bothersome dyskinesias in Parkinson disease patients?
This is an interesting recent article in which a meta-analysis of various anti-Parkinson medications and surgical interventions was looked at for their effect on controlling dyskinesias as compared to placebo. The meta-analysis showed that DBS of the GPI (globus pallidus interna) was more effective ...
Which patients will have earlier diagnosis of multiple sclerosis via the new 2024 McDonald Criteria?
I think the group that will most benefit from the new diagnostic criteria, in terms of earlier diagnosis, is those with a history of optic neuritis. This is because the new criteria expand "typical CNS topographies" from four to 5 to include the optic nerve. In addition, those who present with lesio...
Considering only cerebrovascular indications, are there circumstances in which you would use aspirin along with a DOAC in patients with atrial fibrillation and stroke?
I will use aspirin 81 mg and a DOAC together in patients who "fail" (I hate that term) the DOAC. The combination was used in patients in the original DOAC trials, so it is not unreasonable. Not my first choice, but can be done. It is worth noting that the evidence does not support doing this upfront...
How do you counsel patients interested in carotid endarterectomy for asymptomatic carotid disease as a means to reduce dementia risk?
This is a good question. I reviewed the paper by Vitali et al, PMID 40922111 and I would add that previous studies of patients with asymptomatic carotid stenosis have not found a reduction in dementia with the procedures. In this retrospective study, carotid endarterectomy but not carotid stenting r...
How do you decide when to add steroid-sparing immunotherapy for myasthenia gravis after starting prednisone and Mestinon?
My approach is generally to add a steroid-sparing agent if the patient experiences worsening of their symptoms during prednisone wean, such that they cannot tolerate a prednisone dose lower than 7.5 mg/day without functionally limiting symptoms. However, there are many patient-specific consideration...
How do you workup patients with neuropathy suspected to be secondary to sarcoid?
To answer this question, the attached paper with consensus criteria for the diagnosis of neurosarcoidosis, published in 2018, should be reviewed, Stern et al., PMID 30167654.Based on this paper, a diagnosis of probable or definite neurosarcoidosis requires unequivocal evidence of non-caseating granu...
How do you assess periprocedural risk for patients with incidental silent ischemic infarcts scheduled for elective surgeries, major or intravascular procedures?
If the infarct is definite, I would initiate some work-up to determine risk, at least a CTA head/neck, and an echocardiogram. If hypertensive lacune, BP control might be all that is needed. If a cryptogenic, cortical/subcortical infarction, the CTA and echo would be more important. A risk estimate o...
How do you decide if patients who have a multifocal demyelinating polyneuropathy would benefit from surgical treatment of carpal tunnel syndrome?
I would do median nerve ultrasound at the carpal tunnel and see if there is evidence of compression. If so, surgical release is a reasonable option.