Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
Is moderate-intensity statin plus ezetimibe just as effective as high-intensity statin monotherapy in preventing major cardiovascular events?
The secondary stroke prevention trial showed that high/moderate-intensity statin therapy combined with ezetimibe and titrated to achieve LDLc <70 were equally effective (compared to goal LDLc <100). Overall, the most important determinant of risk reduction is the achieved LDLc, and so moderate inten...
When would you prescribe pharmacologic DVT prophylaxis in bedbound neuromuscular patients?
Short answer: I would still not prescribe pharmacologic DVT prophylaxis routinely for all my bedbound neuromuscular patients in the outpatient settingThe point raised by the question is more than reasonable, andIdeally a randomized trial of prophylaxis vs placebo should occur before we change our pr...
Should mRS be incorporated into determining eligibility for extended window thrombolysis?
Key thrombolysis trials (WAKE UP, OPTION, EXTEND, TIMELESS, ECASS-4, HOPE, EXTEND IA) excluded patients with mRS of 2 or greater. The reason for this was the outcome of functional independence at 90 days. Hence, for trial purposes, to look at the outcome, it was necessary to exclude patients with di...
What clinical history or findings make you more concerned for an amyloid related neuropathy?
Many, including:Presence of a monoclonal IgG or IgA protein on serum or urine protein immunofixation, especially lambda light chain, and especially if kappa to lambda light chain ratio is very lowUnexplained autonomic dysfunction, especially orthostatic hypotension without compensatory tachycardiaSe...
How would you approach the upfront management of a patient with acute unilateral vision loss with strong clinical risk factors for both cardioembolic stroke and GCA if an expedited MRI is not possible due to the presence of an AICD?
I'm definitely not an expert in this topic, but you have many clinical tools to increase/decrease your clinical suspicion for GCA vs. cardioembolic stroke. Some things I would ask: Is this patient currently in Afib? What's their CHADSVASC? Are they anticoagulated? Can we get a TTE to check for vege...
How do you treat steroid-refractory MS flares when PLEX is unavailable?
There is limited evidence on the efficacy of IVIG for MS relapses. A repeat course of IV methylprednisolone within 2-3 weeks could be considered. If the patient is not already on high-efficacy DMT, then I would also promptly initiate anti-CD20 therapy.
When do you obtain nerve biopsy to evaluate for vasculitic neuropathy in patients with distal symmetric polyneuropathies?
Excellent question. Vasculitic neuropathies can occur as part of systemic or isolated peripheral nerve vasculitis (PNSV). While the majority of PNSV presents as mononeuropathy multiplex (>50%), it is well known that the rest of the patients present either with confluent mononeuropathies (which began...
What is your approach to dosing scIG for CIDP in patients stable on IVIG?
There are at least several categories of stable patients (IgG-responders): Stable with no change in initial IVIg dose or interval (minimum effective dose unknown but clinically optimized); Stable with no change in initial IVIg dose or interval (minimum effective dose unknown but NOT clinically opti...
Do 5HT4 agonists such as Metoclopramide actually lead to improvement in symptoms for patients with diabetes related gastroparesis?
Yes, sometimes when the gastroparesis is frequent or the symptoms are tough, I do use Reglan to help. By the time they wind up in the hospital, they are really willing to have me use anything on them that might help. I explain to every patient the side effects of Reglan, including tartive dyskinesia...
What is the utility of a hypercoagulability workup in recurrent cryptogenic stroke, and what specific tests would you recommend?
Ambulatory monitoring for AFib is probably more helpful than such a thorough clotting workup.