Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
What is your approach to managing patients who initially present with symptomatic intracranial large vessel occlusion but subsequently experience resolution of symptoms or become non-disabling before any intervention?
If a large vessel occlusion (LVO), such as ICA-terminus, M1, or Basilar, is present, I would treat it even if there has been a significant improvement in symptoms. As mentioned in the prior post, an occlusion in one of these areas will likely exhaust collateral reserves and become symptomatic again....
What factors would influence your decision to use or avoid heparin bridging in patients with mechanical heart valves resuming anticoagulation after intracerebral hemorrhage?
The main conclusion from the publication by Sakusic et al., PMID 39102615 was that withholding anticoagulation for the first seven days after ICH is safe in patients with mechanical heart valves and bridging with intravenous heparin to coumadin upon resumption of anticoagulation should be avoided. T...
How do you adjust dosing of rozanolixizumb for MG patients who deteriorate before the minimum re-dosing period?
First, I make sure the dose is appropriate for weight. If it is, I am comfortable with shortening the dosing interval. Consider checking the IgG level before doing so to make sure the patient does not have hypogammaglobulinemia.
What do you consider when deciding to use a high-efficacy DMT as an initial treatment in multiple sclerosis?
I'd say the question is when would you "not" consider a high-efficacy DMT in MS. High-efficacy therapies (specifically, B-cell depleting therapies) have a good risk profile and are exceptionally effective in treating relapsing MS. Evidence would suggest that you get the largest "bang for your buck" ...
Do you typically consider Botox for patients with TMJ?
I do a fair number of Botox injections for TMJ (only small doses (5 to 7.5 units) when using Botox for migraines. Patients do report that it is helpful.
What is your treatment approach to neurological Sjogrens disease with both peripheral neuropathy and transverse myelitis?
For transverse myelitis associated with Sjogren syndrome, many (if not the majority) test positive also for anti-AQP4 antibody. This is different from other autoimmune disorders such as Behcet in which the patients usually are seronegative. Therefore, I usually treat with rituximab for myelitis. As ...
How would you evaluate and manage someone with leukoaraiosis and an acute ischemic stroke?
Many patients with acute ischemic stroke have some degree of leukoaraiosis, and unless it is very severe, it would not alter my decision to give thrombolytic or endovascular thrombectomy treatment. If you have a prior MRI available, it would be nice to see a gradient echo to see if there is cerebral...
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...