Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
Would you use a lumbar drain in a patient with spinal stroke from fibrocartilagenous embolism?
There are no clinical trials to suggest any benefit. Smaller studies - particularly case series have shown some benefit with the use of lumbar drain in the first 48 hours and keeping the pressure around 10 mmHg. These include mostly patients post a cardiovascular surgical procedure as a cause of the...
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...
How do you counsel patients on wearable heart monitor devices when they ask about specific products and diagnostic accuracy of these devices available on the market?
It depends on the device. If a patient is experiencing palpitations infrequently, or there is an ongoing need to identify the cause of palpitations, I typically recommend a consumer-facing ambulatory ECG device that is FDA-cleared. They are quite accurate for detecting AFib and ectopic beats such as...
What is your first-line therapy for acute migraine treatment in the ER?
Regarding the abortive and preventive treatment of migraine, in the office or ER, we should focus on migraine-specific medications. These are the ergots, triptans, and gepants abortively, and the CGRP antibodies and gepants preventively. The patients who visit ERs every so often tend to have headach...
What typical lab tests do you send off for evaluation of neuropathy?
Not too much has changed in over a decade regarding the recommendations on how we should approach initial laboratory testing in patients presenting with a neuropathy syndrome. Specifically for cases of distal symmetric polyneuropathy, the AAN practice parameter (reaffirmed in 2022) by England, et al...
What clinical features prompt genetic testing for patients with progressive cerebellar ataxia?
In general, any patient who presents with a chronic progressive cerebellar ataxia and is </=21 years of age deserves genetic testing. If a subacute presentation arises with no clear metabolic, inflammatory, neoplastic, vascular, etc., etiology, I would also recommend genetic testing in this group.Wi...
How do you manage seemingly treatment-resistant chronic migraine?
First, let's define refractory migraine. The most recent and strict diagnosis that I use was a proposal by the European Headache Federation (EHF):Refractory Migraine Established diagnosis of 1.1 Migraine without aura and/or 1.2 Migraine with aura or 1.3 Chronic migraine according to ICHD-III criter...
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.
When and how do you perform genetic testing for congenital myasthenia gravis in seronegative cases?
I believe that these congenital myasthenic syndromes can start at birth or early childhood, as we are all familiar with muscular weakness, particularly extraocular muscles, and bulbar, which is fatigable, worsening with physical activity, and there > 30 genes responsible, and symptoms vary by the Ge...
How to approach reversal of TNK in hemorrhagic conversion of ischemic stroke?
There is no specific "reversal agent" for tenecteplase. Once administered, the thrombolytic effect will persist until the drug is fully metabolized and any residual plasmin has been cleared by alpha-2-antiplasmin. So, perhaps the first question is what can you do if there is an acute bleeding event ...