Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
When do you redose IVIG in GBS patients who were under-treated and are worsening?
Based on recently published data from the randomized SID-GBS trial, this approach is not a good idea. A second course of IVIG not only did not clearly benefit patients with GBS with poor prognosis, but it was associated with a significantly higher risk of adverse events including thromboembolism. Wa...
When do you use plasmapheresis after IVIG in patients with Guillain-Barre Syndrome?
PLEX is, in severe cases, first line including respiratory distress requiring support, and/or rapid paralysis, and/or severe autonomic dysfunction. I may follow that with IVIg depending on the case. The milder presentations, IVIg first line.
Do you start anticoagulation in a patient with infective endocarditis who also has atrial fibrillation and stroke?
In the acute phase, no. You have to get CTA or MRI/MRA with contrast to evaluate for hemorrhagic risk associated with mycotic aneurysms. Even without aneurysms, there is an increased risk of hemorrhage. I normally recommend aspirin in atrial fibrillation patients while the infection is being treated...
Is angioedema secondary to IV tPA considered an absolute contraindication for tPA in future?
In short, no. In general, the only absolute contraindications to alteplase and other forms of tPA are active bleeding or situations that could result in active uncontrollable bleeding; all other considerations are relative. Hemi-orolingual angioedema is thought to arise associated with activation of...
When do you start anticoagulation in a patient with cardioembolic CVA secondary to new onset atrial fibrillation with hemorrhagic conversion?
Those are great questions and there is no right answer. My general practice is to delay anticoagulation beyond the standard 3-14 days initiation period when there is hemorrhage. I would wait longer if the hemorrhage is parenchymal as opposed to petechial but in both cases, I performed follow up scan...
In what subset of traumatic brain injury/concussion patients would you consider use of N-Acetyl Cysteine?
There are some reports that N-Acetyl Cysteine (NAC) may help the patient with TBI for behavioral recovery and it has neuroprotective effects. I also used NAC and Alpha lipoic acid in patients with post-chemotherapy neuropathy as antioxidants. There are limited studies on how effective they are but t...
How do you approach the workup of a patient with incidentally found pachymeningitis?
In general, when we think about the meninges, we consider the leptomeninges and the pachymeninges separately, though many of the disorders of one can also cause disease in the other. We also consider whether the pachymeningitis is focal and nodular or diffuse. Common causes of pachymeningitis are in...
How do you manage and treat post stroke alien hand syndrome?
This is a complicated question as alien hand syndrome is a rather rare phenomenon and there are currently no evidence-based treatment recommendations. A multidisciplinary approach is likely associated with better therapeutic outcomes. There are several anecdotal reports of improved symptom severity ...
How do you treat refractory focal status epilepticus in patients with traumatic bilateral subdural hematomas?
It is important to know a few more facts: Are the subdural hematomas acute/relevant? Or are they chronic findings (remote symptomatic epilepsy)? If they are acute, are they significant enough to cause brain compression needing neuro-surgical intervention? Is this electrographic only (non-clinical) ...
What is the utility in repeating a temporal ultrasound (US) in a previously US diagnosed positive GCA patient who has received treatment and is presenting with recurrent GCA symptoms?
While TA ultrasound may have a role in the assessment of disease relapse, currently there is little evidence to understand its utility in this area. It is well known that the halo sign is steroid responsive and multiple studies have shown that the halo sign recedes within the first several weeks of ...