Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
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...
What is your approach to the diagnostic workup of small fiber neuropathy in patients with known rheumatic disease?
Small fiber sensory neuropathy (SFN), in general, including in patients with rheumatic diseases, should be suspected based on symptoms (positive more than negative sensory symptoms) and ideally confirmed by clinical examination showing altered temperature and/or pain/pinprick perception in the limbs...
How do you manage an MS patient who has had attacks in spite of being on B-cell depleting therapy?
The data behind ocrelizumab, ofatumumab, and ublituximab show at least 70% reduction in annualized relapse rates. When you recall that most MS patients do not have one relapse every year or even every two years, the real-world implications are that having an MS attack while receiving B-cell therapy ...
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...
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...
How do the results of CREST-2 influence your recommendations on screening for asymptomatic carotid stenosis?
Agree with the prior comment. One important nuance is what “medical management” actually meant in CREST-2. This was centralized, protocol-driven care with structured lifestyle counseling and medication escalation, including access to PCSK9 inhibitors with costs covered. Even in that highly organized...
What elements beyond NEDA-3 do you find valuable for tracking disease progression in MS?
I find NEDA-3 useful, but it is clearly incomplete, particularly for detecting gradual progression that occurs independently of relapses or new MRI lesions. In routine practice, fully quantifying progression and quality of life can be challenging, especially in a busy clinic. For me, what the patien...
For MS patients already on a higher-efficacy DMT, how do you assess if it is time to switch to a new DMT when they have new clinically-silent MRI brain lesions?
I do not use an absolute number of new lesions as the sole threshold for switching a patient who is already receiving a high-efficacy DMT. Instead, I interpret new MRI activity in the context of the timing, number, size, and location of the lesions; the mechanism and expected onset of efficacy of th...
When would you escalate moderate efficacy therapy for MS in a clinically stable patient with a single new clinically silent MRI lesion?
Sure. What is 'moderate efficacy therapy'? How is that defined? And who defines that? Refs? Secondly, a new lesion implies BBB breakdown (supposedly, if it is a T1 gad-enhancing lesion) and so, I would change therapy. My slant is always to use the best data available, so I would use the most efficac...
How do you navigate conversations with patients who are reluctant to start high-efficacy DMTs due to infection risk?
Prescribing and changing DMTs involves shared decision-making and patient education. I fall into the large group of MS specialists who use high-efficacy DMTs for many of my patients at early stages of the disease, as well as in patients with signs of progressive disease. One of the concerns about DM...