Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
Do you wait to treat small asymptomatic brain metastases until they reach a certain size?
I typically treat all lesions on MRI that are found to be concerning for brain metastases. This is after a discussion with our neuroradiologist colleagues. If there is uncertainty that a small lesion may not be a brain metastasis, then I will elect to follow with a surveillance MRI and treat in the ...
Would you consider off-label IV thrombolysis in patients taking a DOAC and presenting with disabling acute ischemic stroke within the window?
I usually do not (since there is still equipoise) unless they are not an acute trial or thrombectomy candidate and have severe, disabling deficits, and only if their last DOAC dose was not within 24 hours rather than 48 hours. I also discuss in detail the unknown and the risks with patients or their...
What is your approach to managing hallucinations in dementia?
One thing to remember is that hallucinations are not always disturbing to the patient, but to the caregiver! If the patient is fine with seeing a little girl or dog (often in LBD), the family just needs to be educated to let it go. They don’t need to AGREE that the hallucinations are present; they j...
What objective tools do you use to help determine if a patient is too high risk for anticoagulation to prevent stroke or DVT?
There are a number of risk scores like HASBLED that can be used, but I continue to use clinical judgment and shared decision making. The excellent risk profile of NOACs and the availability of LAAO mean that I can usually come up with a solution for almost every patient that will protect them from s...
Do you generally switch aspirin to another antiplatelet agent if a patient has a non-embolic ischemic stroke and isn't a candidate for DAPT?
I do tend to switch, mainly to impress the patient that I am trying hard to prevent another stroke, and not because there is clear evidence of one antiplatelet over another. Clopidogrel or ticagrelor would be candidates, or I might add cilostazol to aspirin, as this combination has little bleeding r...
How early do you implement PCSK9 inhibitor therapy for stroke patients with very high-risk ASCVD?
For me, it depends case by case. If the patient is statin naive or on a suboptimal dose with above goal LDL and TAG, I will start a statin or increase statin dose/intensity, respectively, with lifestyle and diet changes, and evaluate the trajectory of the parameters in 6 months to see if they are he...
When do you use olanzapine for acute migraine treatment?
Although off-label and not included in guidelines, olanzapine can be helpful for migraine attacks in the ER and even for prevention in chronic migraine that has failed all other treatments. 10 mg is usually given IM and 2.5 or 5 mg IV. The MOA is probably as a dopamine antagonist and it is often use...
When do you check thoracic paraspinals on needle EMG in suspected myopathy or myositis?
The need to sample the paraspinal muscles (especially thoracic) in suspected myopathy is diminishing with more sophisticated genetic testing and better antibody testing for inflammatory myopathies. The most common disorder that people learn to remember to sample the paraspinal muscles in Pompe disea...
In what clinical scenarios do you utilize opioids in patients with restless leg syndrome?
I would say in refractory RLS, i.e., the patient has failed all the options below: Iron supplementation if ferritin <50, Gabapentin/pregabalin, Dopamine agonists, and Non-pharmacological options (like the vibrating pad). *I don't love carbidopa/levodopa for RLS. It very often causes augmentation.
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...