Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
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 tend not to switch patients from Eliquis/apixaban to Pradaxa/dabigratan. There is no good data to support this and while the mechanistic argument may make sense, especially since dabigatran, a direct thrombin inhibitor, was the only DOAC to reduce ischemic stroke events in a statistically signific...
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...
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 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 for monitoring disability progression in patients with MS?
My standard approach to MS patient visits includes asking about past/chronic symptoms and whether they are stable or worsening. I also ask a review of (neuro) systems with particular focus on gait change, bladder dysfunction, and cognitive concerns, as these are strongly associated with disease prog...
Would you consider anti-IL-5 therapy (mepolizumab or benralizumab) to either prevent or treat the more severe manifestations of eosinophilic granulomatosis with polyangiitis, such as "infiltrative" (e.g., cardiomyopathy, pulmonary infiltrates, or gastroenteritis) or "vasculitic" (e.g., neuropathy, palpable purpura, or glomerulonephritis)?
Yes, I would consider early starting biologics for infiltrative EGPA.
When would you consider using occipital nerve blocks to treat episodic cluster headaches?
For many years, it has been known that occipital nerve blocks containing steroids help for a few days in episodic cluster headache. But giving steroids by mouth for 3-5 days also works well and lasts for several days (for migraine attacks, I prefer occipital nerve blocks with local anesthesia and no...
Would you consider giving platelet transfusion in a patient with spontaneous intracerebral hemorrhage who is on an irreversible antiplatelet agent such as prasugrel?
This question seems logical, but in fact, there has been a clinical trial, the PATCH trial, that found no benefit of platelet transfusion; in fact, both deaths and poor outcomes were more prevalent in the platelet transfusion group than in the control group.
What treatments, after appropriate dose reductions/delays, do you offer for patients with oxaliplatin-induced cold allodynia/dysesthesia?
The primary treatments that I use for cold-induced oxaliplatin neurotoxicity are reducing the oxaliplatin dose and limiting the duration of oxaliplatin treatment (usually not more than 16 weeks of oxaliplatin-containing therapy in the initial line of treatment). Medications that are effective for pa...