Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
How do you navigate C-2 refills in patients who are stable in their treatment and do not otherwise need to be clinically seen monthly?
This practice is routine in child psychiatry. We fill stimulant prescriptions electronically at the phone request of the family as long as they are keeping quarterly appointments. We do not charge for that service. We do document it in the medical record. Your question begs another question, however...
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...
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 pharmacological management do you consider in patients with Autism Spectrum Disorder whose primary behavior is aggression?
As with all of my child patients, my approach is never to medicate behavior but rather to medicate suffering. This means that I view “aggression” of all forms as a kind of communication that something is wrong inside and that other means of effective communicating or managing that discomfort or what...
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...
What clinical history or findings make you more concerned for an amyloid-related neuropathy?
Many, including: Presence of a monoclonal IgG or IgA protein on serum or urine protein immunofixation, especially lambda light chain, and especially if kappa to lambda light chain ratio is very low. Unexplained autonomic dysfunction, especially orthostatic hypotension without compensatory tachycard...
Should mRS be incorporated into determining eligibility for extended window thrombolysis?
Key thrombolysis trials (WAKE UP, OPTION, EXTEND, TIMELESS, ECASS-4, HOPE, EXTEND IA) excluded patients with mRS of 2 or greater. The reason for this was the outcome of functional independence at 90 days. Hence, for trial purposes, to look at the outcome, it was necessary to exclude patients with di...
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...
What strategies do you find helpful in advanced care planning with patients/families who are very "miracle" centered?
Hope for the miracle yourself! Broaden: “Are there any other things you are hoping for?” Hope for the best, prepare for the worst: “I see how much you want a miracle. I wonder if we can talk about what we should do if this doesn’t happen.” Consider involving a religious leader if relevant.
Which imaging features do you use when considering Normal Pressure Hydrocephalus to decide whether to proceed with large-volume LP or lumbar drain trial?
At our center, we follow the approach of the NPH clinic at the Imperial College Hospital in London.See this excellent review article for further details: Carswell, PMID 36162853.