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...
Cost and access aside, when might you prefer to start a patient on a triptan instead of a gepant for acute migraine therapy?
For me, the triptans are first line for migraine abortion. They have been on the market for well over three decades, we have a lot of experience with them, a lot of clinical-trial information is available on them, and also in special populations like teenagers and adolescents, as well as pregnant wo...
Do you recommend a "washout" period for anti-CGRP medications before conception?
The CGRP-targeted medications come in two groups: gepants and CGRP antibodies. The half-life of the gepants lies in the order of magnitude of 5-10 hours, which means that they are out of the body in roughly 3 days. The half-life of the CGRP antibodies is about a month, which means that it takes 5 mo...
How do you counsel patients who do you not experience early relief of hemifacial spasm after microvascular decompression surgery?
HFS is unique in that neurovascular compression is always the cause, and the location of NVC is almost always at the initial segment of the emerging facial nerve at the pontomedullary junction. High-resolution imaging pre-op using sub-millimeter voxel T2 MRI (BFFE) and MRA (source images) is recomme...
How do you manage patients with good relief but intolerable chest tightness with sumatriptan?
I have a patient, an internist, who has long-standing chronic migraine with and without aura, with other different seasonal episodes, usually in the fall or early winter, of a form fruste of cluster headache. He was taking sumatriptan 100 mg with excellent relief of his migraines. However, he told m...
How do you approach short term antithrombotic regimen, antiplatelets or anticoagulation, after Watchman device placement in ischemic stroke patients with atrial fibrillation and cerebral amyloid angiopathy who are at high risk for intracranial hemorrhage?
This is a good question. Our group published a paper on a series of patients with CAA who underwent placement of Watchman devices for atrial fib (Schrag et al., PMID 32770310). We usually did not anticoagulate patients at all, and we saw only one very minor stroke. I think that it would also be reas...
Do you recommend a workup for POEMS and/or amyloidosis for IgM monoclonal gammopathies associated with neuropathy?
While IgM monoclonal disorders, amyloidosis, and POEMS syndrome may all be associated with peripheral neuropathy, they are not often confused with one another. A patient with a peripheral neuropathy can be diagnosed most simply by a serum protein electrophoresis. The presence of a monoclonal IgM spi...
Do you recommend endovascular therapy in patients with isolated posterior cerebral artery stroke?
There is limited data on EVT for PCA occlusions. The two studies I am familiar with are the TOPMOST study and the PLATO study, both of which are retrospective. The data from these studies suggest that EVT may improve recovery, including visual outcomes, compared to medical management. However, these...
Do you find onabotulinumtoxinA injections effective for the treatment of trigeminal neuralgia?
I use botulinum toxin (off-label) for two face pain conditions, one rare, i.e., trigeminal neuralgia, and one common, i.e., temporomandibular disorder (TMD). For trigeminal neuralgia, I use a tiny needle to inject very small amounts of the toxin into the affected area of the skin and, if involved in...
When do you consider sciatic nerve imaging in cases of foot drop without clinical or EMG involvement beyond the peroneal nerve without clearly indentified compression site?
I think it would be reasonable to image the sciatic nerve in this scenario. Many sciatic neuropathies, especially those caused by compression or inflammatory (vasculitic) lesions, tend to affect the peroneal division much more than the tibial, therefore clinically mimicking a peroneal neuropathy. Th...