Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
How do you adjust the loading and maintenance doses for Keppra when treating status epilepticus in patients with ESRD, patients on HD, or patients on CVVH?
Ideally, if you have a patient with status epilepticus and known ESRD, then Keppra may not be an ideal first option. You should be reaching for your other status anti-seizure meds that aren’t exclusively renally excreted and are readily available in most hospitals; Depakote (40 mg/kg loading dose) o...
How do you counsel patients who experience diarrhea from mycophenolate mofetil (Cellcept)?
I have them stop the drug, and when their bowels are back to normal (usually just a couple of days), I resume with 1 tablet bid of mycophenolate mofetil (MMF, CellCept), then a few days later go up to 1 tab tid, a few days later 2 tabs bid... etc. I instruct them to go down to the most recent dose ...
Is there benefit of early initiation of antiplatelet therapy or DVT prophylaxis in patients who present with large MCA infarcts and are being considered for hemicraniectomy?
Both aspirin and DVT prophylaxis can be started early in patients on hemicraniectomy watch. There is data on increased risk of stroke recurrence in the first 7 days post-stroke and benefits or early initiation of aspirin (even in afib) and decreasing vascular events, especially in the first few week...
Do you recommend thiamine for patients presenting with acute symptoms of TGA?
Thiamine might be considered, especially if the patient has features of Wernicke-Korsakoff syndrome. However, if the patient has TGA, no drug treatment is needed since the amnesia resolves on its own.
What adjustments do you make to a hemodialysis prescription for a patient with a recent stroke?
There are multiple considerations in the setting of a CVA in a patient requiring hemodialysis. One is addressing potentially high intracerebral pressure (ICP). A slow reduction in BUN to avoid osmotic-related brain cell swelling and an associated rise in ICP may be addressed in a variety of ways. Lo...
What blood pressure targets do you enforce in the first 24-48 hours in a patient who develops an intracranial hemorrhage after mechanical thrombectomy?
Typically post-thrombectomy you encounter hemorrhagic transformation of an ischemic infarct. In this setting, I adjust the SBP goal to the classification of hemorrhagic transformation (HI-1, HI-2, PH-1 or PH-2). HI-1: No specific parameter; SBP goal adjusted according to TICI score. HI-2: SBP 120-...
How do you discontinue ketogenic diets previously used as a treatment for epilepsy?
The caveat in my answer is that I use ketogenic diets (mostly MAD) in adults with medically refractory epilepsy. We typically advise patients to discontinue gradually by adding back ~5 gm carbs/week until they are eating more "normally." Sometimes these patients never go back to their previous Stand...
What criteria are used to choose a specific dose of aspirin in ischemic stroke?
In my training and current practice, most stroke specialists have adjusted from the standard 81 mg aspirin dose (one-size-fits-all) to weight-based dosing. A meta-analysis of RCTs (Rothwell et al., PMID 30017552) suggests that low-dose aspirin may not suffice for stroke prophylaxis for patients who ...
When starting a patient with MS on a DMT, how frequently should MRIs be ordered to assess whether the treatment is effective?
I typically obtain an MRI brain around 6 months after initiation of a new DMT and then monitor MRIs yearly thereafter, unless new clinical symptoms develop.
Does IVIG or subcutaneous Ig interfere with monoclonal antibody therapy (i.e. dupilumab, infliximab, rituximab, etc)?
I definitely agree with Dr. @Dr. First Last concerns. For what it’s worth, I use a lot of IVIG in combination with monoclonal medications in my myositis clinic, and have anecdotally noted multiple instances in which I feel that the efficacy of one of those monoclonals seems to have been worse when t...