Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
When do you consider plasmapheresis instead of (or in addition to) IV steroids for patients with acute MS exacerbation?
I would utilize plasmapheresis in a patient with severe, debilitating symptoms from an MS relapse and incomplete (or non-reassuring trajectory of) improvement after intravenous steroids. This is supported by AAN guidelines (Cortese et al., PMID 21242498). There is less robust data to support IVIG.
When do you prescribe a steroid taper after the high dose IV course for a multiple sclerosis exacerbation?
Most of the available literature is sparse and largely anecdotal. I am not sure there are any class I data available out there that specify if an oral taper is needed vs. it is not. Given such minimal evidence for one over the other, I do not use an oral taper. The 1988 (phew, 34 years ago) ONTT tri...
Do you counsel patients against driving who presents with transient global amnesia?
No. A single episode of TGA is usually isolated and I would never consider driving precautions. No data suggests that an episode of TGA suggests an increased risk of LOC or seizures in the future. Additionally, I am not aware that TGA itself poses a driving risk.
Do you routinely obtain an EEG in patients who are admitted with traumatic intra-cerebral hemorrhage?
We routinely obtain cEEG monitoring on all moderate (GCS 9-12) and severe (GCS 3-8) TBIs at our institution, regardless of their intracranial pathology. It is estimated that in this patient population, the frequency of sub-clinical seizures is around 20-25% and can be associated with elevated ICP, w...
When would you add acyclovir for treatment of Bell's Palsy in addition to steroids and symptomatic care?
At onset along with steroids and PT for neurostim and other modalities.
How do you manage acute exacerbations of trigeminal neuralgia?
I do not have personal experience treating TN exacerbations in the ED. What is generally recommended under those circumstances is intravenous phenytoin. Schnell et al. recently published it in The Journal of Headache and Face Pain (Schnell et al., PMID 32981076). They published the results of a retr...
Would you recommend short-term dual antiplatelet therapy for a patient who received tPA, and is otherwise eligible for dual antiplatelet therapy per POINT or SAMMPRIS trial?
I would recommend dual antiplatelet therapy for 21 days for eligible patients. The risk of recurrence is highest in the first few days and patients will likely still benefit. I would just ensure the patient has no hemorrhage in their 24-hour scan and they would otherwise meet the criteria for the CH...
How do you manage patients with a diagnosis of AIDP who do not respond to initial IVIg?
I disagree. Using PLEX right after IVIG means you've just removed a lot of the latter from circulation. It's a retrospective study, but this demonstrated a lack of benefit from additional PLEX. If anything it was just more expensive and patients were hospitalized for longer. Oczko-Walker et al., PMI...
What is your practice for the timing of resumption of oral anticoagulation after ICH?
These are great questions and no good answers (therefore the question). In the near future, well-designed prospective studies and clinical trials will settle the uncertainties.Timing of resumption of anticoagulation has been addressed in modeling studies of risks of recurrent bleeding and thromboemb...
How do you approach the treatment of SREAT (steroid-responsive encephalopathy with autoimmune thyroiditis) after initial pulse dose steroids?
The diagnosis of this disease entity is hugely debated. I myself do not think that the diagnosis exists. A large segment of the normal population has antibodies and the goal of Rx in supposed cases is unclear/poorly defined.