Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
Is there a utility in getting repeat antibody testing on GBS patients after PLEX?
No, there is not, for a couple of reasons: Most patients with the most common variant of GBS (AIDP) are negative for ganglioside antibodies or other antibodies against nodal/paranodal proteins. Ganglioside antibodies are more often positive in GBS variants like AMAN, AMSAN, Miller Fisher syndrome, s...
How would you approach the decision to escalate DMT in a patient with relapsing multiple sclerosis who has two to three new T2 lesion but no clinical symptoms?
I would escalate to higher-efficacy DMT in this scenario. As highlighted in the linked article, new T2 lesions show that the patient is at heightened risk for clinical relapses and their disease activity is not well controlled. In the linked study, included patients were on low efficacy DMT (interfe...
How long after a motor vehicle accident would you expect symptoms including memory loss, hypersomnia, and mood changes to be attributable to the accident?
I would love to have the answer to this. I can tell you what the Headache Classification Committee of the International Headache Society says:Post-traumatic headache (PTHA) is defined as a secondary headache that develops within 7 days after head trauma (or after regaining consciousness following he...
How do you adjust the loading and maintenance doses for Keppra when treating status epilepticus in patients with ESRD, patients on HD, or patients on CVVH?
Ideally, if you have a patient with status epilepticus and known ESRD, then Keppra may not be an ideal first option. You should be reaching for your other status anti-seizure meds that aren’t exclusively renally excreted and are readily available in most hospitals; Depakote (40 mg/kg loading dose) o...
How do you counsel patients who experience diarrhea from mycophenolate mofetil (Cellcept)?
I have them stop the drug, and when their bowels are back to normal (usually just a couple of days), I resume with 1 tablet bid of mycophenolate mofetil (MMF, CellCept), then a few days later go up to 1 tab tid, a few days later 2 tabs bid... etc. I instruct them to go down to the most recent dose ...
Is there benefit of early initiation of antiplatelet therapy or DVT prophylaxis in patients who present with large MCA infarcts and are being considered for hemicraniectomy?
Both aspirin and DVT prophylaxis can be started early in patients on hemicraniectomy watch. There is data on increased risk of stroke recurrence in the first 7 days post-stroke and benefits or early initiation of aspirin (even in afib) and decreasing vascular events, especially in the first few week...
Do you recommend thiamine for patients presenting with acute symptoms of TGA?
Thiamine might be considered, especially if the patient has features of Wernicke-Korsakoff syndrome. However, if the patient has TGA, no drug treatment is needed since the amnesia resolves on its own.
What adjustments do you make to a hemodialysis prescription for a patient with a recent stroke?
There are multiple considerations in the setting of a CVA in a patient requiring hemodialysis. One is addressing potentially high intracerebral pressure (ICP). A slow reduction in BUN to avoid osmotic-related brain cell swelling and an associated rise in ICP may be addressed in a variety of ways. Lo...
What blood pressure targets do you enforce in the first 24-48 hours in a patient who develops an intracranial hemorrhage after mechanical thrombectomy?
Typically post-thrombectomy you encounter hemorrhagic transformation of an ischemic infarct. In this setting, I adjust the SBP goal to the classification of hemorrhagic transformation (HI-1, HI-2, PH-1 or PH-2). HI-1: No specific parameter; SBP goal adjusted according to TICI score. HI-2: SBP 120-...
How do you discontinue ketogenic diets previously used as a treatment for epilepsy?
The caveat in my answer is that I use ketogenic diets (mostly MAD) in adults with medically refractory epilepsy. We typically advise patients to discontinue gradually by adding back ~5 gm carbs/week until they are eating more "normally." Sometimes these patients never go back to their previous Stand...