Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
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...
If an aphasic patient presenting for ischemic stroke has a confirmed LKW <4.5 hours but you are unable to confirm other absolute contraindications (medications, recent surgeries, GI bleeding, etc.) to tenecteplase, what is your approach to determining thrombolysis eligibility?
I take a case-by-case approach to this type of situation. In practice, you can’t always rule out every major contraindication with 100% confidence within the timeframe required to give a thrombolytic. For example, a patient may not know they have severe thrombocytopenia, but I won’t go looking if th...
Do you typically recommend sleep studies for patients with Parkinsonism?
Not necessarily. If there is concern for sleep apnea (i.e., snoring, etc), then it would be worth doing, as a CPAP can be helpful for sleep quality, but I have found most sleep labs (this includes both community and university-based) are not great at otherwise diagnosing/accounting for other sleep a...
Are there any patients with newly diagnosed GBM in whom you would adopt Early-Start TTFields based on the TRIDENT study?
The authors of EF-32/TRIDENT should be commended for performing this impressive randomized trial of an already FDA-approved therapeutic in GBM maintenance, asking the question of whether an earlier start of TTF, during chemoradiation, improves overall survival. This is also a big ask of the therapeu...
Under what circumstances do you decide to place an EVD for patients with cerbellar ischemic stroke?
Although placement of an EVD in a patient with cerebellar infarction can be lifesaving, I rarely use it as a sole treatment for that condition due to the risk of upward herniation. Typically, when the cerebellar infarction has created enough mass effect to cause hydrocephalus, the patient also requi...
When do you order an MRA to better evaluate results from a CTA?
MRA is better for aneurysms that have been coiled (too much artifact on CTA). CTA is better for aneurysms that have been clipped (too much artifact on MRA). MRA usually focuses on the Circle of Willis. The rare distal MCA/ACA/PCA aneurysms may be missed. In contrast to CTA, MRA does not require cont...
Under what circumstances do you perform an MMA embolization prior to chronic subdural hematoma evacuation?
Current evidence from randomized trials such as EMBOLISE and EMMA demonstrates that MMA embolization reduces the risk of recurrent CSDH. However, the purpose of MMA embolization is to reduce recurrence, not to provide immediate decompression.Therefore, for patients with symptomatic CSDH requiring su...
How does the TOBAS SRS registry change your approach to small AVMs in deep eloquent areas with prior rupture?
I emphasize that SRS is a reasonable attempt to reduce risk with about a 50–65% chance of cure at three years and a roughly 1 in 6 chance of a serious complication, including a 1 in 20 risk of another hemorrhage during follow‑up, and a 5-10% risk of brain injury from radiation-induced changes Micros...
What is your approach to screening for cognitive impairment in hospitalized older adults?
Upon admission to the hospital, all older adults should undergo a brief cognitive screening. This initial step helps establish a baseline and can identify previously unrecognized cognitive issues. Several tools are well-suited for this purpose; we use minicog as the screening tool at our hospital. ...
Can you use leflunomide and rituximab in a patient with both multiple sclerosis and rheumatoid arthritis?
It is rare for a patient to have both diseases, but immunosuppressive therapy can be used for the management of both conditions. A study published in 2021 investigated the use of a combination of rituximab and leflunomide in rheumatoid arthritis (Behrens et al., PMID 33738492). Rituximab has previou...