Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
Under what circumstances do you decide to place an EVD for patients with cerbellar ischemic stroke?
Although placement of an EVD in a patient with cerebellar infarction can be lifesaving, I rarely use it as a sole treatment for that condition due to the risk of upward herniation. Typically, when the cerebellar infarction has created enough mass effect to cause hydrocephalus, the patient also requi...
Do you switch from Eliquis to Pradaxa in patients who experience a recurrent ischemic stroke while on Eliquis considering their different mechanisms of action?
I usually don't switch as there is evidence that making a switch is better for secondary stroke prevention
How would you approach the workup and management of a young patient with recurrent biannual non-scarring oral ulcers and new onset neurologic symptoms with associated CNS white matter lesions concerning for Behcet’s?
This is a challenging case. It should be noted that oral ulcers in Behcet's typically occur more than twice per year (by ISG criteria should occur at least 3x per year) and without other symptoms of BD it can be very challenging to make a probable diagnosis of BD in this scenario. A careful history ...
What is your threshold for pursuing a lumbar puncture in an older hospitalized patient with acute altered mental status when the initial workup — including labs, imaging, and urinalysis — is unrevealing?
My threshold for lumbar puncture in an older hospitalized patient with acute altered mental status is high. In my practice, I will not pursue an LP in a patient over 65 solely because an otherwise routine evaluation for delirium is unrevealing. A negative workup alone does not sufficiently increase ...
How do you manage an MS patient who has had attacks in spite of being on B-cell depleting therapy?
True inflammatory breakthrough during adequately dosed, biologically effective anti-CD20 therapy is uncommon. Consequently, the initial response should prioritize diagnostic reassessment instead of immediate escalation.The first step is to confirm that the event represents a true relapse rather than...
How would you advise a younger patient with residual/recurrent optic nerve meningioma, proceeding with radiotherapy, about the risks of malignant transformation or induction of other brain malignancies because of radiation?
The risk of malignant transformation of an optic nerve sheath meningioma (ONSM) after RT appears to be remarkably low, much lower than the risk of blindness from an untreated, progressive ONSM. In a younger patient, I would lean toward RT for patients with imaging progression or early visual loss, ...
How do you manage glioblastoma presenting with leptomeningeal dissemination?
Hospice is a very legitimate option. As physicians, we recommend this far too infrequently.
Would you consider off-label IV thrombolysis in patients taking a DOAC and presenting with disabling acute ischemic stroke within the window?
In brief, yes, I would and do consider it. I have both treated patients deliberately and inadvertently who were on DOACs (and who took medication in the last 24-hours). When it was inadvertent, I simply did not know and could not know (aphasic patient, no record available, no corroborative informati...
What is your treatment approach to functional cervical dystonia?
This is a relatively common situation. After making sure of the diagnosis of functional cervical dystonia, I explain the reversibility and fluctuation with mood changes (that may or may not be perceived by the patient) and demonstrate that they DO have some control over their movements through distr...
How do you approach treatment of a glioblastoma in pregnancy?
Glioblastoma during pregnancy could be treated safely (to mother and fetus) with certain precautions and modifications. Collaboration and consultation with the patient’s obstetrician are essential. External shielding over the patient’s abdomen during treatment will decrease the external scatter radi...