Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
In what clinical situations do you treat triphasic waves on EEG?
Triphasic waves is an old term, and does not exist as an entity on its own in the new ACNS 2021 guidelines.The new terminology is "Generalized periodic discharges with triphasic morphology". The new definition puts less emphasis on the morphology of discharge, and more emphasis on periodicity itself...
Do you always perform temporal artery biopsy in patients with positive inflammatory markers and high clinical suspicion of GCA?
As with most clinical scenarios, the short answer is 'it depends'. If a patient has cranial symptoms, elevated inflammatory markers, and suspicion for GCA is high, I do refer for temporal artery biopsy to help confirm the diagnosis. This is in line with guidelines from the American College of Rheuma...
How to you treat pregnant women who develop Bell's Palsy?
Bell's palsy is definitely more common in pregnancy and in the immediate postpartum period. For the most part, treatment is identical to how you would treat a non-pregnant patient (which itself is controversial). Whichever treatment is used, it is important to consider initiating treatment within 3 ...
Is either ESR or CRP more sensitive or specific for the diagnosis of GCA?
I typically obtain both an ESR and a CRP in the workup of new onset or relapsing GCA. The CRP may be slightly more sensitive than the ESR based on Kermani et al., PMID 22119103 which demonstrated a sensitivity of 86.9% and 84.1% respectively for CRP and ESR, for a positive TAB. There is discordance ...
In a patient with suspected Miller Fisher syndrome, would you wait until antibody testing results to start IVIG or treat empirically?
Do not wait to treat. Syndromes on the Guillain-Barré spectrum, including Miller-Fisher, are clinical diagnoses. Miller-Fisher may not always have the triad of external ophthalmoplegia, ataxia, and areflexia at the time of presentation and may have overlap features with some other conditions on the ...
How do you treat post-IVIG headache that is not responsive to Tylenol or NSAIDs?
In my opinion, there is no one simple treatment for such headaches. We try slowing the infusion rate, premedicate with steroids, low dose Lasix, or premedicate with Nurtec. Usually, one of these methods helps minimize or eliminate the headaches.
How do you treat patients with symptoms of acute ischemic stroke who have an allergic reaction to alteplase?
For patients with an allergic reaction (i.e. perioral or lingual edema, difficulty breathing, or other serious reactions), our protocol is to stop tPA (and not resume), discuss with the ED attending whether there is a need for epinephrine 0.3 mg (1:1000 dilution) or intubation, monitor respiratory s...
Do you frequently encounter asterixis in patients with UTI associated encephalopathy?
Yes. The teaching that asterixis is only associated with hepatic encephalopathy is definitely false. The major metabolic triad that is associated with asterixis include liver failure, kidney failure (uremia), and hypercarbia. But don't forget toxic causes! Lots of medications (including AEDs) can co...
When do you start anticoagulation for secondary prevention in patients with HFrEF and history of embolic strokes?
Current guidelines consider anticoagulation in patients with reduced EF as class III (no benefit and possibility of harm), which has not changed significantly since WARCEF was published. The most recent randomized large trial, COMMANDER HF, looked at primary stroke prevention (among other thrombotic...
How do you decide between TCAR vs. carotid stenting for patients unstable for CEA?
There would be several factors, but the most important being the experience and outcomes from the local operators. If they have great outcomes with tcar and poor with stent then it’s the primary driving force. Other factors that could favor tcar would be a hostile arch anatomy and a thinner neck; fa...