Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
Do you start anticoagulation in a patient with infective endocarditis who also has atrial fibrillation and stroke?
In the acute phase, no. You have to get CTA or MRI/MRA with contrast to evaluate for hemorrhagic risk associated with mycotic aneurysms. Even without aneurysms, there is an increased risk of hemorrhage. I normally recommend aspirin in atrial fibrillation patients while the infection is being treated...
Is angioedema secondary to IV tPA considered an absolute contraindication for tPA in future?
In short, no. In general, the only absolute contraindications to alteplase and other forms of tPA are active bleeding or situations that could result in active uncontrollable bleeding; all other considerations are relative. Hemi-orolingual angioedema is thought to arise associated with activation of...
When do you start anticoagulation in a patient with cardioembolic CVA secondary to new onset atrial fibrillation with hemorrhagic conversion?
Those are great questions and there is no right answer. My general practice is to delay anticoagulation beyond the standard 3-14 days initiation period when there is hemorrhage. I would wait longer if the hemorrhage is parenchymal as opposed to petechial but in both cases, I performed follow up scan...
In what subset of traumatic brain injury/concussion patients would you consider use of N-Acetyl Cysteine?
There are some reports that N-Acetyl Cysteine (NAC) may help the patient with TBI for behavioral recovery and it has neuroprotective effects. I also used NAC and Alpha lipoic acid in patients with post-chemotherapy neuropathy as antioxidants. There are limited studies on how effective they are but t...
How do you approach the workup of a patient with incidentally found pachymeningitis?
In general, when we think about the meninges, we consider the leptomeninges and the pachymeninges separately, though many of the disorders of one can also cause disease in the other. We also consider whether the pachymeningitis is focal and nodular or diffuse. Common causes of pachymeningitis are in...
How do you manage and treat post stroke alien hand syndrome?
This is a complicated question as alien hand syndrome is a rather rare phenomenon and there are currently no evidence-based treatment recommendations. A multidisciplinary approach is likely associated with better therapeutic outcomes. There are several anecdotal reports of improved symptom severity ...
How do you treat refractory focal status epilepticus in patients with traumatic bilateral subdural hematomas?
It is important to know a few more facts: Are the subdural hematomas acute/relevant? Or are they chronic findings (remote symptomatic epilepsy)? If they are acute, are they significant enough to cause brain compression needing neuro-surgical intervention? Is this electrographic only (non-clinical) ...
What is the utility in repeating a temporal ultrasound (US) in a previously US diagnosed positive GCA patient who has received treatment and is presenting with recurrent GCA symptoms?
While TA ultrasound may have a role in the assessment of disease relapse, currently there is little evidence to understand its utility in this area. It is well known that the halo sign is steroid responsive and multiple studies have shown that the halo sign recedes within the first several weeks of ...
How would you approach treatment of a brainstem AVM after hemorrhage in a patient not a candidate for surgery or embolization?
The question posted is a challenging one.First of all, one has to wait, after a bleed, for all the blood products to disappear before an angiogram to have a good idea of the nidus in terms of location within the brain stem, size, and geometry. The patient’s neurological status after a bleed in the b...
What is the best course of action for a patient with isolated carcinomatous meningitis who is responding well to intrathecal methotrexate but now has MRI findings suspicious for methotrexate leukoencephalopathy?
Neurological toxicities of intrathecal methotrexate tend to be categorized by the timeline of onset after treatment. Acute MTX toxicity includes arachnoiditis, encephalitis, transverse myelopathy, and seizures. This tends to be readily reversible including neuroimaging findings. Subacute MTX toxicit...