Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
In patients presenting with disabling acute ischemic stroke symptoms early in the therapeutic window, would you consider anticoagulation reversal to enable administration of intravenous thrombolytics?
In short, 'no'. For patients who have a large vessel occlusion, there is the option of proceeding directly to EVT without thrombolysis. We know from the direct EVT trials that although concurrent or sequential thrombolytic drug treatment followed by EVT is better, it is better only by a small amount...
What are your preferred treatments for vasospasm in the setting of RCVS?
In the inpatient setting, I like nimodipine. However, in the outpatient setting, patients may not want to, may not be able to, or may not remember to reliably take the medication every 4 hours. As you can imagine, this would be quite disruptive to their overall daily schedule and possibly their qual...
How do you decide on the next therapy for post-ICI triple M syndrome (myositis/myocarditis/myasthenia) after steroids, PLEX, and IVIG?
The short answer is that there is no standard of care, and no way to reliably predict which of the third-line treatments will work best for each individual. As an introduction, 3M syndrome is a horrible combination of 3 immune-related adverse events (iRAEs) after ICI exposure for cancer, including m...
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...
When should you avoid initiating beta blockers in a patient with myasthenia gravis?
In general, my opinion is that there are very few medications that are absolutely contraindicated in MG, and those are: botulinum toxin, aminoglycosides, macrolide antibiotics, and possibly magnesium supplements (unless the patient has dangerous hypomagnesemia). Many other drugs, especially drugs us...
What workup do you recommend for patients with symptoms suggestive of saphenous neuropathy?
In most cases of isolated saphenous neuropathy, the etiology is pretty straightforward, as it usually occurs after surgery or injury/trauma at the medial knee. Another common cause of more distal saphenous neuropathy is saphenous vein harvesting for CABG surgery (less common nowadays). When there is...
Do you recommend a workup for POEMS and/or amyloidosis for IgM monoclonal gammopathies associated with neuropathy?
While IgM monoclonal disorders, amyloidosis, and POEMS syndrome may all be associated with peripheral neuropathy, they are not often confused with one another. A patient with a peripheral neuropathy can be diagnosed most simply by a serum protein electrophoresis. The presence of a monoclonal IgM spi...
Would you consider anti-IL-5 therapy (mepolizumab or benralizumab) to either prevent or treat the more severe manifestations of eosinophilic granulomatosis with polyangiitis, such as "infiltrative" (e.g., cardiomyopathy, pulmonary infiltrates, or gastroenteritis) or "vasculitic" (e.g., neuropathy, palpable purpura, or glomerulonephritis)?
Yes, I would consider early starting biologics for infiltrative EGPA.
When do you consider sciatic nerve imaging in cases of foot drop without clinical or EMG involvement beyond the peroneal nerve without clearly indentified compression site?
I think it would be reasonable to image the sciatic nerve in this scenario. Many sciatic neuropathies, especially those caused by compression or inflammatory (vasculitic) lesions, tend to affect the peroneal division much more than the tibial, therefore clinically mimicking a peroneal neuropathy. Th...
How do you counsel patients who do you not experience early relief of hemifacial spasm after microvascular decompression surgery?
HFS is unique in that neurovascular compression is always the cause, and the location of NVC is almost always at the initial segment of the emerging facial nerve at the pontomedullary junction. High-resolution imaging pre-op using sub-millimeter voxel T2 MRI (BFFE) and MRA (source images) is recomme...