Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
How do you balance short-term efficacy against increased low-grade toxicity and quality-of-life considerations for higher single-fraction regimens in recurrent glioma patients?
When considering radiation options for recurrent glioma, in my mind, one size does not fit all. I consider several aspects of the specific patient’s clinical situation: Patient’s prior treatments: time interval, volume, location, and anatomic site, response to prior treatment, response duration from...
How do you approach evaluating the hemorrhage risk of restarting anticoagulation in a patient with ischemic stroke and infective endocarditis without access to DSA?
This is a really excellent question. First of all, if the patient has infective endocarditis, they really should undergo appropriate antibiotic treatment prior to initiating anticoagulation. I have seen several patients have significant (and in some cases fatal) hemorrhages because anticoagulation w...
How do you decide on the speed and target of blood pressure reduction for spontaneous intracranial hemorrhage?
I think the target and speed of blood pressure reduction in ICH depend on several variables, including initial SBP, clinical stability, hematoma size, and renal function. For patients presenting with SBP >220, I typically aim to lower the pressure to around SBP 160 over the first 12 hours, then grad...
Does persistent focal slowing without epileptiform discharges indicate increased seizure risk in patients without significant structural abnormalities?
Good question! :-) Lateralized rhythmic delta (LRDA), especially temporal (TRDA) certainly does, basically to the same degree as interictal epileptiform discharges (IEDs). Focal polymorphic slowing is of course not technically "epileptiform" but it does indicate some focal dysfunction, so I would sa...
How do you decide between FcRn inhibitors and complement inhibitors for treatment-refractory AChR-positive myasthenia gravis?
UPDATE (02/2025):In the last two years, there have been few real-world comparative efficacy studies published to address this question. I have attached a selection of them below. Overall the conclusion is that equipoise remains- there is no clear evidence of the superiority of complement inhibitors ...
How do the results of CREST-2 influence your recommendations on screening for asymptomatic carotid stenosis?
Agree with the prior comment. One important nuance is what “medical management” actually meant in CREST-2. This was centralized, protocol-driven care with structured lifestyle counseling and medication escalation, including access to PCSK9 inhibitors with costs covered. Even in that highly organized...
When can EMG be deferred in cases of distal sensory polyneuropathy?
Sensory conduction studies provide information as to whether there is a large fiber disorder of the dorsal root ganglion or the nerve fibers distal to the DRG. The simple answer to the question is that you can defer this study when you don't want or need that information. If the symptoms are very di...
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...
What is your approach for LINAC based radiosurgery when dealing with benign perioptic lesions very close to the optics apparatus?
It all starts with the consideration of what I consider an effective dose of SRS or SRT (hypo-fractionated SRS). The minimum effective dose to achieve local control of a metastatic lesion is usually 18 Gy for single fraction, 27 Gy for 3 fractions, and 30 Gy in 5 fractions.I then consider the histol...
Are there any contraindications using nurtec in patients with headaches in the setting of recent RCVS?
I would be comfortable using Nurtec in a patient with a recent RCVS diagnosis. I am comfortable using triptans in patients with a prior stroke or MI with proper patient counseling unless they have critical/severe artery stenosis. I have had cluster headache patients who continue sumatriptan injectio...