Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
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...
At what lab values (ferritin, TSAT%) would you offer IV iron therapy to patients with restless leg syndrome?
1. I am hopeful that practitioners will start understanding that ferritin alone is not enough to assess iron because of its acute phase reactivity. I like to order iron parameters after a 5-9 hour fast so the serum iron is not speciously elevated and get a ferritin and TSAT. If the ferritin is <30 a...
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 your first-line therapy for acute migraine treatment in the ER?
Regarding the abortive and preventive treatment of migraine, in the office or ER, we should focus on migraine-specific medications. These are the ergots, triptans, and gepants abortively, and the CGRP antibodies and gepants preventively. The patients who visit ERs every so often tend to have headach...
How do you utilize Diamox in patients with cerebral venous sinus thrombosis and vision symptoms who do not undergo thrombectomy/recanalization?
Diamox (acetazolamide) is often used to treat papilledema with associated visual loss in cases of CVST. While there is a theoretical risk of dehydration from acetazolamide with potential worsening of the thrombosis, 1) acetazolamide is a weak diuretic and 2) the risk of blinding visual loss usually ...
How do you decide between the different oral longer acting levodopa medications?
The question would be, why are you changing, and what are you changing from? (i.e., are one of these your initial agent, a change due to Sinemet side effects, or a change because of motor fluctuations?) The current theory on dopamine replacement is "smoother is better," so the longer (and lower) you...
How do you convert between tetrabenazine, deutetrabenazine, or valbenazine for management of tardive dyskinesia?
I think of these medications as much more clinically similar than different, with the main differences relating to patients who are fast metabolizers. Fast metabolizers often respond well to lower doses of deutetrabenazine or valbenazine compared to tetrabenazine. When converting from one drug to an...
When do you suspect an autoimmune encephalitis in a child or adolescent with new-onset psychosis?
Given the rarity of true childhood schizophrenia, autoimmune encephalitis, and other medical etiologies should be considered in any patient presenting with new-onset psychosis prior to age 13. In adolescents, sudden onset of symptoms, absence of family history, lack of prodrome, and other atypical p...
How do you manage patients with chronic migraine as well as medication overuse headaches?
I agree with Dr. @Dr. First Last about the treatment for chronic migraine and MOH for patients on opiates and/or barbiturates. If they are taking frequent opiates, I prefer to have a pain management doctor detoxify them. In the past, I slowly decreased their medication while giving them long-acting ...
How would you determine the safety of anticoagulation in patients with evidence of cerebral microhemorrhages who present with acute stroke secondary to cardioembolism?
This question assumes that the patient already had an MRI showing microhemorrhages. The Boston criteria provide guidelines for the number of microbleeds, associated superficial siderosis, or major hemorrhage to make the diagnosis of cerebral amyloid angiopathy. I would also assume that at least some...