Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
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...
Under what circumstances do you decide to place an EVD for patients with cerbellar ischemic stroke?
Although placement of an EVD in a patient with cerebellar infarction can be lifesaving, I rarely use it as a sole treatment for that condition due to the risk of upward herniation. Typically, when the cerebellar infarction has created enough mass effect to cause hydrocephalus, the patient also requi...
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...
For MS patients already on a higher-efficacy DMT, how do you assess if it is time to switch to a new DMT when they have new clinically-silent MRI brain lesions?
I do not use an absolute number of new lesions as the sole threshold for switching a patient who is already receiving a high-efficacy DMT. Instead, I interpret new MRI activity in the context of the timing, number, size, and location of the lesions; the mechanism and expected onset of efficacy of th...
What elements beyond NEDA-3 do you find valuable for tracking disease progression in MS?
I do NOT use NEDA-3 for tracking disease progression. This is because it cannot predict the absence of long-term disability progression, and its weakest link is precisely the "progression" dimension, which is dominated by focal inflammatory MRI activity. It misses the smoldering neurodegeneration th...
What is your approach to the diagnostic workup of small fiber neuropathy in patients with known rheumatic disease?
Small fiber sensory neuropathy (SFN), in general, including in patients with rheumatic diseases, should be suspected based on symptoms (positive more than negative sensory symptoms) and ideally confirmed by clinical examination showing altered temperature and/or pain/pinprick perception in the limbs...
When would you escalate moderate efficacy therapy for MS in a clinically stable patient with a single new clinically silent MRI lesion?
Sure. What is 'moderate efficacy therapy'? How is that defined? And who defines that? Refs? Secondly, a new lesion implies BBB breakdown (supposedly, if it is a T1 gad-enhancing lesion) and so, I would change therapy. My slant is always to use the best data available, so I would use the most efficac...
How do you navigate conversations with patients who are reluctant to start high-efficacy DMTs due to infection risk?
The central message is that the choice is not between treatment and “no risk,” but between the risks of therapy and the risks of inadequately treated MS. Active MS can cause irreversible disability, and disability itself increases infection risk through impaired mobility, bladder dysfunction, dyspha...
What do you do for a patient with Parkinson's Disease and orthostatic hypotension who has failed midodrine, fludrocortisone, droxidopa, pyridostigmine, and atomoxetine?
I would not recommend using amantadine in this situation as it is known to worsen orthostatic hypotension (Perez-Lloret et al., PMID 22336566). This is a tricky situation, and if the patient has failed all of these medications, I would consider an alternate diagnosis, specifically MSA, especially if...
Which calculators, nomograms, or other resources, if any, do you use to help advise and prognosticate patients with newly diagnosed glioblastoma or other gliomas?
This is a rather difficult question to answer because prognosis in patients with glioblastoma (GBM) is best estimated by combining several clinical, molecular, radiographic, and treatment-related factors rather than relying on any single variable. Several validated prognostic models exist, but in cl...