Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
When do you consider discontinuation of treatment in pediatric patients who have responded well to preventive migraine medications?
This is an excellent question and not necessarily straightforward to answer, as there are no current definitive guidelines to determine optimal duration of successful migraine preventive treatment and the best method of preventive medication discontinuation.If you look at the most recent pediatric p...
What is your approach to a pediatric patient presenting with a new daily persistent headache?
My approach is to screen for medication overuse/rebound, lifestyle, and “headache hygiene” maximization and always examine their neck for cervicogenic issues. The neck exam is particularly important for students who often have poor studying posture and neck flexor muscle weakness. They often report ...
How do you counsel migraine patients interested in implanted neurostimulation devices for migraine?
I do not routinely recommend these procedures. Specifically to my knowledge, there are no published studies that have looked at the efficacy or safety of Reed or Omega procedures. I counsel patients that there have never been any studies with these procedures so we do not know the efficacy or safety...
When should one consider obtaining a cardiac MRI in ischemic stroke patients?
This is a terrific question. Cardiac MRI is increasingly utilized in the diagnostic evaluation of ischemic stroke and can uncover clinically covert cardiovascular disease. The clinical utility in ischemic stroke is most in patients with concern for LV thrombus (low EF or recent anterior ST elevation...
How do you complete brain death testing in patients who cannot tolerate apnea testing and are unable to transport for ancillary testing?
The short answer is that you cannot. Brain death diagnosis requires the presence of 3 conditions: persistent coma, absence of brainstem reflexes, and lack of ability to breathe independently. If portions of the clinical exam or apnea test cannot be performed, ancillary testing is necessary to make t...
Do you typically counsel patients to avoid intranasal triptan administration on same side of pain in cluster headaches?
We usually don't. But the idea is for bad clusters, intra nasal may not work anyway so IM sumatriptan may be a better option.
How would you manage a patient who develops acute stroke during neoadjuvant chemotherapy with KEYNOTE-522 for Stage III triple negative breast cancer?
I will try to provide some data for discussion, but also welcome comments from other experts and opinions. I'm assuming this is a younger patient without known risk factors and that an assessment for things like A. Fib, PFO, and DVT have been performed.Chemotherapy has long been associated with thro...
What postural change in FVC is suggestive of respiratory muscle weakness?
In our practice, an assisted ventilation clinic which is enriched with patients who have diagnosed neuromuscular disease and/or chronic respiratory failure of unclear etiology, we often use 12% or 200cc simply by analogy to the criteria we use to assess bronchodilator responsiveness during PFTs. Alt...
Would you proceed with anti-CD20 treatment in an MS patient who is VZV IgG negative in spite of vaccination in the last year?
There is no clear data on management. In my experience, if a patient has been vaccinated in the recent past, then I will proceed with anti-CD20 therapy. However, if vaccination was in the remote past, I have asked patients to repeat vaccination before initiating therapy.
What further testing do you recommend for incidentally found ependymitis granularis as part of headache workup?
I would defer this question to a neuroradiologist.