Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
How do you treat extrapyramidal symptoms secondary to anti-psychotic use in patients who have not benefited from cogentin or benadryl?
In general, when addressing motor symptoms from antipsychotics (or any dopamine-blocking agents including dopamine-blocking antiemetics), I find it useful to break things down more specifically than just EPS. This often will determine the agent that will be most beneficial. First Category: Hypokinet...
How well does a negative non-contrast MRI of the brain exclude metastasis in a patient with squamous cell carcinoma of the lung?
I don't think the question has enough information to give a good answer. For example, if it was a T3, N2 NSCLC, or a small cell, then "yes" I'd repeat the MRI with contrast. On the other hand, if it was a T1, N0 NSCLC, then "no", I wouldn't. In other words, if I thought there was a real risk of havi...
What tools do you use to evaluate for cognitive deficits in young patients?
I typically screen patients for the usual suspects when the working memory is the complaint. These include poor sleep quality, pain anywhere in the body, stress, anxiety/depression. These factors distract the brain and make it difficult to focus and perform cognitively. By addressing these factors, ...
How safe and effective is carotid stenting in carotid dissection?
Stenting in the setting of carotid dissection can be safe and effective, particularly when performed in the appropriate clinical context. The most common scenario where I consider stenting is during a tandem lesion associated with an LVO, where EVT is already being performed. In this setting, dissec...
When do you consider cardiac CT to evaluate for etiology of acute ischemic stroke?
I do it in place of TEE in: Patients with LVO or severe stenosis, for whom I am concerned about hypoperfusion causing another stroke. Elderly patients that may have a higher complication risk from TEE. I am mainly looking for intracardiac thrombus.
When do you use anticoagulation over antiplatelet therapy for secondary stroke prevention in patients with LV injury or dysfunction?
First, I will observe that the recent work is a cohort study, not an RCT< and I would be careful about concluding that anticoagulation is the best approach. We have had prior trials, e.g., WARCEF and the related ESUS trials (NAVIGATE and RESPECT), and others that have looked at possible cardioemboli...
How do you work with patients to establish reasonable treatment goals for the management of fibromyalgia-related pain?
Great question. I explicitly tell my patients that I have no magic-bullet– no penicillin or prednisone-adjacent pill – that will swiftly and reliably alleviate their pain. This expectation, that a pill will eradicate disease, makes sense in the wake of the infectious disease revolution, where target...
What do you recommend to patients when they are having an acute flare of fibromyalgia symptoms?
Great, this is a really important area and unmet need in the field of fibromyalgia management. Unlike other nociplastic disease states (e.g., migraine), there are no rigorously studied abortive therapies to rapidly treat a flare of centralized pain. Indeed, all the therapies we use for FM are intend...
What resources do you find helpful for patients with MSK concerns who may not have access to physical therapy or who cannot afford it?
This is an excellent question and important because every MSK concern needs some form of exercise intervention for maximum benefit/recovery. In some (most?) EMR systems, general, basic home exercise programs (HEP) are available for patients. This is a convenient way to get patients started. Rarely, ...
Is it safe to use monthly injectable CGRP antagonists with oral gepants in the same patient?
Yes. To my knowledge, there is no data to suggest that it is not. I have routinely used oral gepants as abortive treatment in patients who are on a CGRP monoclonal antibody for prevention.There have been at least 2 retrospective studies looking at the safety and tolerability of using oral gepants in...