Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
What is your approach to benign appearing (on MRI) septum pellucidum/intra-ventricular masses?
I typically view "benign-appearing" on MRI as a helpful indicator but one that we usually can't altogether trust in isolation. I would consider size, symptoms, risk of obstruction, and any trajectory of change. I would at least consider cytology and cfDNA from CSF if biopsy is felt infeasible, and p...
Do you typically give GI prophylaxis when providing patients with steroid taper for status migrainosus?
I usually do a 3-6 day taper with prednisone, dexamethasone, or medrol dose pack for status migrainous. Occasionally, I have done a 12-day taper if the status migrainous is prolonged. I have not used GI prophylaxis.
How much does platelet mapping or platelet function analysis influence your management, particularly in patients with recurrent ischemic strokes despite being on dual antiplatelet therapy?
P2Y12 or CYP2C19 testing, when available, is a reasonable part of the workup for recurrent strokes on dual antiplatelet. However, it is only one aspect of the workup, with the rest focusing on uncontrolled risk factors and untreated mechanisms like atrial fibrillation, carotid web, thrombophilia, ca...
Have any of the findings from the 2026 AAN/AHS review of migraine prevention changed your practice?
Neither this nor other reviews or guidelines determine what I do in practice. I base what I do in practice on my knowledge and experience as well as on common sense, of course, always with the best interest of the patient in mind. As I mentioned earlier in posts and also emphasize in my book, HEADAC...
When would you consider continuing valproic acid (Depakote) for seizure prophylaxis preconception or during pregnancy?
Frequent seizures with attempted wean.Nocturnal events increasing risk of SUDEPPrior change in ASMs attempted twice pre-pregnancy with acute breakthroughs
What is your approach to secondary stroke prevention in patients with atrial fibrillation and intracranial stenosis (>70%)?
The patient clearly needs to be on an anticoagulant for stroke prevention with atrial fibrillation and I would choose apixaban. If an antiplatelet is added to the apixaban, the risk of a major bleeding side effect is significantly increased. It is uncertain if apixaban is effective in reducing the r...
What are your preferred beta blockers for migraine prevention treatment?
Beta blockers, originally developed for cardiovascular disease, were serendipitously discovered to reduce the frequency and severity of migraine attacks in the late 1960s. They remain the most widely used class of prescription preventive medications for migraine. Among beta-blockers, only propranolo...
Do you still obtain Tensilon (edrophonium) testing for myasthenia gravis, and what do you feel is the added value over serum testing?
Edrophonium has not been available commercially for years. Neostigmine can be used intramuscularly instead, given with atropine, and the effect assessed 30-45 minutes later. Some seronegative patients will have a positive test, so it can be helpful when you still suspect myasthenia and want further ...
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...
Do you give TNK to patients presenting with transient global amnesia like symptoms within 4.5 hours?
This is a very interesting clinical question that does not come up practically very often. There is next to no study data available on the matter, so most of what I will propose here can be classified as an expert take. I think that the most direct, and clinically relevant way of approaching such a ...