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...
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...
Do you switch from Eliquis to Pradaxa in patients who experience a recurrent ischemic stroke while on Eliquis, considering their different mechanisms of action?
I tend not to switch patients from Eliquis/apixaban to Pradaxa/dabigratan. There is no good data to support this and while the mechanistic argument may make sense, especially since dabigatran, a direct thrombin inhibitor, was the only DOAC to reduce ischemic stroke events in a statistically signific...
How do you assess the risk of developing demyelinating disease when initiating TNF inhibitors?
Demyelinating disease (DD) associated with TNF inhibitors is rare. Risk assessment is mostly clinical. TNF should be avoided if there is a personal history of established DD, especially MS. A strong family history in first-degree relatives or concerning neurological symptoms should warrant caution a...
How do you decide on head-of-bed positioning after mechanical thrombectomy for acute stroke?
First, there is some evidence that HOB positioning is related to deterioration/improvement before endovascular thrombectomy (EVT) from the ZODIAC trial. Second, safety comes first. Follow your ABCs. If the airway is ok, the patient does not develop orthopnea with a supine position, and the BP is ok ...
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...
How long do you recommend holding CGRP inhibitors after an ischemic stroke?
Physiological role of CGRP and theoretical cerebrovascular risks CGRP is a potent vasodilator involved in cerebral vascular regulation, collateral circulation, and potentially neuroprotection during ischemia. Experimental studies suggest that CGRP inhibition may impair compensatory vasodilat...
When should one consider obtaining a cardiac MRI in ischemic stroke patients?
This is a terrific question. Cardiac MRI is increasingly utilized in the diagnostic evaluation of ischemic stroke and can uncover clinically covert cardiovascular disease. The clinical utility in ischemic stroke is most in patients with concern for LV thrombus (low EF or recent anterior ST elevation...
If an aphasic patient presenting for ischemic stroke has a confirmed LKW <4.5 hours but you are unable to confirm other absolute contraindications (medications, recent surgeries, GI bleeding, etc.) to tenecteplase, what is your approach to determining thrombolysis eligibility?
I take a case-by-case approach to this type of situation. In practice, you can’t always rule out every major contraindication with 100% confidence within the timeframe required to give a thrombolytic. For example, a patient may not know they have severe thrombocytopenia, but I won’t go looking if th...
Do you typically recommend sleep studies for patients with Parkinsonism?
Not necessarily. If there is concern for sleep apnea (i.e., snoring, etc), then it would be worth doing, as a CPAP can be helpful for sleep quality, but I have found most sleep labs (this includes both community and university-based) are not great at otherwise diagnosing/accounting for other sleep a...