Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
When do you recommend electrical stimulation (Cefaly device) in patients with chronic migraine, if at all?
The Cefaly device provides transcutaneous electrical nerve stimulation to the supraorbital nerves and has regulatory approval both as an acute and preventive treatment. This device and other neuromodulatory therapies are useful in several settings for the treatment of chronic migraine: Some people ...
Is there utility to ordering biochemical screening labs for global developmental delay?
When suspected, it might be warranted to do an initial screening for metabolic disorders. Genetic testing is also a good idea, starting with a microsomal microarray and fragile X testing. Whole exome sequencing might follow and is becoming more affordable and covered by insurance.
How do you treat patients with stroke thought to be secondary to Lambl excrescence?
Pathophysiologically, these occur through sheer stress to the valvular endocardium causing small areas to be denuded followed by fibrin deposition and microthrombi formation on the endocardial injury, which can embolize. Histopathologically, they have similarities to fibroelastomas (which are larger...
Do you use amyloid lowering therapy in patients on chronic anticoagulation?
I wouldn’t feel comfortable doing this because of the elevated risk of ARIA-H. The Alzheimer’s Association Therapeutics Work Group advised that patients receiving anticoagulants should not be offered lecanemab (Cummings et al., PMID 37357276).
Do you recommend plasmapheresis for treatment of patients with osmotic demyelination?
No. There are insufficient data to routinely recommend plasmapheresis for the treatment of ODS at this time. Current evidence is based predominantly on case series. In the absence of a control group, it is difficult to assess the effectiveness of plasmapheresis in the treatment of ODS.
When do you consider complement inhibitors or FcRN inhibitors in patients with myasthenia gravis?
In my opinion, those meds should be considered for a patient with AchR antibody-positive MG who has suboptimal control of MG symptoms on: Pyridostigmine + prednisone + oral immunosuppressant drugs like azathioprine or MMF. Pyridostigmine + oral immunosuppressant + severe intolerance to steroids (si...
Do you find the UPDRS useful for the care of Parkinson's disease patients outside of research?
The UPDRS and MDS-UPDRS are both useful research tools for Parkinson’s. Parts one, two, and four are interview-based with some rater guidance. Part three is an objective assessment by the clinical rater. Performing part three of either UPDRS test in non-research settings is helpful to improve your u...
What do you advise regarding the timing and safety of major surgery in patients with moderate to severe intracranial atherosclerosis?
One way to approach the question is by considering the timing of surgery following a stroke in general. Observational studies have indicated a heightened risk of perioperative stroke for several months after the initial event. For instance, Jørgensen et al. found that the risk remains elevated for u...
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.