Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
What is your approach to using intra-arterial or intrathecal vasodilators in patients with vasospasm in subarachnoid hemorrhage despite usage of oral nimodipine?
Bottom line up front: The 2023 AHA/ASA focused update on aSAH recommends IA vasodilator infusion or mechanical angioplasty in clinically significant vasospasm refractory to medical therapy (Class IIa, Level B) and states that intraventricular nicardipine “may be considered” in selected patients (Cla...
How effective do you find MAO-B inhibitors for the treatment of Parkinson's disease?
In the earlier stages of PD, MAO inhibitors have a perceptible effect, and in the early stages of treatment of PD, they are used alone or more effectively in combination with L-DOPA.
What experience do you have with paralysis or myasthenia-like symptoms developing on temozolomide?
This is not an established toxicity of temozolomide and would warrant further investigation.
Which patients will have earlier diagnosis of multiple sclerosis via the new 2024 McDonald Criteria?
I think the group that will most benefit from the new diagnostic criteria, in terms of earlier diagnosis, is those with a history of optic neuritis. This is because the new criteria expand "typical CNS topographies" from four to 5 to include the optic nerve. In addition, those who present with lesio...
Considering only cerebrovascular indications, are there circumstances in which you would use aspirin along with a DOAC in patients with atrial fibrillation and stroke?
I will use aspirin 81 mg and a DOAC together in patients who "fail" (I hate that term) the DOAC. The combination was used in patients in the original DOAC trials, so it is not unreasonable. Not my first choice, but can be done. It is worth noting that the evidence does not support doing this upfront...
How do you counsel patients interested in carotid endarterectomy for asymptomatic carotid disease as a means to reduce dementia risk?
This is a good question. I reviewed the paper by Vitali et al, PMID 40922111 and I would add that previous studies of patients with asymptomatic carotid stenosis have not found a reduction in dementia with the procedures. In this retrospective study, carotid endarterectomy but not carotid stenting r...
How do structural and functional findings on echocardiogram influence your decision to anticogulate ESUS cases?
This is a great but very difficult question. It is important to remember that currently, there is NO randomized controlled trial data that provides evidence for anticoagulating patients with ESUS, and the ad hoc analysis of the Arcadia trial you mention simply does not change this. Arcadia specifica...
How do you decide when to add steroid-sparing immunotherapy for myasthenia gravis after starting prednisone and Mestinon?
My approach is generally to add a steroid-sparing agent if the patient experiences worsening of their symptoms during prednisone wean, such that they cannot tolerate a prednisone dose lower than 7.5 mg/day without functionally limiting symptoms. However, there are many patient-specific consideration...
How do you workup patients with neuropathy suspected to be secondary to sarcoid?
To answer this question, the attached paper with consensus criteria for the diagnosis of neurosarcoidosis, published in 2018, should be reviewed, Stern et al., PMID 30167654.Based on this paper, a diagnosis of probable or definite neurosarcoidosis requires unequivocal evidence of non-caseating granu...
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...