Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
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...
What is the minimum headache or migraine days per month that you would consider starting preventative migraine therapy?
4 migraines per month should start the discussion of preventive therapy. It may be considered in less than that if the patient has very disabling or prolonged migraines, where they are missing work or school, and it is disruptive.
How do you counsel patients interested in estrogen containing oral contraceptives who have migraine with aura?
Outside of patients whose attacks are suggestive of hemiplegic migraine, I do not typically avoid the use of estrogen-containing OCPs. While it is my understanding that a number of international organizations and many neurologists (as well as Ob/Gyn) recommend their avoidance, there are several revi...
Do you recommend surveillance MRI for patients with MOGAD?
I do not recommend regular surveillance MRI for all patients. It really depends on the case as some MOGAD patients are very stable and don't even require treatment, whereas others can be quite aggressive and resistant to all treatments. The field is still emerging and our understanding of silent dis...
When is the earliest you escalate treatment for prolonged migraine attacks to parenteral or emergency-level care?
After about 36 hours of status migrainosus.
Have you found that migraine prevention treatments help non-specific vestibular symptoms in migraine patients?
I would say no to this question, so I would encourage further workup to identify the source of the vestibular symptoms.
How do you decide on the next therapy for post-ICI triple M syndrome (myositis/myocarditis/myasthenia) after steroids, PLEX, and IVIG?
The short answer is that there is no standard of care, and no way to reliably predict which of the third-line treatments will work best for each individual. As an introduction, 3M syndrome is a horrible combination of 3 immune-related adverse events (iRAEs) after ICI exposure for cancer, including m...
Would you consider antithrombotic therapy in a patient with refractory migraines and antiphospholipid syndrome?
Yes.
In patients with suspected RCVS, is there a role for preventative CCB if headache has resolved/now asymptomatic?
A number of these patients experience a dull, lingering headache, and I typically maintain them on verapamil, with or without magnesium, until their headache subsides. Afterward, I gradually taper off the medication over 7-10 days. I don't use it as a preventative measure as long as the patient is s...
Would you consider off-label IV thrombolysis in patients taking a DOAC and presenting with disabling acute ischemic stroke within the window?
Addendum: Re- access to serum concentration for the DOAC. Yes - access to serum concentration for the DOAC, like factor Xa levels, for example, for Eliquis and Xarelto, or ECT for dabigatran, does change my management. In those with normal levels of specific anticoagulation tests, I would discuss IV...