Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
When do you restart anticoagulation in patients with atrial fibrillation who just had an ischemic stroke?
The recent ELAN trial (Fischer et al., PMID 37222476) and now the published CATALYST meta-analysis (Dehbi et al., PMID 40570866) all support the concept that early anticoagulation (within 4 days of stroke) with a DOAC is safe and effective. There appears to be no interaction with clinical factors su...
How long can demyelinating findings persist on nerve conduction studies (NCS) after AIDP illness?
This question was studied in a retrospective review in Muscle and Nerve (Guémy et al., PMID 36814082) in a group of patients with AIDP. At least one feature of demyelination was present in 23% of the cohort (14 out of 61) up to 2 years after the onset of the AIDP-like illness. Using the EFNS-PNS cri...
How do structural and functional findings on echocardiogram influence your decision to anticogulate ESUS cases?
This is a great but very difficult question. It is important to remember that currently, there is NO randomized controlled trial data that provides evidence for anticoagulating patients with ESUS, and the ad hoc analysis of the Arcadia trial you mention simply does not change this. Arcadia specifica...
What extended window thrombolysis protocols are your institutions implementing?
Regulatory guidelines set time epochs for IV thrombolysis at 3h (US) and 4.5h (rest of the world). Recent guidelines are similar globally, supporting a 4.5h time window. The Canadian guidelines state that: “Intravenous thrombolysis beyond 4.5 hours may be considered, in consultation with a physician...
Do you consider bleeding risk in elderly, frail patients with atrial fibrillation to be similar for all NOACs?
I believe that apixaban carries a lower risk of bleeding, with particular reference to GI bleed, when compared to rivaroxaban and dabigatran. This is true in the population of AF patients at large and most probably in frail patients as well.
Can you clinically distinguish TIAs from transient focal neurologic episodes (TFNEs) of cerebral amyloid?
It may be difficult to distinguish between those two types of episodes. The first issue would be does a patient has anyloid. If they do, I would err on the side of caution and presume transient focal neurological symptoms were caused by a vascular episode unrelated to amyloid and appropriately explo...
How do you utilize OCT for the diagnosis and management of IIH?
OCT can be a valuable adjunctive objective tool for diagnosing and monitoring papilledema in IIH. However, when it is used, it should not be used alone. It must be integrated with perimetry and fundus exam/photography. It has important limitations that preclude its use as a standalone modality.Limit...
What is your approach to determining eligibility for hospice in persons with Alzheimer's disease?
We strongly recommend early hospice enrollment for patients with dementia as soon as they meet eligibility criteria. In our approach, we carefully evaluate both functional and cognitive decline. One area that is often overlooked, however, is nutrition. When a patient with Alzheimer’s disease begins ...
Should aTTR mutation with bilateral carpal tunnel alone prompt treatment with a gene silencing drug?
Carpal tunnel syndrome does not qualify as a peripheral neuropathy due to TTR amyloid. The amyloid deposition is in the soft and/or connective tissue and not in the nerve. As such, there is no clear indication to treat as much as one might be tempted. Careful follow-up and treatment as soon as neuro...
What is your approach to outpatient antihypertensive therapy after ICH for secondary prevention?
My approach to secondary prevention of ICH depends on the cause.With hypertensive ICH for secondary prevention, the blood pressure goal is less than 130/80 (This is from using the results of the SPS III trial, given the pathological disease mechanisms for both ischemic and hypertensive hemorrhages a...