Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
What monitoring do you routinely perform on lifelong EDS for epilepsy syndromes?
One of the complications inherent in using AEDs in anybody with epilepsy syndrome or neurotypical people with seizures is bone loss. It is especially important to look at their early loss of bone mass. I check for vitamin D levels even in very young patients. I might even do DEXA scans. I'm very pro...
How would you approach the treatment of erosive inflammatory arthritis (RA or SpA) in a patient with multiple sclerosis on ocrelizumab who has failed csDMARD therapy?
This is a challenging situation to confront, however, as more non- rheumatological illnesses are being managed with biologics, we will be facing this issue with greater frequency. Regarding multiple sclerosis (MS), one should be aware that the major metabolite of leflunomide, teriflunomide, is a bra...
When do you obtain head and neck vascular imaging in patients with traumatic brain injury?
When there are skull base fractures that could lead to a dissection, when there is penetrating or blunt neck injury, when it is unclear if the primary event was a brain hemorrhage with secondary TBI, or in the case of imaging that suggests a concomitant ischemic stroke. This is not an exhaustive lis...
Would you recommend a specific workup or change in management for patients with severe, persistent deficits from methotrexate leukoencephalopathy?
In my practice setting, I typically see this as delayed toxicity in adults that is not reversible. In the acute, and particularly pediatric settings, there may be some limited evidence for leucovorin, aminophylline, drugs that modulate NMDA neurotransmission, etc., but usually in adult patients, tre...
Is there utility for endovascular stenting of severe symptomatic vertebral artery stenosis?
This is a great question and one I remember asking during fellowship. There have been several randomized trials that touched on vertebral stenting (CAVATAS, SAMMPRIS, VISSIT, VAST), but VIST is the only one I recall that focused specifically on vertebral artery stenosis. The earlier trials had mixed...
At what timepoint do you do an EMG/NCS in patients with suspected GBS?
In general, nerve conduction studies are often normal early in the disease course. However, during the first week, one may find prolonged minimal F-wave latencies (or even absent responses). This would indicate some degree of involvement of proximal nerve trunks. For years, it has been widely accept...
How do pediatric functional neurologic disorders differ from adult disorders in their presentation and diagnosis?
In terms of presentation, PFND often manifests with an abrupt onset of symptoms, commonly including motor (e.g., limb weakness, gait disturbance) and sensory changes, as well as seizure-like episodes (psychogenic non-epileptic seizures) and pain. Children and adolescents may also present with headac...
Would you offer TPO-RAs to a steroid-refractory chronic ITP patient with history of stroke?
Yes, if needed, though with a bit of trepidation, and it probably wouldn't be my first choice. Second-line chronic ITP treatment can include TPO-RA, rituximab, or splenectomy, and no one treatment is clearly better than the others (Neunert et al., PMID 31794604). Both splenectomy and TPO-RAs have in...
What is your approach to patients with diffuse, patchy paresthesias affecting the head, face, lips, and/or tongue?
1.) Are the symptoms episodic (coming and going) or constant? If episodic, the likelihood of sinister neurological disease is very low. 2.) Do the hyperventilation test. If the patient has no paresthesias before the test and the symptoms are reliably reproduced by 8-10 deep breaths/min, diagnosis = ...
When do you use tirofiban for acute ischemic stroke?
Early tirofiban infusion after IV thrombolysis makes sense for acute strokes due to intracranial stenosis. As an endovascular specialist, I have often seen MCA or basilar occlusions reopen with IV thrombolysis but only to reocclude when there is an underlying severe atherosclerotic lesion. My approa...