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...
When would you consider using occipital nerve blocks to treat episodic cluster headaches?
For many years it has been known that occipital nerve blocks containing steroids help for a few days in episodic cluster headache. But giving steroids by mouth for 3-5 days also works well and lasts for several days. (For migraine attacks, I prefer occipital nerve blocks with local anesthesia and no...
How to approach reversal of TNK in hemorrhagic conversion of ischemic stroke?
There is no specific "reversal agent" for tenecteplase. Once administered, the thrombolytic effect will persist until the drug is fully metabolized and any residual plasmin has been cleared by alpha-2-antiplasmin. So, perhaps the first question is what can you do if there is an acute bleeding event ...
Should mRS be incorporated into determining eligibility for extended window thrombolysis?
Key thrombolysis trials (WAKE UP, OPTION, EXTEND, TIMELESS, ECASS-4, HOPE, EXTEND IA) excluded patients with mRS of 2 or greater. The reason for this was the outcome of functional independence at 90 days. Hence, for trial purposes, to look at the outcome, it was necessary to exclude patients with di...
How do you decide when to intervene directly on a feeder artery aneurysm of an AVM?
Flow-related peri-nidal aneurysms can occur in a few different scenarios, which play an outsized role in determining management. These aneurysms can be located intra-nidal, or can be remote. They can also be detected through routine imaging, but can also present as having ruptured. AVM hemorrhage is...
Do you treat migraine with aura if there is not an associated headache/pain?
It is officially called migraine aura without headache, but I like to refer to it as isolated migraine aura. Although a migraine aura can be visual, somatosensory, or involve speech, the presentation in practice, in my experience, is always visual. The best way to diagnose it is by having the patien...
In ischemic stroke patients with low LDL levels (<30-50 mg/dl), would you consider lowering LDL levels to lower values without concern for any side effects?
If LDL levels are already below 70, I don’t target a lower goal. The SPARCL trial showed that reducing LDL to this range has an NNT of about 45 to prevent one stroke, which I find to be modest at best. From my perspective, lowering LDL further (<30-50 range) shifts the focus to treating a number rat...
How do you navigate C-2 refills in patients who are stable in their treatment and do not otherwise need to be clinically seen monthly?
This practice is routine in child psychiatry. We fill stimulant prescriptions electronically at the phone request of the family as long as they are keeping quarterly appointments. We do not charge for that service. We do document it in the medical record. Your question begs another question, however...
How would you determine the safety of anticoagulation in patients with evidence of cerebral microhemorrhages who present with acute stroke secondary to cardioembolism?
There are observational data that suggest the relative safety of anticoagulation in patients with ischemic stroke or TIA with incidentally found cerebral microhemorrhages. An analysis of pooled data from multiple cohorts totaling 20,322 participants showed that recurrent symptomatic ischemic stroke ...
Is there any contraindication to the use of ezetimibe in patients with a history of statin-induced necrotizing myopathy?
These types of questions are always great to discuss. The reality is there is a risk-benefit ratio to be considered. On one hand, there is a concern for the need for lipid-lowering to prevent cardiovascular disease, and some situations are more pressing than others. A diabetic with a known cardiovas...