Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
How do you distinguish between episodes of vascular steal and seizures in patients with an AVM?
Distinguishing between vascular steal and seizures in patients with AVMs can be challenging, but certain patterns may help. Vascular steal occurs when blood is shunted through the AVM nidus, bypassing the surrounding tissue and causing regional or global oligemia. The shunting can result in transien...
How do you manage patients with atrial fibrillation having a thromboembolic infarct despite being on adequate anticoagulation?
This scenario is always challenging. In terms of anticoagulation, the efficacy of DOACs in preventing embolic events in AF patients is around 70%, which is impressive compared to warfarin but not foolproof. In cases of a second embolic event while on anticoagulation, two reasonable approaches are of...
How do you approaach ischemic stroke from suspected symptomatic ipsilateral carotid web with less than 50% stenosis?
I would need to know what the definition of "suspected symptomatic" means in this setting. Is this the patient's first ischemic event? Or have there been multiple ischemic episodes? Is the stroke pattern sub-cortical/lacunar-type from uncontrolled microvascular risk factors or cortical-appearing sug...
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...
For a patient with acute stroke who cannot tolerate statins, what is your preferred second-line agent for secondary prevention?
First question - is the patient experiencing the nocebo effect? I would explore statin-based symptoms. Ezetimibe - if only needs a small reduction. If you need to be more aggressive, I would use PCSK9 inhibitors. If the patient cannot tolerate a PCSK9 inhibitor or if you need more lowering, you can ...
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 is your treatment approach to functional cervical dystonia?
This is a relatively common situation. After making sure of the diagnosis of functional cervical dystonia, I explain the reversibility and fluctuation with mood changes (that may or may not be perceived by the patient) and demonstrate that they DO have some control over their movements through distr...
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 find consumer grade wrist actigraphy useful in measuring sleep quality and duration?
Consumer wearables are advancing quickly, and there is a lot of variation in their performance, particularly in those with sleep disorders. Unfortunately, there is a wide variation in the performance of devices, even ones using the same signals to calculate sleep/wake. Additionally, orthosomnia is a...
How do you counsel elderly patients who demonstrate mild cognitive impairment but do not meet the criteria for a neurocognitive disorder?
I would let them know that mild cognitive impairment (MCI) is an umbrella diagnosis with many different contributing factors as well as risk factors for progression to dementia. Control what you can control. Limit contributing factors such as pain, mood, and sleep optimization, as well as limiting a...