Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
What would prompt discontinuing treatment versus switching or sequencing treatment in patients treated with an anti-amyloid therapy for Alzheimer's?
To be sure, there is virtually no evidence of outcomes on switching from one antibody to another. If treatment discontinuation occurred due to ARIA, I would strongly discourage rechallenge with another agent. There is no rationale for discontinuing lecanemab or donanemab for lack of efficacy on clin...
When do you recommend neuropsychiatric testing in patients with post-concussive syndrome?
I typically ask the patient what scenarios they experience cognitive issues. The various examples they provide usually relate to difficulty following conversations, forgetfulness within their working memory, and concentration/focus. In the post-concussion patient, they typically have developed adjus...
Have you found that migraine prevention treatments help non-specific vestibular symptoms in migraine patients?
I would say no to this question, so I would encourage further workup to identify the source of the vestibular symptoms.
What techniques do you use to help reduce procedural pain for headache injection treatments?
In my clinic, none of the providers, to my knowledge, use any specific techniques to reduce procedural pain. We do offer ice packs that patients can use during or after a procedure. We do Botox and pericranial nerve blocks. It would be difficult to coordinate using REN prior to procedures. I suppose...
How are you using CYP2C19 genotyping for determining dual antiplatelet therapy for stroke?
In my practice, P2Y12 assays are the primary tool I rely on for guiding dual antiplatelet decisions. They are more widely available across clinical settings, whereas CYP2C19 genotyping requires infrastructure that is not always accessible outside of large academic and tertiary centers. CYP2C19 ident...
What is the role for inpatient limited-montage EEG recording?
Unequivocal YES! For purposes of detecting severe seizures that cause brain injury (i.e., high seizure burden, status epilepticus), a reduced montage EEG is more than adequate, performs equivalently, and in fact BETTER because of the Clarity AI algorithm which continuously monitors, interprets, and ...
How do you counsel B cell-depleted multiple sclerosis patients on the benefits of regular COVID-19 vaccinations?
The fact that B cell-depleted patients render a blunted antibody response is not unexpected, but antibodies do not protect from viral infections - cells do. To measure a proper vaccine response, one wants to test T cells from patients to see if they are able to kill viral infected cells. This is wha...
What primary and secondary stroke prevention strategies do you use for patients with a pulmonary AVM (PAVM)?
This is not a common problem in stroke neurology. I have been involved in this problem for a patient with HHT (also known as Osler-Weber-Rendu syndrome). Sporadic or post-surgical AVMs may also arise but they are uncommon. In general, the treatment in both scenarios (primary and secondary prevention...
What medications are preferred and contraindicated for insomnia in patients with a recent stroke or traumatic brain injury?
In acute brain injury (ABI), which includes stroke and traumatic brain injury the focus is often on neurorehabilitation. The presumption here is that the patient is medically and neurologically stable. For example, not having a stroke in evolution, uncontrolled gastrointestinal bleeding, or similar....
Do you view the difference between oral and sublingual cyclobenzaprine as clinically significant?
Yes. Oral cyclobenzaprine—a TCA analogue structurally identical to amitriptyline aside from a single double bond—has been used off-label for fibromyalgia for many years. Despite long-standing anecdotal benefit, a prospective placebo-controlled RCT showed only transient improvement at 4 weeks, with n...