Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
How do you manage patients with atrial fibrillation having a thromboembolic infarct despite being on adequate anticoagulation?
This scenario is always challenging. In terms of anticoagulation, the efficacy of DOACs in preventing embolic events in AF patients is around 70%, which is impressive compared to warfarin but not foolproof. In cases of a second embolic event while on anticoagulation, two reasonable approaches are of...
When is air travel safe for patients with recent diagnosis of ischemic stroke?
Air travel on a modern commercial jet includes full pressurization and oxygenation, such that I see minimal or no risk to air travel. Flying on a small, private plane would have higher risk, so I would wait longer for that, perhaps even a month. During helicopter flights for acute stroke patients, o...
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.
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 low. Unexplained autonomic dysfunction, especially orthostatic hypotension without compensatory tachycard...
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 setting. The point raised by the question is more than reasonable. Ideally, a randomized trial of prophylaxis vs. placebo should occur before we change our p...
When is it useful to test for multiple amyloid-related biomarkers for patients undergoing work-up for cognitive impairment?
If a patient has a presentation consistent with MCI or early dementia due to AD (slow progressive decline, STM loss, no hallucinations, no neuro deficits), I will get an MRI and amyloid blood-based biomarkers. If the goal is just a diagnosis, I stop there. If they are interested in “mab” therapy, I ...
How do you decide on the speed and target of blood pressure reduction for spontaneous intracranial hemorrhage?
I think the target and speed of blood pressure reduction in ICH depend on several variables, including initial SBP, clinical stability, hematoma size, and renal function. For patients presenting with SBP >220, I typically aim to lower the pressure to around SBP 160 over the first 12 hours, then grad...
What is your approach to management and surveillance in low grade traumatic blunt ICA injury?
For blunt cerebrovascular injury (BCVI), I use the Biffl scale to evaluate the extent of vessel trauma. The extracranial neck vessels, such as the cervical ICA or VA, are most commonly affected. The Biffl classification consists of five categories, with Grade 1 representing a low-grade injury. This ...
How do you manage glioblastoma presenting with leptomeningeal dissemination?
Hospice is a very legitimate option. As physicians, we recommend this far too infrequently.