Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
What is your preferred imaging modality for determining infarct core when evaluating acute stroke cases?
I agree with prior responses. In most cases, a combination of CT & CTA with ASPECTS scoring & collateral assessment is sufficient to determine infarct core burden. I don't routinely rely on MRI for EVT or thrombolysis assessment due to logistical and/or time constraints. CTP can be hit or miss, but ...
How do you decide between the gene silencing drugs for familial amyloidosis with polyneuropathy?
The data to answer this question are very limited to non-existent, exactly because there have been no studies with a head-to-head comparison of the efficacy of different agents. Ultimately, it's a shared decision between the patient and the physician, which should take into account factors such as p...
How do you use optical coherence tomography in the diagnosis and management of patients with multiple sclerosis and related diseases?
Personally, I do not routinely obtain OCTs, but I always find them helpful. Most of my patients who have had optic neuritis tend to have them yearly under the care of their ophthalmologist and I review them for stability. One could argue that these should be done annually along with MRIs for all pat...
Which methods of tracking response to treatment in myasthenia gravis do you find most helpful?
To me, it is still a combination of history and clinical examination supplemented by MG-specific scales. Thus, it is the global impression of how a patient is doing rather than any one metric. Amongst the MG-specific scales, I use the MG activities of daily living (MG-ADL) and MG Composite (MGC) sco...
What is the stepwise investigation of patients suspected of inflammatory myopathy?
I have published an algorithmic approach to suspected inflammatory myopathy in Continuum Lifelong Learning in Neurology from AAN (Manousakis, PMID 36537973). Unfortunately, the article is not free, and I can't attach the algorithm in this response, because it's a PPT file. Happy to provide it upon r...
In what clinical situation would you consider using benzodiazepines in patients with dementia?
I would avoid long-term benzodiazepines treatment if someone has full-blown dementia syndrome or frontal lobe syndrome due to the potential of paradoxical disinhibitions along with amnestic and ataxic side effects. However, I would consider clonazepam for RBD and related REM sleep issues in dementia...
Would you recommend PFO closure in patients >60 years old with presumed paradoxical embolism as their mechanism of stroke?
Technically, based on the available clinical trial evidence, PFO closure is not indicated for patients over age 60 or for patients whose stroke was > 6 months ago. However, we frequently need to extrapolate from clinical trial populations to manage the patients we see in practice. Also, presumably, ...
Have you found sphenopalatine blocks to be an effective treatment for headaches secondary to subarachnoid hemorrhage?
Anecdotally, yes, but we have only been doing this as part of a small research project at our institution. The literature is largely limited to case reports and there is at least one clinical trial (NCT07116408) looking specifically at this, scheduled to finish enrollment in 2026. There are commerci...
How long would you continue chronic transfusion therapy for adult sickle cell patients who have had a stroke?
Management of stroke in adults is not informed by the data that is available for children. Assuming that this was not a hemorrhagic stroke and that there was no moya-moya, I would continue transfusions indefinitely. To slow iron accumulation, I would use an exchange transfusion aiming for an HbS lev...
How do you manage autonomic symptoms in patients with myasthenia gravis?
MG is a pure motor syndrome. Patients should not have any autonomic symptoms unless they have LEMS (dry mouth) or if it is medication-related (e.g., Mestinon’s SE includes excessive salivation, sweating, and GI hypermotility). Thus, if a patient with MG has autonomic symptoms (unless explained by LE...