Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
Do you think that home INR monitoring is a feasible option for elderly, frail patients with atrial fibrillation on VKA treatment, given variations in socioeconomic status and access to care?
Whenever possible, I prescribe home INR monitoring with appropriate equipment. This allows me to monitor my patients on a weekly basis, rather than on a monthly basis at best. Unfortunately, insurance reimbursement is not standard for this equipment, and many patients are unable to obtain it. The ab...
How do you interpret CSF pleocytosis in the context of significant leukocytosis on CBC?
There is no correction factor as there would be for CSF vs serum glucose, for example. A patient with leukocytosis in peripheral blood, for example, due to urosepsis would not always have elevated CSF WBC unless there were concomitant meningoencephalitis. I would consider 100 WBC abnormal for CSF re...
How do you evaluate a patient with MGUS and peripheral neuropathy?
When I see a patient with MGUS and peripheral neuropathy, I think about it in stages: Does the patient have an IgM-monoclonal gammopathy? If so, then I think about DADS-M. An EMG/NCS, anti-MAG antibody, PET scan, and bone marrow biopsy are generally all part of the workup. I try to do MYD88 testing...
What is your approach to patients who develop ARIA-E or ARIA-H during treatment with anti-amyloid therapies?
We follow the recommendations in the drug label that depends on the severity of each ARIA (mild/moderate/severe). Depending on the severity of ARIA, treatment may be held pending follow-up evaluation or discontinued entirely.
What is your approach to immune management in opsoclonus-myoclonus-ataxia syndrome?
I believe immunotherapy for OMAS and all neuroinflammatory diseases should always be individualized to the specific patient, ideally with input from a neuroimmunologist when possible. My practice closely follows the OMAS International Working Group consensus published in 2022 (Rossor et al., PMID 35...
How do you approach anti-seizure medication management when it was started by another team for a seizure-naive patient before/after craniotomy for a tumor?
I would refer you to Dr. @Dr. First Last's answer to a similar question (https://www.themednet.org/question/15031) which beautifully summarizes data and guidelines. I usually counsel patients that everyone regardless of their medical history has a certain risk of seizure under physical stressors, th...
Do you utilize thrombolytic therapy in patients with CRAO?
Yes. The previous trial was negative because patients with CRAO were included after 4.5 hours. There are trials underway in Europe for both tPA and TNK to address that. The retina will irreversibly infarct if the blood flow is not restored within 240 minutes (this is from basic science studies with ...
What is your approach to monitoring the neurologic status of a patient with a traumatic brain injury requiring burst suppression for status epilepticus?
As with any other patient in status epilepticus requiring burst suppression, the neurological exam becomes limited to pupillary light reactivity. Pharmacotherapy used in the management of status epilepticus does not negate pupillary response. Not being able to obtain frequent neurological exams on a...
How do you use cardiac biomarkers, if at all, in prognostication for patients with ischemic stroke?
For those rare patients now out 5 years post GBM treatment and continuous Optune, is there a point one would stop Optune?
I haven’t seen any data from Optune on these very long term survivors. They have released some subset data that patients who used the device 90% of the time or greater had a 29% chance of being alive at 5 years which is pretty remarkable. Certainly think there are diminishing returns beyond 5 years....