Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
What are some commonly missed diagnoses that should be considered in cases of otherwise seronegative yet steroid-responsive autoimmune encephalitis?
One shouldn't neglect to consider lymphoma as another differential in such cases as there had been reports of lymphoid malignancies presenting in such a manner. Ideally, cytology and flow ctyometry would have been obtained at the initial presentation since steroids may alter a CSF profile which migh...
What is your approach to the management of worsening dystonic spasms that are painful and refractory to standard dystonia medications?
Agree with Dr. @Dr. First Last, my friend. I would also add physical therapy specifically asking for a muscle mobilization therapist within a week after chemodenervation. Physical therapy really helps after treatment or without treatment. Also, set realistic expectations about pain management: remin...
Can Guillain-Barre syndrome present with intact reflexes?
GBS is hallmarked by ascending weakness and loss of reflexes simplistically put, with a mean Nadir of 9 days.Tendon reflex loss occurs early in most (70%) but not all patients, progressive reduction during 1st week with the clinical pattern of distribution were in ankles most frequently lost; biceps...
Would you give TNK or IVT to a patient with proximal occlusion and an NIHSS of 0-3 (non-disabling)?
For non-disabling stroke symptoms with an NIHSS 0-5, current AHA Guidelines recommend against IV thrombolysis. (Technically, TNK has not yet made it into the AHA Guidelines, but that's not the topic here). Of course, what is considered disabling is always a debate, but the PRISMS trial defined it as...
Would you give IV thrombolysis to a patient presenting with acute disabling stroke symptoms after a TAVI procedure?
Maybe. If a stroke occurs after a TAVR, it is usually embolic. Theoretically, these patients might be candidates for intravenous thrombolysis, but there are two important reservations. First, patients usually receive full dose of heparin during the procedure, and are loaded with dual antiplatelets i...
When do you start anticoagulation in patients with endocarditis and evidence of mycotic aneursym?
True estimates of the risk of anticoagulation in endocarditis is hard to come by, since anticoagulation is not common in practice and likely the risk is dynamic and decreases with antibiotic treatment. If one considers thrombolysis as a guide, the presence of endocarditis appears to increase the ris...
Do you typically use NOACs or Lovenox in patients with stroke due to hypercoagulability from malignancy?
We can extrapolate from studies of venous thromboembolism associated with cancer. Apixaban (at VTE treatment dose) has been compared to dalteparin in an open-label RCT in the CARAVAGGIO trial and edoxaban was compared to dalteparin in an open-label RCT in the Hokusai VTE Cancer trial. Both painters ...
How do you approach treatment of myoclonic status epilepticus from anoxic brain injury?
Personal experience - I would treat with lorazepam if the myclonus makes the patient acidotic, else I would not treat it.
How do you approach ictal-interictal continuum in patients with presumed toxic/metabolic etiology?
This is a common conundrum in the EEG reading room. If during the routine EEG I get a sense that the GPDs are clearly state-dependent (i.e., more frequent in the alert state, taper off in the quiet state) and they have clear triphasic morphology, I may not do anything further aside from the recommen...
How do you approach the management of EBV Meningoencephalitis (CSF pleocytosis and CSF PCR positive for EBV)?
You have to be extremely careful before making this diagnosis. It is known that positive CSF PCR for EBV can be a "bystander" when there is actually another cause of encephalitis that shouldn't be missed. Therefore, one has to make sure that extensive PCR and/or antibody testing in the CSF has been ...