Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
How do you manage glioblastoma presenting with leptomeningeal dissemination?
Hospice is a very legitimate option. As physicians, we recommend this far too infrequently.
Do you utilize neurofilament light chain to guide your treatment strategy for multiple sclerosis?
I do not routinely use serum neurofilament light chain levels to guide treatment decisions. The vast majority of my patients with relapsing-remitting MS are already on high-efficacy therapy, so it would not change my DMT management. In patients with progressive disease, the NfL trend over time is on...
How do you decide on the speed and target of blood pressure reduction for spontaneous intracranial hemorrhage?
I think the target and speed of blood pressure reduction in ICH depend on several variables, including initial SBP, clinical stability, hematoma size, and renal function. For patients presenting with SBP >220, I typically aim to lower the pressure to around SBP 160 over the first 12 hours, then grad...
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 factors would guide your decision to safely resume anticoagulation for atrial fibrillation following a recent intracranial hemorrhage?
Whether a patient with atrial fibrillation and an intracerebral hemorrhage should resume anticoagulation depends on whether the bleed was attributed to cerebral amyloid angiopathy (CAA). Most patients with CAA should not be on long-term (lifelong) anticoagulation. If a bleed was attributed to hypert...
Do you switch from Eliquis to Pradaxa in patients who experience a recurrent ischemic stroke while on Eliquis, considering their different mechanisms of action?
I usually don't switch, as there is evidence that making a switch is better for secondary stroke prevention.
Does anyone utilize P2Y12 assays to determine if clopidogrel may be ineffective when used for DAPT?
Yes, I use P2Y12 assays in two distinct settings. Medical management: If a patient on clopidogrel mono/dual therapy has disease progression with ICAD or experiences a recurrent ischemic event, I obtain a P2Y12 assay to assess responsiveness. This helps guide the decision to switch to ticagrelor and ...
What are your preferred beta blockers for migraine prevention treatment?
There is good clinical trial evidence for the efficacy of six beta-blockers in migraine prevention. In alphabetical order, these are: atenolol, bisoprolol, metoprolol, nadolol, propranolol, and timolol. They share a lack of partial agonist or intrinsic sympathomimetic activity. This means that they ...
What is your approach to optic neuritis that worsens after weaning steroids?
The most important first step is to confirm that this represents a true relapse. Visual acuity, color vision, and visual fields are helpful, but can be subjective and variable. I would look for objective evidence of recurrent or worsening optic neuritis, such as a new or worsening RAPD, OCT changes,...
Is there any contraindication to the use of ezetimibe in patients with a history of statin-induced necrotizing myopathy?
These types of questions are always great to discuss. The reality is there is a risk-benefit ratio to be considered. On one hand, there is a concern for the need for lipid-lowering to prevent cardiovascular disease, and some situations are more pressing than others. A diabetic with a known cardiovas...