Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
In an older adult hospitalized with recurrent falls, weight loss, without clear injuries, but with an inconsistent or difficult-to-reach caregiver, what findings would make you formally report suspected elder neglect and/or abuse?
I'm so glad that you're thinking about the possibility of abuse/neglect in this scenario! It's important to have it on our differential, or we'll always miss this diagnosis. First, it would be good to see if the patient can explain what is happening and provide contextual information that veers us a...
How do you conduct follow-up on patients with brain mets who have undergone GammaTile placement?
For patients with high-grade gliomas, they get an immediate post-implant CT and MRI for dose calculation, then I schedule serial follow up CE-MRI every 9-10 weeks for at least a year; if stable at the one-year mark, I "graduate" the patient to get MRIs every 12 weeks for the second year of follow-up...
How do you counsel patients and caregivers about the trajectory of cognitive decline in Parkinson’s disease?
I address the subject of cognitive impairment fairly early in PD, since patients may notice mild deficits in multitasking and attention even within the first few years of diagnosis. Strategies such as making lists and breaking down individual tasks are effective in preserving independence. Worsening...
What are your vaccine recommendations while patients are on biologics?
Live vaccines are best completed at least a month before initiation of biologics when these are appropriate (e.g., MMR, chickenpox, yellow fever). The data on non-live vaccines is limited. I personally think that some degree of protection is better than none. I will not interrupt biological therapy ...
When should you seek hyperbaric oxygen therapy for patients with CRAO?
I usually pursue hyperbaric oxygen therapy within the 24-hour window from symptom onset for CRAO. This can be performed following TNK if given. In reality, though, there are multiple barriers to achieving this, including: Few centers offer hyperbaric oxygen therapy Labor intensive Difficulty with i...
What is your preferred workup for patients who present with concern for autonomic neuropathy?
When patients report one or more symptoms suggestive of autonomic dysfunction, objective confirmation of impaired autonomic function is required. This may include the standard battery of autonomic tests included in the CASS score (tilt table testing, response of HR and BP to Valsalva maneuver, and ...
For patients with hydrocephalus secondary to leptomeningeal disease, how do you determine what type of shunt device to place?
For my small part, please ask neuro-oncology if they plan to use intrathecal chemo (and need a hybrid with Ommaya).
Would you start cholinesterase inhibitors for a patient with MCI or mild dementia based on MoCA testing, when there is concern for frontotemporal dementia?
No, there is no benefit of cholinesterase inhibitors and even a risk of harm from them in FTD.
Which imaging features do you use when considering Normal Pressure Hydrocephalus to decide whether to proceed with large-volume LP or lumbar drain trial?
At our center, we follow the approach of the NPH clinic at the Imperial College Hospital in London.See this excellent review article for further details: Carswell, PMID 36162853.
In advanced Parkinson’s disease, how should clinicians assess symptom management and quality of life when patients are no longer able to communicate themselves?
This is challenging and why palliative care professionals are not familiar with neurodegenerative conditions, questions their efficacy in helping our patients. Using validated tools can help such as the ESAS-rPD. This scale can be used to assess response to interventions. Family members may be able ...