Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
How do you approach the management of poorly controlled migraines during pregnancy?
This is an excellent question and area of frequent discussion. You can start with Lidocaine nerve blocks: occipital, supra-orbital, and temporal. Sometimes, just IV fluids will help for acute migraines. Other options include Reglan, caffeine, and APAP. If in the second trimester, I will do steroid t...
In which clinical scenarios do you find medial and lateral plantar sensory or mixed nerve conduction studies to be valuable?
If you suspect (and believe in the diagnosis of) tarsal tunnel syndrome. When there are concerns about more proximal tibial mononeuropathy or sciatic neuropathy with predominantly tibial division pathology. I have had a couple of cases where the sural SNAP amplitude on the affected side was normal ...
Do you treat cerebral vein thrombosis with parenchymal hemorrhage using full dose heparin protocol rather than the high risk protocol?
I just want to clarify the question a bit. I will assume that you mean cerebral venous sinus thrombosis with cerebral vein thrombosis here. IV heparin is considered a standard treatment for cerebral venous sinus thrombus, but not necessarily cerebral vein thrombosis. Heparin for isolated cortical ve...
What is your strategy for treating persistent headaches in the aftermath of subarachnoid hemorrhage?
In the immediate aftermath of a subarachnoid hemorrhage, regardless of whether the aneurysm has been secured or not, the following strategies can be employed to manage headaches: Headache Cocktail: This may consist of magnesium infusions, Benadryl, and an antiemetic like Compazine. Magnesium infusi...
How do you manage pregnant individuals with newly diagnosed idiopathic intracranial hypertension?
Pregnancy in IIH is managed the same as if the patient did not have IIH with one caveat. IIH patients should stay within the recommended weight gain their obstetrician targets. Pregnancy is not a cause of IIH, but the excessive weight gain that can occur can trigger or worsen IIH. Labor and delivery...
When might you soften the post-thrombolysis monitoring requirements for patients receiving TPA for acute stroke?
The recent study by Anderson et al., PMID 40412428, suggests that a pattern of reduced monitoring after tPA was noninferior to standard monitoring in patients with initial NIHSS < 10, treated within 2 hours of symptom onset. This is suggestive that the reduced monitoring protocol is safe in patients...
How long do you typically wait before starting anticoagulation after holding Leqembi/Kisunla in patients with cognitive impairment?
Lecanemab's half-life is about 5-7 days. This means wait for about 3 to 4 weeks before starting anticoagulation. The half-life of Donanemab (Kisnula) is about 12 days, which means waiting for anti-coagulation for about 6 to 8 weeks. These are not hard and fast rules; it is done out of an abundance o...
When do you start cyclophosphamide for the treatment of anti-NMDA receptor encephalitis?
First-line immunotherapy for anti-NMDA receptor encephalitis includes high-dose steroids, intravenous immunoglobulin (IVIg), and plasma exchange (PLEX), sequentially or concurrently. Second-line immunotherapy includes a trial of rituximab first and then cyclophosphamide due to the serious side effec...
What is the effectiveness of transmagnetic stimulation for patients with chronic pain, including chronic headaches?
In addition to repetitive TMS (rTMS) discussed helpfully by Dr. @Dr. First Last, single pulse TMS (sTMS) is an FDA-approved treatment for migraine. In contrast with rTMS administered in a clinical setting, sTMS is administered at home with a lightweight device designed for home administration. Effic...
How do you decide when to pursue genetic testing for cerebral palsy?
Unless there is a very obvious cause that has a very low likelihood of a genetic etiology (e.g., neonatal meningitis, embolic stroke from a discovered source, etc.), I almost always perform genetic testing. Even cases of presumed HIE can have an underlying genetic contributor that increased the risk...