Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
How do you counsel patients with postural orthostatic tachycardia syndrome (POTS) regarding safe and effective exercise regimens?
It depends on where they're starting from. If they're starting from scratch, I give them two recommendations: first is the Children's Hospital of Philadelphia protocol, and if they live in town, I refer them to our PT facility at Vanderbilt (The Dayani Center) to have our PT folks help them get star...
When is air travel safe for patients who have developed an intracranial bleed?
I tried to find evidence-based guidance from the literature, but I found only a few pieces of advice. After ICH, unless it was tiny and of clear cause, I would wait at least 4-6 weeks. After SDH, if neurosurgical drainage was performed, then also at least 6 weeks. After SAH, assuming the causative a...
When do you start anticoagulation in patients with endocarditis and evidence of mycotic aneursym?
True estimates of the risk of anticoagulation in endocarditis is hard to come by, since anticoagulation is not common in practice and likely the risk is dynamic and decreases with antibiotic treatment. If one considers thrombolysis as a guide, the presence of endocarditis appears to increase the ris...
How does lack of success of rituximab treatment affect your decision to trial anti-CD19 therapies like inebilizumab?
I strongly believe that deeper and broader CD19 theraphy such as inebilizumab, works on a key different target: offering better disease control due to its broader B-cell targeting, as in CD19, plasmablasts, than rituximab, which targets CD20 (mature B cells), leading to more broad b cell depletion,...
How do you differentiate between HIV associated neurocognitive disease (HAND) and other causes of neurocognitive impairment?
This is a great question. In the era of test and treat, where many people with HIV have never had significant immunocompromise, cognitive impairment due to HIV itself is now relatively rare. On the other hand, people with HIV experience conditions of aging about 10 years earlier than people without ...
What are the best practices for centers interested in providing anti-amyloid therapies for early Alzheimer's to ensure treatment delivery success?
I would use the same criteria for AAA treatment as those required for entering AAA clinical trials. Overall, our center has not had difficulty with ensuring that patients have timely MRIs before treatments. I enlist caregivers and patients to remind me when they are scheduled for their next infusion...
When do you consider hemispherectomy for patients with Rasmussen encephalitis with stable epilepsy and preserved function of the affected half of body?
Depends on several factors. First, how debilitating are the seizures? If the person cannot function, like going to school for children or adult activities, then surgery to stop the seizures should be considered. Also, age is a factor. Children under the age of 5 years should be considered to make us...
What do you do for a patient with Parkinson's Disease and orthostatic hypotension who has failed midodrine, fludrocortisone, droxidopa, pyridostigmine, and atomoxetine?
I would not recommend using amantadine in this situation as it is known to worsen orthostatic hypotension (Perez-Lloret et al., PMID 22336566). This is a tricky situation, and if the patient has failed all of these medications, I would consider an alternate diagnosis, specifically MSA, especially if...
What is the most updated consensus regarding the use of pill in the pocket oral anticoagulation in paroxysmal atrial fibrillation, and populations of patients who are most likely to be considered for enrollment in clinical trials?
I'm not sure that there is a consensus. The best available large trial data would recommend anticoagulation based on a CHADS2Vasc score of 2 or higher, while a score of 0 patients could be off anticoagulation, and if the score is 1, patients would benefit from shared decision-making. For the CHADS2V...
Which clinical or imaging features of cerebral amyloid angiopathy aid in predicting future risk of intracerebral hemorrhage?
Hemorrhagic imaging features of cerebral amyloid angiopathy can help understand the future risk of intracerebral hemorrhage (ICH). Observational studies have found that patients with cortical microbleeds without lobar hemorrhage have an ~5% risk of future ICH. In those with prior lobar ICH, this ris...