Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
What considerations do you take regarding using valproic acid in men who are hoping to conceive with a partner?
A recent cohort study (Meng et al., PMID 41733407) utilizing national databases in Norway and Taiwan examined associations between exposure to paternal valproate monotherapy during the 90 days preceding conception and incidence of neurodevelopmental disorders (NDDs) among offspring after at least 6 ...
How do you approach short term antithrombotic regimen, antiplatelets or anticoagulation, after Watchman device placement in ischemic stroke patients with atrial fibrillation and cerebral amyloid angiopathy who are at high risk for intracranial hemorrhage?
This is a good question. Our group published a paper on a series of patients with CAA who underwent placement of Watchman devices for atrial fib (Schrag et al., PMID 32770310). We usually did not anticoagulate patients at all, and we saw only one very minor stroke. I think that it would also be reas...
When do you consider tapering tocilizumab in patients with GCA in remission?
This is a timely question and recent data sheds some light on this important topic. The risk of GCA relapse is approximately 50% (Mainbourg et al., PMID 30951256) in all comers. The GIACTA trial (Stone et al., PMID 28745999) utilized a one-year course of TCZ. A recent publication of the extension ph...
How do you manage glioblastoma presenting with leptomeningeal dissemination?
Hospice is a very legitimate option. As physicians, we recommend this far too infrequently.
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...
In a young patient with recurrent low-grade glioma s/p gross total resection, is there any role for further observation instead of radiation and chemotherapy?
As simple as this question seems to be on the surface, it is actually a very difficult clinical scenario to opine with certainty, primarily because of a lack of data. So, let us address this with each option in mind, weighing the pros and cons: Observation: We do know that in resected patients, radi...
How would you approach the consideration of a levodopa trial in an older adult with a history of schizophrenia, stable on antipsychotic medication, who has changes consistent with drug-induced Parkinsonism vs Parkinson's disease?
The first step is to establish if it is degenerative Parkinsonism, such as Parkinson's disease (presynaptic dopaminergic loss) or drug-induced Parkinsonism DIP (due to postsynaptic dopaminergic blockade). I will order a DaT scan to differentiate between the two. If the DaT scan is abnormal, I will s...
What maximum core volume or core-to-penumbra ratio do you use for eligibility for extended window thrombolysis beyond 4.5 hours?
For the CTP, most trials used a core less than 70 mL, a mismatch volume of 10 mL or greater, and a mismatch ratio of > 1.2. Most extended-window thrombolysis trials used these parameters.
How do you explain the use of an AI scribe to patients the first time it is used in their care?
I use an AI scribe in my outpatient clinic, and around 90–95% of my patients agree to it. I obtain consent at the start of each visit and make it clear that it's completely optional—that they can say no at the start or change their mind at any point in the visit, with no impact on their care. I also...
Do you obtain an MSLT or start empiric therapy with modafinil in patients with residual excessive daytime sleepiness despite optimal adherence to PAP therapy?
In this situation I would start either modafinil, armodafinil, or solriamfetol for residual EDS if the OSA was appropriately controlled without need for MSLT. We have an FDA label for these medications in this situation to support this practice. If I felt like there was concern for a combination of ...