Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
How do you manage a glioblastoma of the brainstem/upper cervical spinal cord?
It used to be that we didn’t get biopsies in this location, and we treated suspected astrocytic tumors in the brainstem/upper spinal cord to 54 Gy in 30 fractions without tissue. The outcome was never good. But now we generally have at least a stereotactic biopsy. The outcome is still not good of co...
Would you recommend dual antiplatelet therapy or anticoagulation for a patient previously on aspirin who has a breakthrough stroke with history of CADASIL?
CADASIL is a genetic condition with a presumed mechanism of vascular injury to be disruption of the blood-brain barrier and non-atherosclerotic angiopathy. Thus, it makes sense that no anti-thrombotic has been show to reduce stroke risk. It's expert consensus to do daily aspirin, but this is more to...
What is the optimal antithrombotic management, if at all, in patients with incidentally identified findings of multiple silent embolic appearing cerebral infarcts?
It is important to confirm the pattern is embolic. If unsure, input from a specialized physician (such as vascular neurology or neuro-radiology, if available) can aid in confirming the diagnosis. Various white matter findings may mimic an embolic pattern, and distinguishing between unilateral...
What criteria do you use to decide the duration of IV steroids in patients with optic neuritis?
This question has long gone unanswered because it is complicated. Short optic nerve segment enhancement (MS):In this situation, I do not routinely recommend steroid treatment. For the optic neuritis of multiple sclerosis, the Optic Neuritis Treatment Trial (Beck and Gal, PMID 18625951) clearly showe...
How do you decide when to use andexanet (ANDEXXA) for intracranial hemorrhage associated with factor Xa inhibitors?
The ANNEXA-I trial presents a mixed perspective. The data demonstrated that Andexanet is superior to standard care in reducing hematoma expansion for intracerebral hemorrhage associated with factor Xa inhibitors. This conclusion is based on an imaging-based primary endpoint, supported by previous st...
How do you manage Raynaud's symptoms that develop in patient on CGRP inhibitors?
Research and practice combined, I have worked with the CGRP-receptor antagonists or gepants and CGRP-antibodies for over 20 years. I have not seen or heard of Raynaud's symptoms as a side effect of those medications, which, across the board, are very well tolerated. Hence, I would like to learn more...
When do you consider discontinuation of treatment in pediatric patients who have responded well to preventive migraine medications?
This is an excellent question and not necessarily straightforward to answer, as there are no current definitive guidelines to determine optimal duration of successful migraine preventive treatment and the best method of preventive medication discontinuation.If you look at the most recent pediatric p...
What is your approach to a pediatric patient presenting with a new daily persistent headache?
My approach is to screen for medication overuse/rebound, lifestyle, and “headache hygiene” maximization and always examine their neck for cervicogenic issues. The neck exam is particularly important for students who often have poor studying posture and neck flexor muscle weakness. They often report ...
How do you counsel migraine patients interested in implanted neurostimulation devices for migraine?
I do not routinely recommend these procedures. Specifically to my knowledge, there are no published studies that have looked at the efficacy or safety of Reed or Omega procedures. I counsel patients that there have never been any studies with these procedures so we do not know the efficacy or safety...
When should one consider obtaining a cardiac MRI in ischemic stroke patients?
This is a terrific question. Cardiac MRI is increasingly utilized in the diagnostic evaluation of ischemic stroke and can uncover clinically covert cardiovascular disease. The clinical utility in ischemic stroke is most in patients with concern for LV thrombus (low EF or recent anterior ST elevation...