Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
How do you counsel patients and caregivers about the trajectory of cognitive decline in Parkinson’s disease?
I address the subject of cognitive impairment fairly early in PD, since patients may notice mild deficits in multitasking and attention even within the first few years of diagnosis. Strategies such as making lists and breaking down individual tasks are effective in preserving independence. Worsening...
Are triptans contraindicated for migraine treatment in patients with sickle cell disease?
Although triptans are not formally contraindicated in sickle cell disease, many SCD patients have silent cerebral infarcts and significant cerebrovascular vasculopathy, which are absolute contraindications to triptans. A thorough assessment for silent strokes, such as MRI/MRA, is recommended, and ex...
How do you treat patients with stroke thought to be secondary to Lambl excrescence?
Pathophysiologically, these occur through sheer stress to the valvular endocardium causing small areas to be denuded followed by fibrin deposition and microthrombi formation on the endocardial injury, which can embolize. Histopathologically, they have similarities to fibroelastomas (which are larger...
Would you consider off-label IV thrombolysis in patients taking a DOAC and presenting with disabling acute ischemic stroke within the window?
Addendum: Re- access to serum concentration for the DOAC. Yes - access to serum concentration for the DOAC, like factor Xa levels, for example, for Eliquis and Xarelto, or ECT for dabigatran, does change my management. In those with normal levels of specific anticoagulation tests, I would discuss IV...
How do you determine personalized blood pressure targets after ischemic stroke?
This is an excellent question and really takes careful consideration of individual patient characteristics. This also requires detailed discussions with your Neuro-Interventional Radiology Team so that you can best understand what happened during thrombectomy and how successful reperfusion therapy w...
Would you use a lumbar drain in a patient with spinal stroke from fibrocartilagenous embolism?
There are no clinical trials to suggest any benefit. Smaller studies - particularly case series have shown some benefit with the use of lumbar drain in the first 48 hours and keeping the pressure around 10 mmHg. These include mostly patients post a cardiovascular surgical procedure as a cause in the...
Is there a role for using an external ventricular drain (EVD) trial in the workup of normal pressure hydrocephalus?
Typically, the work-up of normal pressure hydrocephalus involves either a large volume lumbar puncture or a 48-72 hour lumbar drain trial (and sometimes both). An external ventricular drain would be too invasive.There is an excellent review article that was recently published regarding this topic:Ca...
What is your approach to REM behavior disorder not adequately treated with melatonin and clonazepam?
Rule out comorbidities like sleep apnea or medications causing RBD. Optimize doses for melatonin and clonazepam, and consider dual therapy with these. Other options are gabapentin or pramipexole. Thanks,Sam Morkous
What medications are preferred and contraindicated for insomnia in patients with a recent stroke or traumatic brain injury?
In acute brain injury (ABI), which includes stroke and traumatic brain injury the focus is often on neurorehabilitation. The presumption here is that the patient is medically and neurologically stable. For example, not having a stroke in evolution, uncontrolled gastrointestinal bleeding, or similar....
What factors would guide your decision to safely resume anticoagulation for atrial fibrillation following a recent intracranial hemorrhage?
Whether a patient with atrial fibrillation and an intracerebral hemorrhage should resume anticoagulation depends on whether the bleed was attributed to cerebral amyloid angiopathy (CAA). Most patients with CAA should not be on long-term (lifelong) anticoagulation. If a bleed was attributed to hypert...