Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
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...
What maximum core volume or core-to-penumbra ratio do you use for eligibility for extended window thrombolysis beyond 4.5 hours?
For the CTP, most trials used a core less than 70 mL, a mismatch volume of 10 mL or greater, and a mismatch ratio of > 1.2. Most extended-window thrombolysis trials used these parameters.
Do you obtain an MSLT or start empiric therapy with modafinil in patients with residual excessive daytime sleepiness despite optimal adherence to PAP therapy?
In this situation I would start either modafinil, armodafinil, or solriamfetol for residual EDS if the OSA was appropriately controlled without need for MSLT. We have an FDA label for these medications in this situation to support this practice. If I felt like there was concern for a combination of ...
What extended window thrombolysis protocols are your institutions implementing?
For those with disabling deficits with last known well that is unknown and within 4.5 hours from symptom discovery or wake-up stroke with a non-intervenable LVO or no LVO, we pursue Fast Stroke MRI for IV thrombolysis assessment after CT head non-contrast and CTA head and neck. If there is an interv...
How do you explain the use of an AI scribe to patients the first time it is used in their care?
I use an AI scribe in my outpatient clinic, and around 90–95% of my patients agree to it. I obtain consent at the start of each visit and make it clear that it's completely optional—that they can say no at the start or change their mind at any point in the visit, with no impact on their care. I also...
For stroke patients with ablated paroxysmal atrial fibrillation without known recurrence and ICAD, would you recommend dual antiplatelet therapy or anticoagulation with or without an antiplatelet agent?
Ablation treats cardiopulmonary symptoms, but it has not been adequately tested against anticoagulation for AFib-related stroke. Anecdotally, at least once a month, I will see a patient with an acute embolic-appearing stroke after their cardiologist has stopped their anticoagulation because they wer...
Is moderate-intensity statin plus ezetimibe just as effective as high-intensity statin monotherapy in preventing major cardiovascular events?
The secondary stroke prevention trial showed that high/moderate-intensity statin therapy combined with ezetimibe and titrated to achieve LDLc <70 were equally effective (compared to goal LDLc <100). Overall, the most important determinant of risk reduction is the achieved LDLc, and so moderate inten...
What types of cardiac conduction abnormalities would lead you to avoid using tricyclic antidepressants?
I wouldn’t say it is a definite contraindication. But, I would want to be sure it is a longstanding patient and they are seeing a cardiologist regularly. Then, if the QTc were within reason, I would consider it; but it wouldn’t be high on my list of options.
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...
How do you decide on switching to a different preventative anti-CGRP treatment in migraine patients who are experiencing reduced effectiveness with their current treatment?
On occasion, I have found that patients who were diagnosed with chronic migraine actually have EPH or CPH and respond to an indomethacin trial. Alternatively, those with less-than-ideal responses to CGRP antagonists or gepants, Botox injections can offer more relief. These patients tend to have a si...