Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
Can you use leflunomide and rituximab in a patient with both multiple sclerosis and rheumatoid arthritis?
It is rare for a patient to have both diseases, but immunosuppressive therapy can be used for the management of both conditions. A study published in 2021 investigated the use of a combination of rituximab and leflunomide in rheumatoid arthritis (Behrens et al., PMID 33738492). Rituximab has previou...
What pharmacological management do you consider for self-injurious behavior in patients with autism spectrum disorder?
This is a great question but requires a nuanced answer. It all depends. In short, what I think the clinician needs to know is whether the patient with ASD and self-injury has a treatable condition that is driving self-injury. Perhaps the most critical is whether the patient has a medical problem tha...
How do you treat nocturnal leg cramps?
Nocturnal leg cramps are similar to daytime leg cramps, but stretching may be less convenient to use as a remedy, as sleep can be further disrupted. Treating and preventing leg cramps typically utilizes some combination of hydration and electrolytes but sometimes, medications can help. Consider the ...
How do you decide when to discontinue immunotherapy for primary angiitis of the central nervous system (PACNS)?
I take a multidisciplinary approach with involvement of my neurobiology and rheumatology colleagues for the immunotherapy. PACNS can be relapsing or remitting. So needs close monitoring with radiologic (MRI and MRA high resolution vessel wall imaging or CTA/MRA with CSF studies 6 months and then 1 y...
Are there any patients with newly diagnosed GBM in whom you would adopt Early-Start TTFields based on the TRIDENT study?
The authors of EF-32/TRIDENT should be commended for performing this impressive randomized trial of an already FDA-approved therapeutic in GBM maintenance, asking the question of whether an earlier start of TTF, during chemoradiation, improves overall survival. This is also a big ask of the therapeu...
What is your approach to bloody CSF (that does not clear with sequential tubes) in a patient without acute finding on a head CT?
I still think there is value looking for xanthochromia if CSF obtained >12 h after onset of symptoms. Yes, there are occasional false positives of xanthochromia with traumatic taps, but if a patient presents to ED with sudden onset of a severe headache, negative CT, lots of RBCs on tube 1 and tube 4...
What is your threshold for pursuing a lumbar puncture in an older hospitalized patient with acute altered mental status when the initial workup — including labs, imaging, and urinalysis — is unrevealing?
My threshold for lumbar puncture in an older hospitalized patient with acute altered mental status is high. In my practice, I will not pursue an LP in a patient over 65 solely because an otherwise routine evaluation for delirium is unrevealing. A negative workup alone does not sufficiently increase ...
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 early clinical findings help in differentiating CIDP vs. POEMS?
I would like to share that I had a very challenging experience last year with a patient ultimately diagnosed with POEMS by myself, after more than one year of treatment as CIDP. There were multiple reasons it was challenging:1.) The patient presented initially with NO systemic features - just the ne...
What is your approach to secondary stroke prevention in patients with atrial fibrillation and intracranial stenosis (>70%)?
The patient clearly needs to be on an anticoagulant for stroke prevention with atrial fibrillation and I would choose apixaban. If an antiplatelet is added to the apixaban, the risk of a major bleeding side effect is significantly increased. It is uncertain if apixaban is effective in reducing the r...