Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
Do you send CSF or serum ACE levels in the workup of neurosarcoidosis?
Unfortunately, serum and/or CSF ACE levels are just not sensitive or specific enough to guide the diagnosis or treatment of sarcoidosis, particularly neurosarcoid. Rather, imaging characteristics, specific organ system involvement, and biopsy results are much more useful in my practice.Bradshaw et a...
Is intracranial hemorrhage a contraindication for valproic acid?
The short answer is no. Valproic Acid (VPA) can cause bone marrow suppression leading to thrombocytopenia, as well has hypofibrinogenemia. Through these mechanisms, and possibly others, platelet aggregation is reduced, which may place one at risk for hemorrhagic expansion, but in my experience, and ...
When do you consider lumbar spinal fluid drainage after acute spinal cord injury?
Extremely rarely indicated.
Do you take any special precautions when treating cervical spine metastases?
For each spine met case, it's important to determine whether it's a surgical or radiotherapy case. Spinal instability neoplastic score (SINS) and Bilsky grade (epidural cord compression) are two important parameters to consider. If SINS is 6 or below and if Bilsky grade is 1c or below, surgical inte...
Do you refer all patients with new findings of CNS or epidural mets/tumor to ED for evaluation or are there some that can be managed completely outpatient?
Interesting question: Sending patients to the ED for non-emergent conditions is not advised. Our EDs around the country are struggling for a variety of reasons (e.g., they are often holding patients awaiting placement or admission), thus our society will benefit by us avoiding sending patients to t...
Would you consider DHE for patients with status migrainous with elevated blood pressure at the time of presentation?
No, I would not. DHE is a very potent and non-selective arterial vasoconstrictor and would potentially further increase elevated blood pressure. When a patient who presents with a headache is found to have elevated blood pressure, it should be assumed that the elevated blood pressure is the cause of...
When do you consider stopping anti-seizure medications in seizure-free pediatric epilepsy patients?
Prior to 1988, we would never dare take a patient off seizure medicine if the patient was seizure-free.Callaghan's paper published in the New England Journal of Medicine (Callaghan et al., PMID 3127710) clearly showed that patients who were seizure-free on Tegretol for 3 years had a 90% chance of be...
How frequently do you recommend ordering labs to monitor for side effects of disease-modifying therapies for multiple sclerosis?
Yes, the monitoring depends on which DMT the patient is on. For patients on B-cell-depleting therapies, I screen for Hep B and latent TB prior to therapy and check a CBC and CMP every 6 months, with yearly immunoglobulin monitoring. For JCV Ab-negative patients on Tysabri, I check a CBC, CMP, and JC...
How do you distinguish between primary progressive MS versus relapsing remitting MS with superimposed relapses in a newly diagnosed patient that is naive to treatment?
Relapsing versus progressive MS are clinical phenotypes lacking clear objective radiologic or paraclinical distinctions. Recent literature emphasizes commonalities between these phenotypes, largely framing them as a spectrum of one disease rather than discrete disorders. Originally, these clinical p...
How do you approach the psychiatric symptom management of Huntington’s Disease?
The neuropsychiatric features of Huntington's disease are not as consistent as the motor or cognitive features. Still, they can cause substantial disability, be prominent early in the disease, and even occur as initial features. The majority of Huntington’s disease (HD) mutation carriers experience ...