Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
When would you add acyclovir for treatment of Bell's Palsy in addition to steroids and symptomatic care?
At onset along with steroids and PT for neurostim and other modalities.
How do you manage acute exacerbations of trigeminal neuralgia?
I do not have personal experience treating TN exacerbations in the ED. What is generally recommended under those circumstances is intravenous phenytoin. Schnell et al. recently published it in The Journal of Headache and Face Pain (Schnell et al., PMID 32981076). They published the results of a retr...
Would you recommend short-term dual antiplatelet therapy for a patient who received tPA, and is otherwise eligible for dual antiplatelet therapy per POINT or SAMMPRIS trial?
I would agree. tPA is not a contraindication to the later prescription of dual antiplatelet therapy. I do not see a definite answer to the question of 21 days versus 90 days, the CHANCE trial (Wang et al., PMID 23803136) supports 21 days and the POINT trial (Johnston et al., PMID 29766750) 90 days. ...
How do you manage patients with a diagnosis of AIDP who do not respond to initial IVIg?
I disagree. Using PLEX right after IVIG means you've just removed a lot of the latter from circulation. It's a retrospective study, but this demonstrated a lack of benefit from additional PLEX. If anything it was just more expensive and patients were hospitalized for longer. Oczko-Walker et al., PMI...
What is your practice for the timing of resumption of oral anticoagulation after ICH?
These are great questions and no good answers (therefore the question). In the near future, well-designed prospective studies and clinical trials will settle the uncertainties.Timing of resumption of anticoagulation has been addressed in modeling studies of risks of recurrent bleeding and thromboemb...
How do you approach the treatment of SREAT (steroid-responsive encephalopathy with autoimmune thyroiditis) after initial pulse dose steroids?
The diagnosis of this disease entity is hugely debated. I myself do not think that the diagnosis exists. A large segment of the normal population has antibodies and the goal of Rx in supposed cases is unclear/poorly defined.
Would you favor restarting anticoagulation or pursuing left atrial appendage closure in a patient with hemorrhagic stroke on anticoagulation for non-valvular atrial fibrillation?
That is a great question, thank you for bringing it up. The answer really depends on the likely etiology of the intracerebral hemorrhage. For example, if the hemorrhage is subcortical and the etiology is thought to be likely related to hypertension, it is reasonable to resume anticoagulation when sa...
Do you use a combination of anticoagulant and antiplatelet therapy for treating intraluminal internal cerebral artery thrombus causing stroke?
Yes, typically a combination of Intravenous heparin along with an anti-platelet agent (Aspirin or Plavix) is preferable. The natural history of intraluminal thrombus is variable, but the prognosis is usually favorable, and typically short-term follow-up vessel imaging can guide further anti-thrombot...
When do you redose IVIG in GBS patients who were under-treated and are worsening?
Based on recently published data from the randomized SID-GBS trial, this approach is not a good idea. A second course of IVIG not only did not clearly benefit patients with GBS with poor prognosis, but it was associated with a significantly higher risk of adverse events including thromboembolism. Wa...
When do you use plasmapheresis after IVIG in patients with Guillain-Barre Syndrome?
PLEX is, in severe cases, first line including respiratory distress requiring support, and/or rapid paralysis, and/or severe autonomic dysfunction. I may follow that with IVIg depending on the case. The milder presentations, IVIg first line.