Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
Would you consider IV thrombolytics in patients with acute ischemic stroke, with or without a large vessel occlusion, if they have a history of von Willebrand disease (VWD), regardless of its type?
I would still consider it unless the INR >1.7 or they are on anticoagulation for some clinical reason.
Do you recommend surveillance lumbar punctures for patients with Mollaret's meningitis after diagnosis or in between clinical episodes?
No. My focus with these patients is to establish the diagnosis, which is often difficult, with false-negative CSF PCR tests, and then do everything I can to prevent and alleviate the attacks. I see no role for surveillance LPs because either the patient is better clinically or they are not, and CSF ...
How do you approach the decision of when to perform left heart catheterization in a patient with an NSTEMI who recently had an acute ischemic stroke?
This is a complicated question. Most acute CVA patients have non-MI troponin elevations, and I generally treat them medically. If there is a true NSTEMI associated with CVA, it requires a thoughtful approach. I generally divide my NSTEMI patients into high-risk and non-high-risk. I will perform a di...
Which factors help you choose between intermittent phenobarbital dosing versus continuous pentobarbital infusion for pharmacological burst suppression in refractory status epilepticus?
I am not aware of any guidelines or data that recommend the use of phenobarbital over pentobarbital for burst suppression in refractory status epilepticus. In fact, guidelines tend to favor pentobarbital in patients who have failed propofol and midazolam. Phenobarbital can certainly be used for seiz...
How do you identify patients with false positive AcHR antibodies?
First of all, of course, one should look for the clinical correlation. Even a weakly positive AchR binding antibody is likely to be "real" (true positive) if accompanied by unequivocal clinical signs of MG, e.g., fatigable ptosis with positive ice pack test, or fatigable bulbar/limb weakness. Ideall...
Do you start an anti-seizure medication in a patient with a first unprovoked nocturnal seizure with a normal exam, imaging, and EEG; or wait until the second seizure?
Not with the first seizure unless history suggests otherwise. Also, what is the age of the patient? For example, are benign epilepsy syndromes like rolandic epilepsy on your differential? If age does not fit, monitor the patient clinically. Repeat EEG after a few months with sleep recorded.
How do you approach pain management in patients with idiopathic polyneuropathy?
There are a few different guidelines/recommendations depending on which professional society you search. However, I tend to adhere most closely to the table cited below, with an approach that looks something like: First line: Gabapentin 300mg TID titrating up to 1000mg TID Pregabalin 75mg BID titra...
Are there instances where tracheostomy alone without mechanical ventilation can be sufficient to manage neuromuscular respiratory failure?
This is a very rare circumstance in our assisted ventilation clinic. This situation usually arises because a patient underwent tracheostomy during an acute illness while they were requiring invasive ventilatory support, and were able to wean from the ventilator but had dyspnea or hypercarbia while t...
Do you always initiate hypercoagulable work up in a patient with recurrent stroke?
As always, this is a more complex problem than it appears. A history of both prior other thrombosis and family history of thrombosis is essential. Are there good reasons for the stroke and/or has it been worked out in past including carotid disease, atrial fibrillation, underlying malignancy, valvul...
How will you treat a young man with recurrent cryptogenic strokes with no identifiable cause, with MTHFR A1298C homozygous mutation and normal homocysteine level?
The genetic variant you report seems to be a SNP that, while it has been reported to be statistically associated with various diseases in GWAS studies, is not pathogenic. SNPs that are significant in GWAS studies have very small effect sizes that can be measured when considered in thousands of peopl...