Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
In a patient with suspected Miller Fisher syndrome, would you wait until antibody testing results to start IVIG or treat empirically?
Do not wait to treat. Syndromes on the Guillain-Barré spectrum, including Miller-Fisher, are clinical diagnoses. Miller-Fisher may not always have the triad of external ophthalmoplegia, ataxia, and areflexia at the time of presentation and may have overlap features with some other conditions on the ...
How do you treat post-IVIG headache that is not responsive to Tylenol or NSAIDs?
In my opinion, there is no one simple treatment for such headaches. We try slowing the infusion rate, premedicate with steroids, low dose Lasix, or premedicate with Nurtec. Usually, one of these methods helps minimize or eliminate the headaches.
How do you treat patients with symptoms of acute ischemic stroke who have an allergic reaction to alteplase?
For patients with an allergic reaction (i.e. perioral or lingual edema, difficulty breathing, or other serious reactions), our protocol is to stop tPA (and not resume), discuss with the ED attending whether there is a need for epinephrine 0.3 mg (1:1000 dilution) or intubation, monitor respiratory s...
Do you frequently encounter asterixis in patients with UTI associated encephalopathy?
Yes. The teaching that asterixis is only associated with hepatic encephalopathy is definitely false. The major metabolic triad that is associated with asterixis include liver failure, kidney failure (uremia), and hypercarbia. But don't forget toxic causes! Lots of medications (including AEDs) can co...
When do you start anticoagulation for secondary prevention in patients with HFrEF and history of embolic strokes?
Current guidelines consider anticoagulation in patients with reduced EF as class III (no benefit and possibility of harm), which has not changed significantly since WARCEF was published. The most recent randomized large trial, COMMANDER HF, looked at primary stroke prevention (among other thrombotic...
How do you decide between TCAR vs. carotid stenting for patients unstable for CEA?
There would be several factors, but the most important being the experience and outcomes from the local operators. If they have great outcomes with tcar and poor with stent then it’s the primary driving force. Other factors that could favor tcar would be a hostile arch anatomy and a thinner neck; fa...
What DHE migraine protocol works best for acute treatment both in terms of dosage and timeframe?
Dihydroergotamine (DHE) is a non-specific ergot that acts on the serotonergic, dopaminergic, and adrenergic pathways. It is used as an acute migraine treatment that can be given parenterally or nasally. Oral does exist, but is not available in the USA. It may be used acutely as a rescue treatment du...
Do you always pursue stroke work up in patients diagnosed with transient global amnesia?
I do not routinely recommend imaging or EEG for clinically straight-forward patients with Transient Global Amnesia (TGA), although I suspect I am in the minority. When the diagnosis is in question, or when the symptoms have not resolved, then yes, I would do additional workup, including MRI and EEG....
For patients with ischemic stroke status-post decompressive hemi-craniectomy, when should they start aspirin for secondary stroke prevention?
The practical answer to the question would be when the patient is alert enough to be able to swallow safely so an actual number of days cannot be given. It will be different for each patient.
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...