Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
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 ...
How would you approach treatment of a brainstem AVM after hemorrhage in a patient not a candidate for surgery or embolization?
The question posted is a challenging one.First of all, one has to wait, after a bleed, for all the blood products to disappear before an angiogram to have a good idea of the nidus in terms of location within the brain stem, size, and geometry. The patient’s neurological status after a bleed in the b...
What is the best course of action for a patient with isolated carcinomatous meningitis who is responding well to intrathecal methotrexate but now has MRI findings suspicious for methotrexate leukoencephalopathy?
Neurological toxicities of intrathecal methotrexate tend to be categorized by the timeline of onset after treatment. Acute MTX toxicity includes arachnoiditis, encephalitis, transverse myelopathy, and seizures. This tends to be readily reversible including neuroimaging findings. Subacute MTX toxicit...
How do you approach patients with suspected CNS lymphoma who have been treated with steroids?
It depends. I proceed with an expeditious biopsy in symptomatic patients or others likely to benefit from urgent therapy. While steroids often make path diagnosis challenging, sometimes a tissue diagnosis can still be secured. I stop corticosteroids and repeat imaging in hopes of having a good targe...
What symptomatic management do you recommend in patients with post LP headaches?
In my clinical experience, the symptomatic/medical management of post lumbar puncture (LP) headache is challenging and of limited utility. In contrast, for the vast majority of cases, a large volume autologous epidural lumbar patch ("blood patch") is highly effective (and much appreciated by the pat...
How do you evaluate and treat patients with cerebral edema secondary to hyperammonemia?
The previous answer is a reasonable plan for the raised ICP. We need to remove ammonia - ammonia scavengers or dialysis are reasonable. If not liver cirrhosis, look for urea cycle issues even in adults, old GI surgical procedure that creates blind pouch with bacterial overgrowth, etc as other potent...
When is follow-up imaging warranted in patients with anoxic brain injury?
Acutely, either MRI or CT can be used to assess for cerebral edema and impending herniation. However, MRI is much better to assess for extent of ischemic injury. Imaging can be helpful in prognostication as one part of the puzzle, but not in isolation, and prognostication based on imaging alone is p...
What is your approach for a patient with an acute ischemic stroke caused by an aortic thrombus?
It depends upon the risks, factors, and age of the patients. If they have hypercoagulable states then the patient needs anticoagulation otherwise, aortic atheroma is generally "white" clot which is made up of platelets and cholesterol and hence, treatment would be anti-platelets and cholesterol lowe...
When do you consider middle meningeal artery embolization in patients with recurrent subdural hemorrhages?
I recommend middle meningeal artery embolization in patients with larger subdural hematomas.