Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
When do you consider prescribing medications such as Aricept in patients with Down Syndrome who start having memory issues?
By age 60, there's a 60% chance that most people with Down syndrome will begin developing symptoms or signs of Alzheimer's disease. However, it’s important to also keep in mind that there are many other reasons why a person with Down syndrome may show signs of decline and it may not be Alzheimer's d...
When would you suspect metabolic myopathy and what is your approach to initial workup?
Great question and really important to rheumatology practice. As always, a history and physical exam is the best initial diagnostic tool. It’s a little bit difficult because of the sheer number and heterogeneity of non-autoimmune myopathies that clinicians may encounter, but a few general principles...
Would you consider skipping intravenous thrombolysis in patients with tandem occlusions who qualify for endovascular thrombectomy?
In cases of tandem occlusions eligible for EVT, I typically administer thrombolytics if the patient is within the window. A common scenario involves an intracranial occlusion with an ipsilateral extracranial atherosclerotic lesion. However, I may consider withholding thrombolytics if there is an int...
Do you send CSF or serum ACE levels in the workup of neurosarcoidosis?
Unfortunately, serum and/or CSF ACE levels are just not sensitive or specific enough to guide the diagnosis or treatment of sarcoidosis, particularly neurosarcoid. Rather, imaging characteristics, specific organ system involvement, and biopsy results are much more useful in my practice.Bradshaw et a...
Is intracranial hemorrhage a contraindication for valproic acid?
The short answer is no. Valproic Acid (VPA) can cause bone marrow suppression leading to thrombocytopenia, as well has hypofibrinogenemia. Through these mechanisms, and possibly others, platelet aggregation is reduced, which may place one at risk for hemorrhagic expansion, but in my experience, and ...
Can you use leflunomide and rituximab in a patient with both multiple sclerosis and rheumatoid arthritis?
It is rare for a patient to have both diseases, but immunosuppressive therapy can be used for the management of both conditions. A study published in 2021 investigated the use of a combination of rituximab and leflunomide in rheumatoid arthritis (Behrens et al., PMID 33738492). Rituximab has previou...
When do you consider lumbar spinal fluid drainage after acute spinal cord injury?
Extremely rarely indicated.
Do you take any special precautions when treating cervical spine metastases?
For each spine met case, it's important to determine whether it's a surgical or radiotherapy case. Spinal instability neoplastic score (SINS) and Bilsky grade (epidural cord compression) are two important parameters to consider. If SINS is 6 or below and if Bilsky grade is 1c or below, surgical inte...
Do you refer all patients with new findings of CNS or epidural mets/tumor to ED for evaluation or are there some that can be managed completely outpatient?
Interesting question: Sending patients to the ED for non-emergent conditions is not advised. Our EDs around the country are struggling for a variety of reasons (e.g., they are often holding patients awaiting placement or admission), thus our society will benefit by us avoiding sending patients to t...
Would you consider DHE for patients with status migrainous with elevated blood pressure at the time of presentation?
No, I would not. DHE is a very potent and non-selective arterial vasoconstrictor and would potentially further increase elevated blood pressure. When a patient who presents with a headache is found to have elevated blood pressure, it should be assumed that the elevated blood pressure is the cause of...