Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
Is there a stroke volume threshold you use for giving or not giving DAPT for an acute ischemic stroke?
This is not incorrect but it is only part of the story. Antiplatelet meds are rarely associated with ICH in either situation; many other factors are involved in the risk of ICH such as BP, age, and other MRI scan abnormalities.
When do you recommend hyperacute MRI for patients with wake-up stroke?
Wake-up stroke patients with arrival within 4.5 hours of symptom discovery may be eligible for tPA or tenecteplase if the acute MRI shows a DWI lesion but little or no FLAIR lesion.
What is the recommendation for women with migraine with aura who are planning to undergo IVF hormone therapy?
I would not change my migraine management approach. With pregnancy planning, I would avoid medications that are not recommended in pregnancy. I would counsel on the safety of different acute and preventative treatments in pregnancy.
How do you manage multiple cavernous malformations that have bled and enlarged over time?
Intracranial hemorrhage (ICH) is one of the most common manifestations of cerebral cavernous malformations (CCMs) occurring in about 25% of the cases. Two recent meta-analyses report a risk of 15% of ICH at 5 years. The treatment of these patients is very controversial. A recent population-based stu...
Would you consider using a TNFi in a patient with a family history of demyelinating disease, in the absence of a personal history?
No contraindication based on family history of MS that I am aware of. One could consider MRI head to rule out radiologically isolated syndrome, as a biomarker of risk.
What is the value of sending placental pathology in neonatal patients who have suffered an in-utero arterial ischemic stroke?
Placenta is most helpful in defining whether there has been an infection (chorioamnionitis). It's also helpful in determining if there have been any clots or thromboses. I have attached articles for reference. Dueck et al., PMID 19955347 Hirschel et al., PMID 38502326
Would you discontinue romosozumab in a patient who develops a hemorrhagic stroke while on therapy?
Considering the boxed warning to stop Evenity in a patient who has a stroke or MI while receiving it, yes, I would stop it. It is the prudent thing to do. However, I know of no evidence of harm with continuing it, and I might consider continuing it if the balance of benefits and risks were overwhelm...
How do you approach the "wearing off" phenomenon for patients with multiple sclerosis on B-cell-depleting therapies?
This is a fairly common, but not universal, phenomenon, and more frequent for patients on ocrelizumab compared to rituximab, ublituximab, and even ofatumumab. I try to make action plans for symptomatic treatment during these periods, e.g., addressing fatigue, pain, and cognitive fog. We can increase...
How do you determine which patients with ICAS are the best candidates for balloon angioplasty versus those who should continue with aggressive medical management alone?
A recent study on JAMA network found angioplasty superior to medical therapy (dual antiplatelet and statin), whereas previous studies have found angioplasty combined with stenting more risky. I am not sure that appropriate guidelines have yet been developed, but I would think that the stenosis must ...
If a patient who has previously been taking lamotrigine stops taking it for between two weeks and a month, do you have to uptitrate it all over again or do you have another way to resume it?
I'm not aware of good data to answer this question. To be safest, I would probably titrate again at the usual schedule as though starting from scratch. In the epilepsy monitoring unit, we're typically comfortable with restarting at-home doses without retitrating up to 14 days off meds (the lower lim...