Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
When do you consider tapering tocilizumab in patients with GCA in remission?
This is a timely question and recent data sheds some light on this important topic. The risk of GCA relapse is approximately 50% (Mainbourg et al., PMID 30951256) in all comers. The GIACTA trial (Stone et al., PMID 28745999) utilized a one-year course of TCZ. A recent publication of the extension ph...
How do you counsel patients with Parkinson's disease who are interested in starting GLP-1 agonists for neuroprotective benefits?
This is an important question, thank you. The Parkinson's disease community has been desperate to find an intervention other than exercise that can slow the progression of the disease and provide neuroprotective benefits. We might be heading in the right direction with glucagon-like peptide-1 (GLP-1...
Have you seen improvement in non-migraine-type headaches with the usage of drugs targeting CGRP?
For prevention, I have only used the 4 monoclonal antibodies or the 2 preventive gepants for documented migraine with and without aura, and also for cluster headache. I tend to use the one that is approved for cluster headache, eptinezumab, at the higher dose of 300 mg via IV infusion. For acute car...
How long would you stop standard GBM radiotherapy if the patient had a fall with minor head trauma?
I would do everything possible to minimize or ideally avoid treatment breaks, given no intracranial bleed. I would evaluate skin dose over the area of laceration and consider adapting the plan to meet skin constraints or lower dose to the suture if possible and not already low. If significant swelli...
What is the role of radiation in intra labyrinthine (cochlear) schwannoma?
This is a bit of a tricky question to answer without knowing the size of the lesion, the age of the patient, their current symptoms, and whether they have serviceable hearing.If the tumor is small, and the patient has residual serviceable hearing, it might be best to delay treatment and order a repe...
How do you counsel elderly patients who demonstrate mild cognitive impairment but do not meet the criteria for a neurocognitive disorder?
I would let them know that mild cognitive impairment (MCI) is an umbrella diagnosis with many different contributing factors as well as risk factors for progression to dementia. Control what you can control. Limit contributing factors such as pain, mood, and sleep optimization, as well as limiting a...
When do you consider ambulatory EEG to assess for future seizure risk in someone with seemingly resolved acute symptomatic seizures?
Generally, when I am unsure if the known events are truly symptomatic or whether they may represent more of a risk of recurrence without the "acute" etiology.
How would you manage leptomeningeal disease of the spine in the setting of prior WBRT?
This is an extremely challenging clinical situation. The decision points depend on treatment goals: If the goal is local palliation, simply treat local areas of disease, e.g. spinal segments. If effective systemic therapeutic options are available, obviously consider those first, including intrathe...
How do you manage Moya-Moya disease medically for patients that are unable to receive EC-IC bypass?
It depends on the cause. Usually for patients either moya moya disease (in contrast to moya moya syndrome where symptomatic patients would benefit from EDAS or surgical management ) due to atherosclerosis or radiation induced if someone has continued ischemic events or silent infarcts on aspirin mon...
Do you recommend life long aspirin 81 mg daily for non-specific T2 white matter hyper-intensities on MRI brain?
"Non-specific" means non-specific, indeed, and ASA risks of bleeding increase with age.