Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
What is the utility of a hypercoagulability workup in recurrent cryptogenic stroke, and what specific tests would you recommend?
Ambulatory monitoring for AFib is probably more helpful than such a thorough clotting workup.
When would you repeat antibody testing for seronegative myasthenia gravis?
I will usually recheck in 1-2 years, but I mostly focus on acetylcholine receptor antibodies. I have never seen seroconversion from MuSK negative to MuSK positive. Also, if initial antibody testing for Acetylcholine receptor binding/modulating and MuSK antibodies is negative by RIA assay, I recommen...
Do you recommend endovascular therapy in patients with isolated posterior cerebral artery stroke?
The general approach to acute ischemic stroke - (1) assess your patient for clinical suitability for EVT and then (2) look at your imaging - still applies to ischemic stroke due to PCA occlusion. For example, if the deficit is only a quadrantanopia in an elderly patient who already does not drive, t...
Are there any contraindications using nurtec in patients with headaches in the setting of recent RCVS?
I would be comfortable using Nurtec in a patient with a recent RCVS diagnosis. I am comfortable using triptans in patients with a prior stroke or MI with proper patient counseling unless they have critical/severe artery stenosis. I have had cluster headache patients who continue sumatriptan injectio...
What is your approach to management of severe hyponatremia in patients with alcohol use disorder who experience seizures that could be secondary to the electrolyte derangement or alcohol withdrawal?
Since it is difficult to make a definitive distinction as to whether the seizure is due to severe hyponatremia or alcohol withdrawal, it is prudent to treat both severe hyponatremia and alcohol withdrawal concurrently. Given that the seizure may be contributed to by the severe hyponatremia, 3% hyper...
When should one consider obtaining a cardiac MRI in ischemic stroke patients?
This is a terrific question. Cardiac MRI is increasingly utilized in the diagnostic evaluation of ischemic stroke and can uncover clinically covert cardiovascular disease. The clinical utility in ischemic stroke is most in patients with concern for LV thrombus (low EF or recent anterior ST elevation...
How do you utilize OCT for the diagnosis and management of IIH?
OCT can be a valuable adjunctive objective tool for diagnosing and monitoring papilledema in IIH. However, when it is used, it should not be used alone. It must be integrated with perimetry and fundus exam/photography. It has important limitations that preclude its use as a standalone modality.Limit...
How do you decide on head-of-bed positioning after mechanical thrombectomy for acute stroke?
First, there is some evidence that HOB positioning is related to deterioration/improvement before endovascular thrombectomy (EVT) from the ZODIAC trial. Second, safety comes first. Follow your ABCs. If the airway is ok, the patient does not develop orthopnea with a supine position, and the BP is ok ...
What is the minimum headache or migraine days per month that you would consider starting preventative migraine therapy?
I would start thinking about preventive therapy when headaches get to be about 4-6 times a month. This is the number at which there is evidence that headaches will start to progress to chronic, which is considered to be 15 times a month. If a patient is increasing their abortive use or each migraine...
When do you consider using stimulants in patients with cognitive impairments secondary to traumatic brain injury?
Perhaps most importantly, prescribing medication to address cognitive difficulties conveys hope to TBI patients that even if they have suffered structural brain damage, they can improve. Though the improvement may be fairly small, it can have important implications for better general functioning. We...