Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
Do you add antiplatelet medications to patients already on anticoagulation for atrial fibrillation if they have a stroke due to a competing etiology?
Adding antiplatelet therapy to anticoagulation in patients with atrial fibrillation and a noncardioembolic stroke has not shown a clear benefit and definitely increases bleeding risk. Okazaki et al., PMID 41051787 did not find a benefit and increased bleeding risk. An exception might be in acute MI ...
What resources do you find helpful for patients with MSK concerns who may not have access to physical therapy or who cannot afford it?
I would recommend that all primary care providers purchase a copy of “The Sports Medicine Patient Advisor” by Pierre Rozier (now 3rd edition). It is entirely comprised of handouts with permission to copy for patients. That is my go-to resource for patients. I’ve used a version of it since my fellows...
What follow-up monitoring would you recommend for a patient with self-resolved idiopathic pupil-sparing third nerve palsy?
I have only seen this with diabetics and it’s rare even then. I don’t have any specific follow-up if the tests are all negative.
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...
Is it safe to use monthly injectable CGRP antagonists with oral gepants in the same patient?
Yes. To my knowledge, there is no data to suggest that it is not. I have routinely used oral gepants as abortive treatment in patients who are on a CGRP monoclonal antibody for prevention.There have been at least 2 retrospective studies looking at the safety and tolerability of using oral gepants in...
When do you use anticoagulation over antiplatelet therapy for secondary stroke prevention in patients with LV injury or dysfunction?
First, I will observe that the recent work is a cohort study, not an RCT< and I would be careful about concluding that anticoagulation is the best approach. We have had prior trials, e.g., WARCEF and the related ESUS trials (NAVIGATE and RESPECT), and others that have looked at possible cardioemboli...
What have you found helpful in counseling patients with migraine reluctant to take preventative medications?
I think all of the responses here are very reasonable, but often the hesitancy is based less on resistance to a specific medication than on the self-stigmatization we see in patients with chronic headache, migraine, or other primary or secondary headaches. Because migraine is not a life-threatening ...
What tools do you use to evaluate for cognitive deficits in young patients?
I typically screen patients for the usual suspects when the working memory is the complaint. These include poor sleep quality, pain anywhere in the body, stress, anxiety/depression. These factors distract the brain and make it difficult to focus and perform cognitively. By addressing these factors, ...
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 is the utility of a hypercoagulability workup in recurrent cryptogenic stroke, and what specific tests would you recommend?
Ambulatory monitoring for AFib is probably more helpful than such a thorough clotting workup.