Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
Regarding CVST, what protocol of heparin dosing do you regularly use and does it change depending on clot burden/ICH status?
There is very limited randomized evidence for the use of anticoagulation in any form for CVST. We often rely on extrapolations from data on the acute management of DVT in the leg and pulmonary embolus. We are mainly limited to cohort studies and small RCTs. Recent trials in this area include the TO-...
Do you choose an antibiotic with CSF penetration, such as nafcillin over cefazolin, in the setting of MSSA endocarditis with septic emboli to the brain (assuming no concomitant meningitis or brain abscess)?
The prevailing theory that cefazolin has poor CNS penetration is really based on 3-4 studies performed in the 1980s (Nolan & Ulmer, PMID 7365282) where they were extrapolating data from studies looking at cephalothin concentration in CSF. Another study looking specifically at cefazolin concentration...
What is your recommended long term management of extensive dural venous sinus thrombosis in an otherwise healthy young patient?
From a Vascular Neurology perspective, there are two considerations when faced with patients with venous sinus thrombosis. First is the status of the intracranial venous circulation and whether or not there has been adequate reconstitution of venous outflow, either through recanalization or collater...
Do you counsel patients to acutely treat migraine with aura at the onset of aura or headache?
The timing of acute treatments for migraine attacks has been widely discussed for a number of years. Here are some principles: Once the pain begins, pain-free rates are higher if the patient treats early in the attack, while the pain is still mild. This is broadly true for triptans, NSAIDs, aspirin...
What imaging features can help distinguish between an acute versus chronic cervical internal carotid occlusion?
Distinguishing between acute and chronic cervical ICA occlusion is often challenging, but CTA and CTP can offer helpful clues in assessing lesion acuity. On CTA, contrast enhancement along the vessel wall at the site of occlusion, sometimes referred to as the "ring sign," may suggest an acute thromb...
How do you manage long-term pain associated with sensory ganglionopathy?
There is no difference in the management of neuropathic pain from sensory ganglionopathy vs. neuropathic pain caused by a typical length-dependent distal sensory polyneuropathy, like diabetic.
When do you use wearable EEG or epilepsy detection devices for epilepsy management?
We use it when there is a diagnostic question and we estimate that the chance of capturing an event in a reasonable period of time (24-72 hours) exists.
How do you approach use of DMARDs and/or biologics for inflammatory arthritis in patients with a history of seizure disorder on anti-epileptic medications?
Polypharmacy should always be a worry in our treatment of rheumatoid arthritis. Fortunately, the biologics, reflecting their immunoglobulin framework, are rarely a concern for drug-drug interactions. This is in contrast to small molecule inhibitors such as methotrexate, leflunomide, and the jak inhi...
How effective do you find lifestyle modifications in management of migraine?
Lifestyle modifications may be effective when there is a convincing relationship to identifiable triggers: food/drink, sleep deprivation/irregular cycles, exertion, stress, and/or imperfect coping mechanisms. However, even when that is the case, the extent to which accommodation constraints a normal...
What is the preferred management plan for patients diagnosed with a concussion in the acute setting?
For acute concussion, if sports related, they should be removed from play immediately and not allowed to return for the duration of the game. For any cause of concussion, it is generally accepted to avoid NSAIDs and use acetaminophen for the first 24 hours if needed for headache. After the initial 2...