Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
How would you advise a younger patient with residual/recurrent optic nerve meningioma, proceeding with radiotherapy, about the risks of malignant transformation or induction of other brain malignancies because of radiation?
The risk of malignant transformation of an optic nerve sheath meningioma (ONSM) after RT appears to be remarkably low, much lower than the risk of blindness from an untreated, progressive ONSM. In a younger patient, I would lean toward RT for patients with imaging progression or early visual loss, ...
What would be your radiotherapy plan for a patient with recurrent GBM (WHO grade 4, IDH wild-type) s/p 2 prior resections with no prior radiation?
The scenario described in this clinical case is not uncommon. I have had patients who either live several hours away from our center or were unwilling to receive the Stupp protocol of 60 Gy in 6 weeks and were successfully treated with 3 weeks of hypofractionated RT (HFRT). HFRT over 1–3 weeks (25 G...
How do you conduct follow-up on patients with brain mets who have undergone GammaTile placement?
For patients with high-grade gliomas, they get an immediate post-implant CT and MRI for dose calculation, then I schedule serial follow up CE-MRI every 9-10 weeks for at least a year; if stable at the one-year mark, I "graduate" the patient to get MRIs every 12 weeks for the second year of follow-up...
How would you manage a rare presentation of an older adult after gross total resection of an "infant-type hemispheric glioma" of the left frontal lobe, IDH1 negative and negative for MYB fusions?
Infant-type hemispheric gliomas (IHGs) are rare high-grade astrocytic tumors characterized by giant size and abundant vascularity, often with regions of cystic transformation. They are aggressive brain tumors that occur during early infancy, usually between 0 and 12 months of age. They are often ver...
For a patient with large volume glioblastoma, what do you do if they are found to have a subdural infection in the middle of chemoRT requiring repeat surgery?
In this scenario, the patient will likely stop the daily treatments for a variable period of time that I would estimate to be measured in weeks while recuperating from surgery and receiving IV antibiotics. When cleared for radiation, I would start by doing a new Simulation using an updated MRI to ac...
What are your vaccine recommendations while patients are on biologics?
Live vaccines are best completed at least a month before initiation of biologics when these are appropriate (e.g., MMR, chickenpox, yellow fever). The data on non-live vaccines is limited. I personally think that some degree of protection is better than none. I will not interrupt biological therapy ...
How do structural and functional findings on echocardiogram influence your decision to anticogulate ESUS cases?
This is a great but very difficult question. It is important to remember that currently, there is NO randomized controlled trial data that provides evidence for anticoagulating patients with ESUS, and the ad hoc analysis of the Arcadia trial you mention simply does not change this. Arcadia specifica...
How do you approach selecting optimal muscle biopsy site when evaluating a patient for suspected inflammatory myopathy?
There are a few things to consider when formulating your approach to this, which include 1) the clinical exam, 2) ease of biopsy of muscle, and 3) potential confounders of diagnosis. The goal is to get a specimen from a muscle that is undergoing active inflammation. These muscles will generally be w...
For trigeminal neuralgia in patients with multiple sclerosis, do you consider microvascular decompression or stereotactic radiosurgery as treatment options?
Secondary trigeminal neuralgia attributed to multiple sclerosis occurs when there is an "MS plaque at the trigeminal root entry zone or in the pons affecting the intrapontine primary afferents" according to ICHD-3. Note that according to ICHD-3 "Pontine lesions affecting the second order neurones of...
Do you routinely check CSF cell counts and cultures on patients with external ventricular drains to monitor for infection?
I think protocols still vary widely by institution, but we only check CSF cell counts and cultures from an EVD if there is a clinical concern for hospital-acquired meningitis/ventriculitis. It is clear that the more times you access the EVD setup for CSF collection, you are increasing the risk for i...