Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
How do you counsel patients who want to understand why sublingual cyclobenzaprine works to relieve their fibromyalgia pain and other related symptoms?
I like to set the stage with patients and make sure they clearly understand the link between sleep disruption and pain sensitivity, particularly in the context of central pain and fibromyalgia. One of my rheumatology attendings during fellowship used to explain this using classic sleep research from...
Do you view the difference between oral and sublingual cyclobenzaprine as clinically significant?
Yes. Oral cyclobenzaprine—a TCA analogue structurally identical to amitriptyline aside from a single double bond—has been used off-label for fibromyalgia for many years. Despite long-standing anecdotal benefit, a prospective placebo-controlled RCT showed only transient improvement at 4 weeks, with n...
How do you decide when to treat transient global amnesia with antithrombotic therapy?
Most cases are idiopathic and do not require treatment. However, as we had earlier reported in 1086, TGA secondary to ICH. Similarly, there can be other etiologies precipitating TGA, including ischemic stroke. Antithrombotic therapy will be useful in cases precipitated by an ischemic stroke/ TIA. Th...
Do you recommend surveillance MRI for patients with MOGAD?
I do not recommend regular surveillance MRI for all patients. It really depends on the case as some MOGAD patients are very stable and don't even require treatment, whereas others can be quite aggressive and resistant to all treatments. The field is still emerging and our understanding of silent dis...
Would patients receiving targeted therapies be eligible for TTFields for brain metastases?
Conceptually, I can certainly hypothesize and conjecture the value of combining TTFields for brain metastases with targeted therapies. However, this specific population was excluded from the current trial, and therefore, we have no direct data to report or answer this question with greater specifi...
Among patients with secured subarachnoid hemorrhage who are receiving daily TCDs, what is the appropriate frequency of post operative neurological assessments?
I think a textbook might state something like "every 1-2 hours in the acute setting." However, in my opinion, the frequency of neurological examinations should be tailored to the individual patient and involves considerable clinical judgement. Factors that might influence this decision include a) se...
How early do you implement PCSK9 inhibitor therapy for stroke patients with very high-risk ASCVD?
For me, it depends case by case. If the patient is statin naive or on a suboptimal dose with above goal LDL and TAG, I will start a statin or increase statin dose/intensity, respectively, with lifestyle and diet changes, and evaluate the trajectory of the parameters in 6 months to see if they are he...
What is your approach to managing hallucinations in dementia?
One thing to remember is that hallucinations are not always disturbing to the patient, but to the caregiver! If the patient is fine with seeing a little girl or dog (often in LBD), the family just needs to be educated to let it go. They don’t need to AGREE that the hallucinations are present; they j...
What would be your radiotherapy plan for a patient with recurrent GBM (WHO grade 4, IDH wild-type) s/p 2 prior resections with no prior radiation?
The scenario described in this clinical case is not uncommon. I have had patients who either live several hours away from our center or were unwilling to receive the Stupp protocol of 60 Gy in 6 weeks and were successfully treated with 3 weeks of hypofractionated RT (HFRT). HFRT over 1–3 weeks (25 G...
Do you add antiplatelet medications to patients already on anticoagulation for atrial fibrillation if they have a stroke due to a competing etiology?
Adding antiplatelet therapy to anticoagulation in patients with atrial fibrillation and a noncardioembolic stroke has not shown a clear benefit and definitely increases bleeding risk. Okazaki et al., PMID 41051787 did not find a benefit and increased bleeding risk. An exception might be in acute MI ...