Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
How do you determine personalized blood pressure targets after ischemic stroke?
This is an excellent question and really takes careful consideration of individual patient characteristics. This also requires detailed discussions with your Neuro-Interventional Radiology Team so that you can best understand what happened during thrombectomy and how successful reperfusion therapy w...
Does anyone utilize P2Y12 assays to determine if clopidogrel may be ineffective when used for DAPT?
Yes, I use P2Y12 assays in two distinct settings. Medical management: If a patient on clopidogrel mono/dual therapy has disease progression with ICAD or experiences a recurrent ischemic event, I obtain a P2Y12 assay to assess responsiveness. This helps guide the decision to switch to ticagrelor and ...
Do you titrate anti-seizure medication doses in the setting of high or low serum drug levels if patients remain seizure free?
The short answer is "no", especially in the setting of high levels, if there are no side effects reported, and other appropriate surveillance labs look good (such as CBC and LFTs for VPA). The only case where I might increase the dose slightly would be for a below-therapeutic range level in a seizur...
When do you consider using general anesthesia for endovascular thrombectomy?
I perform all of my thrombectomy cases under general anesthesia. There is better hemodynamic control, no patient movement to manage, which increases procedural efficiency as a result. In moderate sedation cases, patients can feel aspiration and stent retriever passes through the vessel, which causes...
Would you consider off-label IV thrombolysis in patients taking a DOAC and presenting with disabling acute ischemic stroke within the window?
Addendum: Re- access to serum concentration for the DOAC. Yes - access to serum concentration for the DOAC, like factor Xa levels, for example, for Eliquis and Xarelto, or ECT for dabigatran, does change my management. In those with normal levels of specific anticoagulation tests, I would discuss IV...
When do you use greater occipital nerve block to treat acute refractory migraine?
I frequently offer ONBs for patients with acute migraine when they have persistent headache, despite migraine cocktail & other initial ER interventions. Since occipital nerve blocks are safe, effective, and have Level A recommendations from the American Headache Society, I perform them quite frequen...
What is your preferred first-line treatment for chronic fatigue in patients with long COVID-19?
Assuming that a thorough workup for other causes of fatigue (anemia, thyroid dysfunction, sleep apnea, etc.) has been performed and is negative, no single medication has been proven by a randomized placebo-controlled trial to help chronic fatigue in PASC. Anecdotally, my colleagues who treat PASC ha...
When do you use seizure prophylaxis in patients on clozapine?
The topic of the use of anticonvulsants for primary prophylaxis of clozapine-induced seizures continues to be debated. The idea of prescribing anticonvulsants prophylactically for patients taking >600 mg/day of clozapine was suggested by Devinksy et al., PMID 2006003 in 1991. Clozapine-induced seizu...
When do you consider starting short-term DAPT in patients who present more than 24 hours after the onset of a high-risk TIA or minor stroke syndrome?
Immediately. Unless tPA has been given, then at 24 hours.
Do you typically give GI prophylaxis when providing patients with steroid taper for status migrainosus?
I usually do a 3-6 day taper with prednisone, dexamethasone, or medrol dose pack for status migrainous. Occasionally, I have done a 12-day taper if the status migrainous is prolonged. I have not used GI prophylaxis.