Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
How would you empirically manage a large sellar/suprasellar mass with encasement of the right cavernous and terminal internal carotid arteries?
Knowing the histology of the mass would really help in creating more accurate treatment recommendations. A biopsy of a sellar mass is usually accomplished by an endonasal-endoscopic transsphenoidal approach utilizing the expertise of an ENT surgeon and a skull-base neurosurgeon. However, in this cas...
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...
How should the possibility of more chronic forms of autoimmune encephalitis influence our neuronal antibody testing thresholds for patients with slower progressive cognitive decline?
I will disclose I am not a Cognitive/Behavioral Neurology specialist nor a Neuroimmunologist per se, but I would exercise caution interpreting the conclusions of the paper that was cited. I went over the paper briefly, and I realized that: 28 patients were diagnosed with "autoimmune dementia", many ...
Do you order screening echocardiograms for patients with migraine with aura?
I do not and would not, based on that abstract. We would need higher-quality studies to prove that closing PFO decreases adverse vascular outcomes in patients with migraine disorder with aura.
For a patient with glioblastoma also found to have a distant presumed meningioma with a location/size such that you would have otherwise recommended RT, would you offer concurrent treatment?
I think if the situation is non-urgent and the lesion (meningioma) can be safely monitored, one approach would be to prioritize treatment of the glioblastoma while observing the meningioma. If, however, the meningioma demonstrates interval growth and/or is located in an area at higher risk for causi...
How do you determine personalized blood pressure targets after ischemic stroke?
This is an excellent question about an article that is still in press. The authors of the study attempted to optimize BP after mechanical thrombectomy for stroke by determining an optimal BP range for each patient and by determining optimal tissue oxygenation via near-infrared spectroscopy in respon...
Does anyone utilize P2Y12 assays to determine if clopidogrel may be ineffective when used for DAPT?
Yes, I use P2Y12 assays in two distinct settings. Medical management: If a patient on clopidogrel mono/dual therapy has disease progression with ICAD or experiences a recurrent ischemic event, I obtain a P2Y12 assay to assess responsiveness. This helps guide the decision to switch to ticagrelor and ...
How do you manage patients with good relief but intolerable chest tightness with sumatriptan?
An abstract I collaborated on was accepted by the European Society of Cardiology reported that patients with angina diagnosed with migraine have a higher prevalence of vasospastic angina, otherwise known as angina and non-obstructive coronary artery disease (ANOCA). We are recommending that these pa...
Do you titrate anti-seizure medication doses in the setting of high or low serum drug levels if patients remain seizure free?
The short answer is "no", especially in the setting of high levels, if there are no side effects reported, and other appropriate surveillance labs look good (such as CBC and LFTs for VPA). The only case where I might increase the dose slightly would be for a below-therapeutic range level in a seizur...
What is your approach to escalating therapies for stiff person syndrome that is refractory to IVIG and steroids?
Step 1: Make sure the diagnosis is correct, especially if seronegative, or very weakly positive for GAD65 antibodies.Misdiagnosis of SPS is common and diagnostic criteria have been recently proposed (Reference 1). Patients who complain of subjective stiffness/muscle spasms, but do not have objective...