Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
What factors influence whether you treat a suspected flare of NMOSD (neuromyelitis optica spectrum disorder) with pulse dose steroids versus plasmaphereis?
I almost always begin with high-dose IV steroids but have a low threshold for layering on plasmapheresis. The two can be given concurrently. Thus, particularly for patients with myelitis/brainstem syndromes or those who have not begun to improve with a few days of steroids, I may consider adding pla...
When do you recommend MRA in patients with spontaneous ICH and negative CTA?
1. In short, never. MRA, specifically, is not superior to CTA for determining if there is abnormal vascular anatomy as a cause of a spontaneous ICH. 2. However, the use of MR imaging can be very useful. In general, I recommend waiting 8-12 weeks to allow the blood to clear so that an underlying lesi...
Do you typically recommend platelet transfusions in patients with spontaneous ICH?
Enthusiasm for platelet transfusion for spontaneous intracerebral hemorrhage among patients on antiplatelet therapy has been dampened by the results of the PATCH study. The small 190-patient randomized study demonstrated worse outcomes for those assigned to platelet transfusion. While the serious ad...
Do you typically recommend four factor prothrombin complex concentrate versus fresh frozen plasma for INR correction in patients with vitamin K antagonist associated spontaneous ICH?
Great question! Despite the lack of large randomized controlled trials, PCCs achieve faster reversal of the INR level than FFPs do, and thus I favor using PCCs with Vitamin K as a first line agent for Vitamin K antagonist related ICH.
Do you typically recommend CT angiogram and CT venogram to assess for patients with lobar spontaneous ICH?
For lobar hemorrhages I routinely obtain CTA (head/neck) & MRI (brain with contrast). On MRI, GRE/SWI sequences are good to look for micro-hemorrhage/amyloid-type of pathology. I only get MRA if patient has an elevated creatinine/CKD or anaphylaxis reaction to iodinated contrast. In my opinion, CTA ...
For a patient with high suspicion for NMDA receptor encephalitis, is there a role for giving rituximab along with methylprednisolone & IVIG (all three together) while the CSF anti-NMDAR antibodies are still pending?
The answer to this question was reported in Graus et al., PMID 26906964.
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...