Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
How do you counsel patients who develop DVT or atrial fibrillation requiring anticoagulation when being treated with lecanemab or donanemab?
I believe until further data/studies are available, I would prefer not to use anticoagulation (at least long term) without comprehensive discussion among other treating physicians depending on the indication. The lecanemab appropriate use recommendations (Cummings et al., PMID 37357276) recommend ag...
How do you counsel patients with GCA on the benefits of steroids who have already experienced vision loss?
I first tell the patient they are at considerable risk for further visual loss in the same eye or the other eye over the next 1-2 weeks. I also let them know that, even though their risk of visual loss has been reduced, their best option for preventing further visual loss is immediately starting hig...
Are there any serum markers that can be used to measure disease response to multiple sclerosis therapies?
sNfL, though not specific to MS, in someone with no other confounders, is the only positive biomarker to demonstrate treatment response. All approved DMTs have been shown to reduce sNfL levels, providing positive feedback of a biological response. Once stable, any substantial increase should signal ...
How do concerning TCD trends affect your management of a clinically stable patient with aneurysmal subarachnoid hemorrhage?
I have been relying on TCD to manage clinically stable SAH patients for years. There are several management interventions that I might make in a patient who is showing significant vasospasm on TCD but otherwise seems clinically stable. These interventions include keeping a patient in ICU for frequen...
Does screening for sleep apnea in asymptomatic patients reduce long-term dementia risk?
Obstructive sleep apnea (OSA) is common, underdiagnosed, and increasingly recognized as a potentially modifiable contributor to late-life cognitive decline. Observational studies consistently report associations between OSA, intermittent hypoxemia, sleep fragmentation, cerebrovascular injury, Alzhei...
Which patients are good candidates for transcranial electrical stimulation for the treatment of chronic insomnia?
Transcranial magnetic stimulation (TMS) is a noninvasive neuromodulation technique that has demonstrated efficacy in the treatment of insomnia in randomized clinical trials, although evidence supporting its long-term effectiveness remains limited. Studies have reported improvements in both subjectiv...
How do you make the decision to empirically treat for GCA when a patient is referred but cannot be immediately seen in clinic?
This is an important question because referrals for possible GCA are common scenarios when a rheumatologist may be asked to recommend a treatment before seeing the patient which are often challenging scenarior. The factors I typically rely on to rate the probability of GCA include: - Specific sympto...
What do you recommend as a first-line antidepressant in patients with major depressive disorder and migraines?
In my clinical practice, I have found SNRI medication, particularly extended-release venlafaxine (dosed from 37.5 mg to 225 mg), to be helpful for patients with both comorbidities. Other medication classes I have seen used to good effect include TCAs (amitriptyline, nortriptyline) and some SSRIs (se...
When do you add corticosteroids to the treatment of HSV encephalitis?
My practice does not involve adding corticosteroids to confirmed HSV encephalitis unless there is a significant concern for malignant edema and midline shift. We lack large randomized, placebo-controlled trials, therefore their role is uncertain as of yet.
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...