Questions discussed in this category
Which factors would influence your decision?
Can you explain when would you consider light chain amyloidosis work up with fat pad biopsy?
Do you favor specific medications or surgical interventions?
Typically, neurologists were taught to treat with triptans at the onset of headache pain. Do you still follow this teaching, or do you treat at the on...
In light of the publication by Ganesh et al., PMID 39503052.
Are there any clinical trials underway to study additional therapies?
Is there a role in adjusting the medication doses to levels in seizure-free patients; or is it sufficient to just monitor patients clinically?
In light of the publication of results from the EPISODE study.
How is it that I'm able to prescribe medications to patients (in my state) via legitimate mail order pharmacies that are located in a different state?...
Have recent trials (TRAIN trial and HEMOTION trial) influenced your approach?
In light of the STOP-CAD study
Would you consider charging a small fee for managing C-2 prescriptions between appointments instead of requiring the patient to come monthly?
Labs with normal PT, but prolonged PTT (47 sec, ULN 40 sec) that does not correct on immediate mix. Lupus anticoagulant negative (DRVVT and hexagonal ...
It seems clear that longer monitoring yields more AF detected. What is less clear to me is whether all ILR-detected AF is relevant and merits anticoag...
Would having infarct expansion during hospitalization change your approach?
In patients who have decreased arousal after ischemic stroke, do you use amantadine or modafinil to aid with wakefulness and interaction with therapy ...
Do you generally recommend anti-diarrheals, dietary modifications, or consider this an unacceptable side effect and move to other therapies?
A large stroke in cortical regions might have a low NIHSS, while a small internal capsule lacune might have a large NIHSS. ICH risk is thought to be a...
Would you recommend left atrial appendage occlusion with or without continuing anticoagulation? In light of Maarse et al., JAMA Neurology 2024.
In light of a recent publication by Sun et al., PMID 39235816 on the BASIS trial for balloon angioplasty for ICAS.
Would your approach differ through telemedicine for small ERs without access to onsite ophthalmology or neurology?
In light of the INSPIRES trial publication.
How would you adjust statin therapy in these patients?
In light of a publication by Sakusic et al., PMID 39102615 suggests an increased risk of ICH expansion in patients with heparin bridge compared to sta...
Blood pressure targets for ischemic stroke and intracerebral hemorrhage are described in several guidelines. However, in patients with acute stroke wh...
In light of a study by Caroll et al., PMID 38820488 on epidural blood patches for patients with headaches attributed to SIH that were non-conforming t...
Would you adjust your approach based on the infarct size, symptom severity, or stroke etiology?
Is there any concern for drug interactions of DMARDs and/or biologics with anti seizure medications?
Thrombophilia testing, including JAK2 is negative. When would you stop anticoagulation?
How do you balance between having a higher long-term blood pressure to prevent flow failure and leading to worsening of stenosis or occlusion from the...
Peripheral nerve surgical decompression, i.e., "migraine surgery" is a controversial procedure mostly being advanced by plastic surgeons. The evidence...
In patients with average of less than 5 respiratory events per hour, adequate sleep duration and hygiene confirmed on sleep log, absent cataplexy and ...
E.g., a patient with newly diagnosed CIDP who is wheelchair-bound.
Is a biopsy or EMG helpful in confirming the etiology? What is the best treatment for sarcoid neuropathy?
E.g., nasal, rectal, buccal.
Would your management be different if the LVO was found on imaging without preceding associated symptoms?
Should some patients get 325 mg instead of 81mg at least for a certain amount of time, such as patients in the acute phase of ischemic stroke or patie...
If yes, if the assay shows they are a non-responder, do you switch to ticagrelor?
Considering the short half-life, at what point would it be deemed too late to administer any reversal agent, and to consider withholding it?
How would you counsel the patient given the drug interactions present?
How do you guide what contraceptive type when asked by the medical team?
In light of ANNEXA-I RCT results: Connolly et al., PMID 38749032.
Are there specific mass features that would influence your treatment decision?
In light of TIMELESS and TRACE-III trials.
If so, what is the typical duration?
Is there utility when classic inflammatory markers (ESR,CRP) or disease specific markers (C3, C4, dsDNA) do not correlate with patients disease activi...
For example, in the setting of TBI, how do you guide the duration of the medical treatment?
Would you consider using cilostazol instead of antiplatelets?
I found a study in which 32 patients continued on Botox for the treatment of chronic migraine. Only one had a miscarriage at 9 weeks and the rest seem...
Does it influence your choice of antithrombotic therapy? Do you perform serial follow-up imaging?
In light of meta-analysis data showing favorable outcomes in this normally excluded subset of patients (Katsanos et al., PMID 37775318).
Is there management guidance on when to start after stroke onset?
When would you consider using anticoagulation and for how long?
I am aware that the radiological signs can be subtle or overlooked, or confused with a Chiari malformation, hence, I will typically review images with...
What is your strategy for treating persistent headaches in the aftermath of subarachnoid hemorrhage?
Does your strategy change depending on whether or not it is a secured or unsecured aneurysmal SAH?
Does your approach differ if the stenosis is symptomatic or flow-limiting?
Individual times in the therapeutic range while on VKA treatment was not registered in FRAIL-AF.
If a patient progresses from discrete episodes (hours long) of mild vertigo with rare headaches, but associated migrainous features (photophobia and n...
Is there any evidence supporting the use of heparin boluses?
The ASH 2020 guidelines have "recommended that adults with HbSS or HbSβ0 thalassemia be screened at least once for silent cerebral infarcts even ...
For example, a patient who is already on botulinum toxin injections, CGRP inhibitors, as well as an SSRI. Are there any new treatment modalities avail...
If so, how long would you hold? This medication is given for migraines as q3 month infusions and some data suggest that CGRP plays a role in immune-mo...
In light of the evidence associating cerebral amyloid angiopathy (CAA) with subdural hemorrhage; Rivier et al., PMID 38147345.
In what clinical scenarios do you utilize post-cardiac arrest targeted temperature management (TTM)?
In the span between the HACA trial and the Targeted Temperature Management in Out-of-Hospital Cardiac Arrest study (Dankiewicz et al., PMID 34133859),...
What are the sources for this and are they reliable by today’s standards? Numerous case series report various abnormal movements but how reliabl...
Visual aura is commonly described as a scintillating scotoma. In practice, there is a much wider spectrum of visual symptoms in the migraine populatio...
If yes, is there a preference with MRI or CT technique?
Does the approach differ if the tremor stems from essential tremor or Parkinson's disease?
E.g., a patient has an intracranial hemorrhage after TBI with convulsive status epilepticus.
I.e., 20 minutes vs 30 minutes vs 1 hour.
How would you treat it?
Short-term glucocorticoids are often prescribed as "bridge" therapy to avoid ER visits. What else should we consider?
How does the 2HELPS2B scoring tool play a role in your decision-making?
We have seen 81 vs 162 vs 325 mg up to 1300 mg.
How about a distal occlusion? The patient was initially symptomatic but symptoms improved or mostly resolved.
Plasmapheresis first or IVIG first in GBS? What other treatment options are there for severe disabling GBS?
In patients with chronic migraine and possible medication overuse headaches due to chronic narcotic use, what’s your strategy for those patients...
Are there variations with different patient populations?
While some have the practice of 90 days per SAMMPRIS trial, the lower rates of ischemic stroke in the medical therapy group were driven by events with...
The patient is on mesalamine for Crohn’s and CellCept and HCQ for skin manifestations (currently on hold during workup). The infectious workup i...
This is not an infrequent finding in outpatient neurology practice, often in the absence of any lacunar disease in the typical regions, though I usual...
In FRAIL-AF, switching VKA therapy to a NOAC was associated with higher risk of bleeding in elderly, frail patients.
Given the risk of elevated ICP, would you attempt a brain MRI to further characterize the lesion? Or would CT imaging suffice prior to intervention?
In FRAIL-AF, participants were switched from VKA to dabigatran, rivaroxaban, apixaban, and edoxaban.
Should MTCTA be standard for anyone with LKN>=6h?
Per 2021 GCA Vasculitis Guidelines: low evidence, but conditional recommendation for CTA neck, chest, abd/pelvis. Is anybody following this or do you ...
Would you continue KEYNOTE-522 neoadjuvant therapy? The patient has a PMH of sarcoidosis with no stroke risk factors. No residual deficits.
What is the utility of it?
See Benbadis, AAN Commentary February 2023; 13 (1).
What are the diagnosis and treatment for hypnagogic shooting headache?
Many recent studies cast doubt on continuous vs repeated routine EEG.
Current guidelines (AHA, ESO, etc.) are not clear. In addition, if a patient arrives with BP>240 how do you balance the risk of hypoperfusion with ...
Fibrinogen level >200.
Also how would you manage this perioperatively?
For patients with ischemic stroke status-post decompressive hemi-craniectomy, when should they start aspirin for secondary stroke prevention? POD 5? P...
In addition, what formula do you use to calculate the IgG index?
If a patient is has GERD or avoids NSAIDs, do you avoid Ketorolac IV?
Are there any diagnostic tests or imaging that you recommend?
There are some data supporting the use of IV lidocaine as an abortive treatment for migraine, NDPH, and some trigeminal autonomic cephalalgias, when d...
Would you anticoagulate if this screening is negative pending PFO closure?
The patient has no known history of autoimmune disease.
Which genetic/other testing should be considered in an early-onset dementia work-up?
How does pravastatin differ in advantage from other high-intensity statins?
Do you distinguish between primary and secondary prevention? Wilson et al., PMID 31130428 is helpful, but curious how people apply this data in practi...
Do all malignant posterior fossa infarcts need sub-occipital craniectomy or are there a subset of cases that can be managed with EVD?
If so, what is the recommended maximum dose of clozapine for PD patients?
Are there any instances where you would prefer a biosimilar rather than the reference product?
If the patient is in burst-suppression once EEG is connected, how long do you keep patient in burst-suppression before weaning sedation?
Regimen currently 25 mg lenalidomide D1-21 of D28 day cycles, Daratumumab 16 mg/kg every 2 weeks.
For patients who are unable to have complete brain stem testing, would you recommend apnea testing prior to ancillary tests in case of suspected brain...
For patients undergoing outpatient MR imaging for other indications who have instantly found acute stroke, do you typically recommend the patient be a...
Do you offer this person a vascular intervention (i.e., CEA or stenting)?
Or love to share personal experiences/articles?
In what ways, if any, does the timing of perfusion imaging from onset of stroke symptoms affect its utility in informing quality of distal perfusion?
For instance, if the patient doesn’t tolerate apnea testing, is too unstable to go for ancillary testing outside the ICU, and TCDs/EEG are unava...
Do you wait 12 weeks for confirmation to begin treatment if patient is declining?
When it seems fairly certain that this is a drug effect is it something that can just be monitored or requires a change in approach?
How do you recommend titration?
For example, a patient with 2 Hz GPDs with hepatic or uremic encephalopathy.
Does timing relative to initiation of antibiotics matter?
What are some high-yield instances where triphasic waves on electroencephalogram (EEG) are more than just harmless markers of gross toxic-metabolic en...
What modality do you prefer?
Should one restart lamotrigine or look for an alternative? If no other alternative available, is slow titration vs regular titration preferred?
If so, for how long?
Would the checkpoint inhibitor still work if blocking only that portion of the inflammatory cascade as opposed to more global blockade with steroids?
Are VDRL titers useful?
Do you just use antibiotic prophylaxis if therapy is started prior to meningococcal vaccination?
Is there data for CGRP inhibitors?
Do you order any imaging beforehand? Are there other studies that you order?
What is your preferred approach to a pregnant patient who is in status migrainosus that is refractory to first line treatments?
When do you consider a blood patch?
While it is an excellent score for objectively assessing concerning EEG features, there are pathologies where it can be argued that long-term monitori...
Do we prophylactically place patients on anticoagulation after one episode?
Besides MRI/MRV brain, are there other diagnostic imaging that should b...
With studies showing rare risk of developing epilepsy after PRES do you just taper medications over the following weeks-months? Any need for outpatien...
(e.g. Alzheimer's disease)?
Do you have a particular cutoff?
Do you ever recommend any specific sequences on MRA?
For patients clinically presenting with Transient Global Amnesia and no other focal neurologic deficits, do you always pursue work up to rule out stro...
Which triptans are safer in stroke induced migraines?
What is the cost and accessibility of CYP2C19 gene testing? Does the limited availability of rapid genotyping techniques limit the clinical applicabil...
How do you plan to incorporate the results of the CHANCE-2 trial (Wang et al., PMID 34708996) in your own practice?
What is the etiology/pathology for tinnitus in Intracranial hypotension? How often is this symptom encountered in patients with intracranial hypotensi...
No thrombus detected on echocardiogram and no evidence of atrial fibrillation is present.
Do you perform routine screening for coronary artery disease in aging patients already taking these therapies?
If so, what would you consider ordering?
What are your thoughts on the ethics of inpatient use of sedatives in these patients to help with agitation to “protect themselves from harm and...
Is there role for IVIG? Would you alter the dose or time course of steroid therapy?
Which holistic treatments for migraine without aura do you recommend for patients who are refractory to standard treatments?
Occasionally, patients referred for dedicated epilepsy management for "medication refractory epilepsy" are found to have purely non-epileptic spells. ...
In the setting of no personal or family history and no other risk factors for thrombosis, is systemic anticoagulation warranted if local treatments (e...
This question is intended to include consideration of cardiac diagnostic screening, as well as initiation & maintenance of lamotrigine, in epileps...
What effective modalities have you found for acute exacerbations of trigeminal neuralgia including in patients who present to the ED?
How can one safely taper off and stop clonazepam in a woman of reproductive age with epilepsy who is taking it chronically for epilepsy and is plannin...
How do you approach secondary stroke prevention for patients with ischemic stroke, atrial fibrillation, and signs of cerebral amyloid angiopathy/micro...
What factors influence your thinking?
How do you treat dangerous behavioral disturbances (aggression, nighttime wandering) in patients with dementia with Lewy bodies (DLB)?
For what duration do you use therapy?
Is there any benefit to starting hyperosmolar therapy prior to the development of depressed level of consciousness or midline shift?
The thought being, if no clearly defined lesion exists on available neuroimaging, how do we balance the benefits, risks, and uncertainty in choosing w...
In patients diagnosed with pseudotumor cerebri, is vaginal delivery safe? How do you manage this condition during the pregnancy?
e.g. DITP from eptifibatide after a cardiac intervention
By completely unremarkable, I mean zero clinical events AND zero interictal abnormalities despite full withdrawal of medications. Assume, for the sake...
What testing do you typically proceed with?
How do you treat refractory focal status epilepticus in an adult with history of alcoholism and traumatic bilateral subdural hematomas who is failing ...
Additionally, what is the current role for temporal artery ultrasound in workup for GCA?
What is the your preferred loading (and maintenance) dose for use of Perampanel in the treatment of refractory status epilepticus?
Specifically, how do you treat the delayed headache, not the headache that develops during the infusion where pre-hydration and slowing down the rate ...
How does presence of intraventricular hemorrhage change your recommendations?
The question is broad and is meant to include patients who have healthy BMD, osteopenia, and osteoporosis, as well as exposure to first generation AED...
What modality do you prefer?
How do you approach treatment?
In what clinical scenario would you refer a patient for embolization? Are there any contraindications?
Can you expand on this by sharing exactly what this routine workup should include? What additional tests outside of evaluating for POEMS and amyloidos...
What is the best way to determine if patients with new PCA territory infarct can drive? Upon discharge from the hospital, do you routinely refer them ...
Thoughts on sarilumab vs methotrexate, or just treat with steroids alone
How would you treat patients with symptoms of AIS who have an allergic reaction to TPA with no evidence of large vessel occlusion on imaging? What nex...
Small study in pediatric PACNS have evaluated this as a potential marker (Cellucci et al., PMID 22740622)
For a relatively young, medically compliant patient with HFrEF (EF<35%) and h/o embolic stroke, what is the consensus of starting AC for secondary ...
Is there an AED of choice?
Does this add any value?
In patients undergoing continuous EEG monitoring in the ICU, we often encounter EEG patterns that lie along the inter-ictal continuum (IIC). In such c...
Are there contra-indications while breast-feeding?
At what point could starting AEDs be considered for patients with recurrent simple febrile seizures?
What steps should be taken to wean them off?
For example, with a Watchman device? What is the evidence behind this?
Specifically, do you reach for Rituximab or cyclophosphamide?
If so, how do you decide when to restart anticoagulants?
When would you consider stenting or CEA even if there is less than 50 obstruction when no other etiology has been found?
Given the slow recovery of nerve damage, what would you expect to see on a repeat EMG after treatment? Continued denervation or just sequelae of past ...
Papers discussed in this category
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Stroke, 2020 Aug 06
Neurology. Clinical practice, 2018-02
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