Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
How often is a contrast-enhanced brain MRI truly normal in the setting of spontaneous intracranial hypotension?
In a paper by D'Antona et al., PMID 33393980:"Of 6878 articles, 144 met the selection criteria and reported on average 53 patients with SIH each (range, 10-568 patients). The most common symptoms were orthostatic headache (92% [95% CI, 87%-96%]), nausea (54% [95% CI, 46%-62%]), and neck pain/stiffne...
How do you manage patients with status dystonicus?
Many times, severe, seemingly uncontrollable generalized dystonia can occur in patients with or without a prior history of dystonia. In cases of severe encephalopathy, often treating the encephalopathy is the best overall approach, with medications specifically targeting the movement disorder used s...
Would you attempt a brain MRI in patients who present to the ER with subacute presentation of obstructive hydrocephalus?
I think an MRI is warranted to characterize the cause of the hydrocephalus in almost all cases, especially in the setting of a mass. The MRI can help identify the nature of the mass and the absolute size, and help with the differential diagnosis. It will also help you identify the mass as a solitary...
What would be the clinical benefit of multiphase CTA over CTP?
Fundamentally, no one has ever formally tested and proven that one imaging modality (or imaging approach) is better than another in any time window, for any kind of stroke, when the test is treatment decision-making. Therefore the brief answer to your question is: we do not know. The imaging approac...
How would you work up and manage an isolated CN3 deficit with anisocoria?
This question proposes an isolated CN 3 deficit, with almost no other clinical information. (Just as an aside, it would be important to note whether there is any evidence of aberrant regeneration of CN 3 and also check to make sure that there is no involvement of CN 4, which would immediately shift ...
Does management of NMDA receptor encephalitis change in a patient with HIV/AIDS?
In a patient who is immunodeficient, one must be mindful of the risk of opportunistic infections from additional immunosuppression. With that being said, I would still proceed with first-line therapy (pulse steroids and oral taper, IVIG) and symptomatic/supportive care with anti-seizure medicines an...
Would you consider dual antiplatelet therapy for stroke prevention for ICAD in patients with a history of SAH?
It depends on the strength of the indication for DAPT and the cause of SAH. It is important to keep things in perspective: the absolute risk reduction from DAPT for secondary stroke prevention in the POINT, CHANCE, and THALES trials was small (on the order of 1-3% absolute risk reduction) for minor ...
For patients with acute ischemic stroke and BP >185/110, at what point do you consider persistently elevated BP too refractory to safely give thrombolysis?
Elevated BP is only very rarely truly refractory. I have never encountered a situation where I could not lower the BP in a timely fashion. So, directly, if the patient is appropriate for intravenous thrombolysis, I generally treat BP (give IV medications) in one IV and give thrombolysis in the other...
In patients with embolic stroke and a PFO, how often do you go beyond venous Doppler of the lower extremities to screen for DVT (e.g. MRV or CTV abdomen and pelvis)?
No other testing; treat with anticoagulants long term or until PFO fixed & no venous clots.
When can you utilize external ventricular drains (EVDs) in the management of posterior fossa strokes?
I would use an EVD only in combination with posterior fossa craniectomy in patients with large cerebellar infarctions. An EVD alone could result in upward herniation.