Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
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.
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.