Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
What pharmacological management do you consider for self-injurious behavior in patients with autism spectrum disorder?
This is a great question but requires a nuanced answer. It all depends. In short, what I think the clinician needs to know is whether the patient with ASD and self-injury has a treatable condition that is driving self-injury. Perhaps the most critical is whether the patient has a medical problem tha...
What is your preferred first-line treatment for chronic fatigue in patients with long COVID-19?
Assuming that a thorough workup for other causes of fatigue (anemia, thyroid dysfunction, sleep apnea, etc.) has been performed and is negative, no single medication has been proven by a randomized placebo-controlled trial to help chronic fatigue in PASC. Anecdotally, my colleagues who treat PASC ha...
What imaging do you recommend for patients with suspected CSF leak?
MR brain is usually the best place to start, but if you have a high clinical suspicion and unrevealing results, there are a few other imaging methods to consider. CT myelogram is the gold standard for spinal leaks, and a combination of high-resolution CT and CT cisternography can be useful for crani...
What are your go-to options for managing ICU delirium in patients with contraindications to antipsychotics?
Evidence for Ramelteon (Yu et al., PMID 36726202)Delirium with behavioral disturbances Depakote Clonidine Propranolol, especially with TBI Non pharmacological Make sure they're closer to the nursing station. Constant re-orientation. Shades open during the day and close at night. Bring anything they ...
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...
What treatment strategies would you utilize in a patient with newly diagnosed HLA-B27+ axial spondyloarthritis (with active and chronic sacroiliitis on MRI) and recent diagnosis of MS that is well-controlled MS ocrelizumab given the need to avoid TNF inhibitors?
This is a very challenging scenario. On one hand, TNFi are generally unsafe for MS due to demyelination risk, and on the other hand, anti-CD20 therapies for MS are linked to new AxSpA, but B-cell depletion might also benefit AxSpA. Thus, management requires specialized care in balancing both disease...
What is your approach towards continuing cancer screening in a young adult with Tif-1+ dermatomyositis, and negative initial CT chest/abd/pelvis?
Young TIF-1 is likely behave as juvenile DM with TIF-1, where the risk of cancer is much lower. I have many young TIF-1 that never developed cancer. I still think that careful ongoing monitoring is needed for 3 years from diagnosis. For cancer risk assessment and management, use the International gu...
For patients with hydrocephalus secondary to leptomeningeal disease, how do you determine what type of shunt device to place?
I don't think one is especially better than another from a hydraulic point of view. The Certas Plus valve offers the "virtual off" setting so that IT chemotherapy can be allowed to circulate for a period of time before the shunt is "turned back on".
Should ASPECTS be used to determine eligiblity for thrombolysis beyond 4.5 hours?
You can use CT and CTA (often mCTA) to decide to thrombolyse beyond 4.5h. You do not necessarily require CTP. Both cohort studies and at least two randomized trials have reported benefit from this approach. ASPECTS is a measurement scale dependent on the quality of the NCCT imaging, the quality and ...
How do you approach an acute non-LVO stroke with a known large core (>70 mL, 0-5 ASPECTS, or other metric)?
As with any treatment, you have to weigh the individual patient characteristics and overall risks vs. benefits. If there is no LVO, then the question is whether to pursue thrombolysis. In the extended window, thrombolysis was really only helpful in very small core patients, so if the patient is beyo...