Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
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...
In patients with recurrent ischemic infarcts on the same side as an internal carotid artery lesion, is intervention warranted even if there is less than 50% obstruction?
If a carotid web is found, it would be reasonable to consider intervention to prevent thrombus formation and embolization. Grory et al., PMID 30621527
Is an EMG/NCS required to clinically diagnose Guillain barre syndrome?
GBS remains a primarily clinical diagnosis, characterized by rapidly progressive large fiber sensorimotor deficits with early arreflexia, supported by albuminocytologic dissociation in cerebrospinal fluid. EMG/NCS can be normal or non-specific in up to half of the patients in the first week and only...
How do you determine the timing of anticoagulation for patients with large MCA strokes secondary to atrial fibrillation?
Timing for anticoagulation initiation depends on the size of the stroke and whether a thrombus is present outside the cerebral vasculature. In general, between 4-14 days is standard practice, with early initiation in smaller strokes (to prevent recurrent stroke) and later in larger strokes (to preve...
Do you treat HIV/AIDS-associated CNS vasculitis with antiretrovirals alone or in combination with steroids?
This is a tough question and like most viral associated forms of vasculitis i.e., HCV, VZ, other... of unclear immunopathogenic mechanisms, it is approached empirically. Antiviral therapy is the cornerstone but at least short-term immunosuppression is generally needed in the acute phase as host medi...
How frequently do you monitor EKGs for patients newly initiated on lacosimide?
In patients who are over the age of 50, smokers, or others with a higher risk of heart disease, I get an EKG at baseline and then at a maintenance dose. During treatment, if the patient reports any new potential cardiac symptoms like palpitations, PVCs, SOB, etc, I will get another EKG.
When do you start to cross-titrate from steroids to CellCept in patients with Myasthenia Gravis?
It depends on the severity of the MG. In more severe cases, such as patients hospitalized for MG exacerbation with severe dysphagia, aspiration, or respiratory failure requiring ICU, we often prescribe steroids and CellCept simultaneously after IVIG or PLEX treatment, without cross-titration. I usua...
How do you factor in a negative tilt table test in the workup for patients with suspected autonomic dysfunction?
Autonomic dysfunction encompasses a wide range of symptoms and conditions, making it more of a descriptor than a specific diagnosis. It's akin to diagnosing "lung dysfunction" or a "blood disorder". The next question should be "Which one?" or "Tell me more.". When assessing autonomic symptoms, it's ...