Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
When are you using colchicine for stroke or MACE reduction?
I agree, colchicine is not ready for prime time. Paul Schanfield, MN
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 do you pursue further epilepsy workup in a patient with unexplained falls?
In practice, I think I rarely see patients who have experienced an unexplained fall. Most of the time, I'd be asked to see a patient after their first presentation with a seizure, and we might uncover the history of the unexplained fall in our first visit. If I got a call from an emergency departmen...
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...
How do you determine when to wean patients with idiopathic intracranial hypertension off of acetazolamide?
As a neuro-ophthalmologist, my greatest concern is vision-threatening papilledema in IIH. So if there is no papilledema, that threat should be resolved for the time being, right? Not so fast. Accurate direct ophthalmoscopy has become an "optional" skill set for most neurologists. Subtle papilledema ...
How do you taper steroids to treat tremors due to immune checkpoint inhibitor reactions?
I think this depends on the type of tremor and the certainty that it represents irAE, as steroids can also cause tremors (and movement disorders relative to ICI are also relatively uncommon). In general, though, grading severity and tapering in alignment with established guidelines is reasonable.
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.
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...
What other conditions should you consider in someone with presumed Tolosa Hunt but without significant improvement on steroid therapy?
Sufficient workup should ideally be obtained before initiating steroids in order to exclude disorders that may have a similar presentation with quite a different approach to management. These investigations include but are not limited to the following: brain MRI with contrast + thin slices through t...
How do you decide on head-of-bed positioning after mechanical thrombectomy for acute stroke?
First, there is some evidence that HOB positioning is related to deterioration/improvement before endovascular thrombectomy (EVT) from the ZODIAC trial. Second, safety comes first. Follow your ABCs. If the airway is ok, the patient does not develop orthopnea with a supine position, and the BP is ok ...