Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
Is there a role for using parenteral anticoagulation for occlusive extensive ICA thrombus with acute onset of symptoms when patients are not candidates for endovascular therapy, such as low NIHSS?
If interpreting the question correctly, it refers to an extensive/occlusive thrombus in the ICA as an acute vessel occlusion? In such cases, my decision between the medical and endovascular approaches largely depends on the segmental location of the occlusion. For a proximal cervical-segment ICA occ...
How frequently do you re-evaluate AChR and MuSK antibodies in patients with clinical and electrodiagnostic evidence of seronegative myasthenia gravis?
I usually recheck AchR binding antibodies 1-2 years after the initial negative test because some patients will “seroconvert”. I don’t recheck MuSk if the initial was negative. And one recent “secret”: the University of Oxford in the UK for years had patented the development of a cell-based assay to ...
Is there any evidence that radiotherapy can worsen balance, dizziness, or vertigo in patients treated for vestibular schwannoma due to transient edema?
While the answer from Dr. @Dr. First Last addresses a much broader category of patients treated with SRS, we have looked specifically at post radiation side effects after treatment of vestibular schwannomas treated with either SRS (12.5 Gy), hypofractionated SRS (hSRT with 5 fractions of 5 Gy), or c...
Would testing for ATTR cardiac amyloidosis be considered in an older patient with bilateral carpal tunnel surgeries and multiple spinal stenosis surgeries, but no obvious cardiac symptoms?
I would not look for ATTR-CM in the absence of cardiac findings such as abnormal echo (increased LV thickness) or conduction abnormalities that are suggestive. Only 10% of patients with bilateral CTS have ATTR-CM. I would do an echo if not done and review ECG. As much as we are concerned about under...
When do you consider repeating CSF studies in a patient with suspected viral encephalitis but overall initially unrevealing CSF?
Definitely not an expert on this topic, but this situation does come up, particularly for HSV encephalitis! One question worth asking your lab is what kind of assay are they using to run this test. If it's a dedicated HSV PCR assay (e.g., Simplexa), then the sensitivity is going to be quite robust, ...
How do you decide between using an intracranial pressure monitor (bolt) versus an extraventricular drain (EVD) for intracranial pressure monitoring in cases of diffuse cerebral injury?
I think the decision about whether to place an external ventricular drain (EVD) or an intraparenchymal ICP monitor (IPM) rests on many factors, including:1) Need for CSF drainage - if the patient has hydrocephalus or CSF drainage is anticipated to be useful in controlling ICP, then an EVD is prefera...
When do you consider testing with stroke gene panels in young stroke patients?
Broadly, I ask for genetic testing only when I have a specific diagnosis in mind. This testing is not routine in my practice. Examples are: A patient is referred for white matter lesions found on brain MR and a transient neurological episode. The question of CADASIL(NOTCH-3) or related disorders is...
What prompts you to procure EEG and/or imaging in patients presenting with multiple simple febrile seizures?
History always plays a key role. Is the child developing normally, and how old is the child? Also, were all of the seizures truly simple, or were there other features that make me suspicious that this is actually a "lower seizure threshold" in a patient with underlying epilepsy? Fortunately, a sleep...
In what cases, if any, do you find the use of naltrexone to augment lifestyle interventions (i.e., cognitive behavioral therapy, graded exercise therapy) for chronic fatigue to be helpful?
Absolutely no.
How do you manage stroke-related abulia?
There is surprisingly little recent evidence-based guidance on this front. Most therapeutic options focus on agonism or potentiation of dopamine in the frontal-subcortical circuits. Depending on the center and provider, options include psychostimulants. Any type might do but I prefer methylphenidate...