Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
When are steroids indicated in the treatment of strep pneumo meningitis?
Yes, I recommend a four-day regimen of dexamethasone 0.4-0.6 mg per kilogram daily given before or with the first dose of antibiotics. Delaying the administration of corticosteroids would reduce the desired anti-inflammatory effects. van de Beek et al., PMID 14998499 Brouwer et al., PMID 26362566...
When do you recommend treating stimulus-induced generalized periodic discharges (GPDs)?
If they are on the ictal-interictal continuum (1-2.5 Hz), I would perform an AED trial, but non-aggressive management especially if there is a known metabolic or systemic etiology. In general, some factors that would suggest a less aggressive more observant approach: Generalized discharges No "plus...
What blood pressure goals do you typically target for patients in the immediate post thrombectomy period?
There aren't excellent data to guide this decision. In general, I make a patient-specific decision. For all patients (both tPA treated and otherwise), I target <180/100. If they're TICI 0-1, I usually keep to that. With TICI 2a, I usually lower to <160 and with 2b/3 I usually lower to <140. The guid...
What antithrombotic regimen do you recommend prior to and in anticipation of CEA for patients with symptomatic carotid stenosis?
Dual antiplatelet therapy with aspirin and clopidogrel
What factors influence whether you treat a suspected flare of NMOSD (neuromyelitis optica spectrum disorder) with pulse dose steroids versus plasmaphereis?
I almost always begin with high-dose IV steroids but have a low threshold for layering on plasmapheresis. The two can be given concurrently. Thus, particularly for patients with myelitis/brainstem syndromes or those who have not begun to improve with a few days of steroids, I may consider adding pla...
When do you recommend MRA in patients with spontaneous ICH and negative CTA?
1. In short, never. MRA, specifically, is not superior to CTA for determining if there is abnormal vascular anatomy as a cause of a spontaneous ICH. 2. However, the use of MR imaging can be very useful. In general, I recommend waiting 8-12 weeks to allow the blood to clear so that an underlying lesi...
Do you typically recommend platelet transfusions in patients with spontaneous ICH?
Enthusiasm for platelet transfusion for spontaneous intracerebral hemorrhage among patients on antiplatelet therapy has been dampened by the results of the PATCH study. The small 190-patient randomized study demonstrated worse outcomes for those assigned to platelet transfusion. While the serious ad...
Do you typically recommend four factor prothrombin complex concentrate versus fresh frozen plasma for INR correction in patients with vitamin K antagonist associated spontaneous ICH?
Great question! Despite the lack of large randomized controlled trials, PCCs achieve faster reversal of the INR level than FFPs do, and thus I favor using PCCs with Vitamin K as a first line agent for Vitamin K antagonist related ICH.
Do you typically recommend CT angiogram and CT venogram to assess for patients with lobar spontaneous ICH?
For lobar hemorrhages I routinely obtain CTA (head/neck) & MRI (brain with contrast). On MRI, GRE/SWI sequences are good to look for micro-hemorrhage/amyloid-type of pathology. I only get MRA if patient has an elevated creatinine/CKD or anaphylaxis reaction to iodinated contrast. In my opinion, CTA ...
For a patient with high suspicion for NMDA receptor encephalitis, is there a role for giving rituximab along with methylprednisolone & IVIG (all three together) while the CSF anti-NMDAR antibodies are still pending?
The answer to this question was reported in Graus et al., PMID 26906964.