Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
Have you found sumatriptan to be an effective bridging therapy for trigeminal neuralgia exacerbations until a new maintenance prophylaxis dose becomes effective?
I do not have experience with this kind of use of sumatriptan, and I also do not see a rationale for it to work. My preferred treatment for trigeminal neuralgia is botulinum toxin, especially because of its great tolerability in older patients.
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 repeat antibody testing for seronegative myasthenia gravis?
I will usually recheck in 1-2 years, but I mostly focus on acetylcholine receptor antibodies. I have never seen seroconversion from MuSK negative to MuSK positive. Also, if initial antibody testing for Acetylcholine receptor binding/modulating and MuSK antibodies is negative by RIA assay, I recommen...
How do structural and functional findings on echocardiogram influence your decision to anticogulate ESUS cases?
This is a great but very difficult question. It is important to remember that currently, there is NO randomized controlled trial data that provides evidence for anticoagulating patients with ESUS, and the ad hoc analysis of the Arcadia trial you mention simply does not change this. Arcadia specifica...
In a young patient with recurrent low-grade glioma s/p gross total resection, is there any role for further observation instead of radiation and chemotherapy?
As simple as this question seems to be on the surface, it is actually a very difficult clinical scenario to opine with certainty, primarily because of a lack of data. So, let us address this with each option in mind, weighing the pros and cons: Observation: We do know that in resected patients, radi...
How long do you need to wait to obtain OCT to evaluate for retrobulbar optic neuritis?
There is no need to wait to obtain OCT in suspected retrobulbar optic neuritis. I recommend obtaining OCT at the initial presentation. Acutely, the peripapillary RNFL may be thickened from optic nerve edema, which can help support an acute attack and provide a useful quantitative baseline, although ...
In older adults with mild cognitive impairment, do you ever prescribe cholinesterase inhibitors and/or memantine?
This is a great question, and of course, "do you ever" will get you in trouble every time! Let me start by saying that, in general, I do not prescribe these drugs for MCI. Cholinesterase inhibitors are clearly indicated for the mild-moderate stage of some kinds of dementia (some people would include...
How do you approach timing of repeat plasma p-tau217/Aβ42 monitoring to detect conversion in MCI due to suspected Alzheimer’s disease?
I think that this question is purely “academic” and not relevant for clinical practice. If a patient has clear evidence of MCI based on history and bedside cognitive testing results, and ptau217/Αβ42 ratio falls within the intermediate/non-diagnostic range, then the appropriate course of action, if ...
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...
What brain imaging findings do you find reliable to help support a diagnosis of idiopathic intracranial hypertension?
In a study by Bidot et al., PMID 26457687, transverse venous sinus stenosis (TVSS) was the most useful sign of IIH because of its high pooled sensitivity (97%) and specificity(93%). Orbital findings, such as optic nerve head protrusion, posterior scleral flattening, optic nerve tortuosity, and diste...