Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
How do you approach a mildly positive finding on an autoimmune encephalitis panel when there is no other evidence of encephalitis (such as elevated CSF protein, abnormal imaging, or EEG findings)?
In general, low positive Abs by ELISA or radioimmunoprecipitation assays have low predictive value for neurological disease and cancer outside of specific clinical contexts (e.g. a PQ of 0.03 nmol/L in a patient with myasthenic syndrome).For encephalitis, GAD65 < 20 nmol/L, and PQ type calcium chann...
In patients in the ICU who are on the inter-ictal continuum, how do you decide whether or not to treat for potential non-convulsive status epilepticus?
In those situations, you will have to take into account the whole clinical picture - what the etiology is (are we dealing with a structural injury and those periodic patterns may not resolve, and in those situations, your goal is not resolution of the EEG); if the concern is for an autoimmune etiolo...
How do you manage autonomic storming in patients with increased intracranial pressure?
In many respects, the treatment of paroxysmal sympathetic hyperactivity (PSH), or storming, is similar whether or not there is elevated ICP. The goal is to limit stimuli that provoke the episodes of storming and reduce sympathetic outflow or block its downstream effects. The difference is in those p...
For patients with generalized tonic-clonic seizures lasting > 2 minutes without IV access, what alternative medications can be used?
You can use intranasal midazolam (Nayzilam), intranasal diazepam (Valtoco) or rectal diazepam (Diastat). Other options are buccal or intramuscular midazolam using the IV solution.
How do you acutely manage a free-floating thrombus in a major artery in a patient with a stroke as a result of it?
There is no clear guidance from trials. My own practice has been to anticoagulate for 72 hours, then repeat the CTA. If the thrombus is no longer visible, I switch to dual anti-platelet Rx; if still there switch to DOAC for 30 days and reimage.
How do you approach the management of a large vessel stroke if you anticipate the development of malignant cerebral edema?
In ischemic strokes with anticipated malignant cerebral edema, I would base some initial management decisions for prevention of edema on the labs obtained at admission. If the sodium is less than 130, I would start hyperosmolar therapy to bring levels into a normal range. If less than 135, normal sa...
In women of childbearing age with NMDA encephalitis and normal pelvic imaging, is there a role for oophorectomy for possible microteratoma?
Pelvic imaging of female patients with anti-NMDA-receptor encephalitis for ovarian teratoma should consist of MRI of pelvis or ultrasound of pelvis with transvaginal views. If this testing is unrevealing, the recommendation, in general, is not to proceed with oophorectomy. There have been reports of...
What is your decision process on decreasing the sodium goal for patients with cerebral edema?
In my practice, when treating an adult patient with cerebral edema, we avoid hyponatremia but do not set a specific sodium goal. Rather, we titrate therapies (e.g., mannitol, hypertonic saline) to achieve a specific ICP goal (e.g., ICP < 22 mmHg). We stop administering mannitol if the osmolar gap > ...
How do you approach management of cerebral venous sinus thrombosis in a patient with severe thrombocytopenia?
Many patients with thrombocytopenia have abnormally functioning platelets, and as such still benefit from anticoagulation treatment. In patients with cerebral venous sinus thrombosis and counts <50K, I recommend involving hematology to help determine the appropriate regimen, which may involve a hepa...
When do you consider starting hypertonic saline solution in patients with an acute ischemic stroke?
Hypertonic (3%) saline is infrequently used, and mainly applies to patients who have signs of significant midline shift or cerebral edema on CT or MRI with a depressed loss of consciousness. In stroke patients in the awake/alert state with a large stroke and risk for edema development in the next 24...