Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
When do you consider using general anesthesia for endovascular thrombectomy?
I perform all of my thrombectomy cases under general anesthesia. There is better hemodynamic control, no patient movement to manage, which increases procedural efficiency as a result. In moderate sedation cases, patients can feel aspiration and stent retriever passes through the vessel, which causes...
What maximum core volume or core-to-penumbra ratio do you use for eligibility for extended window thrombolysis beyond 4.5 hours?
For the CTP most trials used core less than 70 ml, mismatch volume 10 ml or greater, mismatch ratio > 1.2. Most extended window thrombolysis trials used these parameters.
Do you wait to treat small asymptomatic brain metastases until they reach a certain size?
I typically treat all lesions on MRI that are found to be concerning for brain metastases. This is after a discussion with our neuroradiologist colleagues. If there is uncertainty that a small lesion may not be a brain metastasis, then I will elect to follow with a surveillance MRI and treat in the ...
What are your vaccine recommendations while patients are on biologics?
Live vaccines are best completed at least a month before initiation of biologics when these are appropriate (e.g., MMR, chickenpox, yellow fever). The data on non-live vaccines is limited. I personally think that some degree of protection is better than none. I will not interrupt biological therapy ...
How do you approach short term antithrombotic regimen, antiplatelets or anticoagulation, after Watchman device placement in ischemic stroke patients with atrial fibrillation and cerebral amyloid angiopathy who are at high risk for intracranial hemorrhage?
This is a good question. Our group published a paper on a series of patients with CAA who underwent placement of Watchman devices for atrial fib (Schrag et al., PMID 32770310). We usually did not anticoagulate patients at all, and we saw only one very minor stroke. I think that it would also be reas...
Have you changed your practice in treating CRAO with IV thrombolysis?
The recent THEIA trial had a limited sample size to draw conclusions, even though there was a non-significant trend of improved visual acuity initially in the thrombolysis group. Even the TenCRAOS trial had a small sample size with recruitment challenges, where subtle small differences cannot be acc...
How do you taper dopamine agonists for RLS in patients experiencing augmentation?
Slowly. Abrupt withdrawal from agonists can cause mood dysregulation (dopamine agonist withdrawal syndrome) and in RLS patients, would likely exacerbate RLS symptoms.Adding gabapentin to the regimen prior to slow withdrawal of the agonist would probably help avoid worsening RLS symptoms during this ...
What is your strategy to help prevent paclitaxel-related neuropathy?
There are no proven strategies for prevention of CIPN and the use of these supplements is not recommended. Some supplements such as acetyl carnitine can actually worsen neuropathy outcomes and some supplements such as B12, vitamin C, and others may negatively interact with chemotherapy and worsen di...
What experience do you have with paralysis or myasthenia-like symptoms developing on temozolomide?
This is not an established toxicity of temozolomide and would warrant further investigation.
Do you ever consider steroid treatment for grade 1 ICANS without CRS?
We typically do not, but these patients receive neurology consultation and are very closely monitored.