Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
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 ...
When do you, if ever, use plasma exchange for multiple sclerosis flares?
I have considered PLEX for patients who have new relapses or enhancing lesions within 30 days of high-dose steroids. Unfortunately, it has been difficult to get this approved by the hospitals, and I have had to either use an additional course of high-dose steroids or IVIG. For those who do not have ...
In an older adult hospitalized with recurrent falls, weight loss, without clear injuries, but with an inconsistent or difficult-to-reach caregiver, what findings would make you formally report suspected elder neglect and/or abuse?
I'm so glad that you're thinking about the possibility of abuse/neglect in this scenario! It's important to have it on our differential, or we'll always miss this diagnosis. First, it would be good to see if the patient can explain what is happening and provide contextual information that veers us a...
Which patients with oligodendrogliomas are good candidates for vorasidenib to delay radiation therapy?
Patients with WHO 2 tumors without enhancement who have had gross total resections and have no worrisome molecular pathology findings usually do better with upfront vorasidenib, delaying more aggressive interventions with chemotherapy and radiation, often for years, sometimes decades, and occasional...
Do you typically load DAPT in patients with ICAD?
If the ICAD lesion is symptomatic and the patient is aspirin-naive, I administer a one-time loading dose of 325 mg of aspirin, followed by 81 mg after that. I do not administer a loading dose of the P2Y12-inhibiting agent (such as clopidogrel, ticagrelor, etc.). I continue DAPT for 3 months then tra...
What recommendations do you have for patients with post-vaccination neurologic amyotrophy (Parsonage-Turner syndrome) regarding their future vaccinations?
Neuralgic amyotrophy (NA), acute brachial neuritis (ABN), or PTS are, inter alia, several names for an inflammatory microvasculitic plexopathy. Its broad presentation can range from a highly restricted “fasciculopathy” to a pan-plexopathy. The decision of whether to vaccinate after post-vaccinationa...
For which stroke patients, if any, do you recommend implantable loop recorder for long-term cardiac monitoring and why?
Fantastic and pertinent question! I won't pretend that I have an answer, but do have a few thoughts that may help frame further discussion: We derive our evidence for the efficacy of anticoagulation in stroke prevention from older trials designed to answer that specific question (SPAF, etc.). In the...
Which patients are good candidates for transcranial electrical stimulation for the treatment of chronic insomnia?
Transcranial magnetic stimulation (TMS) is a noninvasive neuromodulation technique that has demonstrated efficacy in the treatment of insomnia in randomized clinical trials, although evidence supporting its long-term effectiveness remains limited. Studies have reported improvements in both subjectiv...
Do you counsel patients to acutely treat migraine with aura at the onset of aura or headache?
The timing of acute treatments for migraine attacks has been widely discussed for a number of years. Here are some principles: Once the pain begins, pain-free rates are higher if the patient treats early in the attack, while the pain is still mild. This is broadly true for triptans, NSAIDs, aspirin...
In what clinical scenarios do you utilize opioids in patients with restless leg syndrome?
I would say in refractory RLS, i.e., the patient has failed all the options below: Iron supplementation if ferritin <50, Gabapentin/pregabalin, Dopamine agonists, and Non-pharmacological options (like the vibrating pad). *I don't love carbidopa/levodopa for RLS. It very often causes augmentation.