Neurohospitalist&nbsp;&nbsp;&nbsp;

What are the current treatment options for progressive multifocal leukoencephalopathy in patients without HIV/AIDS?

Are there any clinical trials underway to study additional therapies?

Do you utilize thrombolytic therapy in patients with CRAO?

Do you recommend CT perfusion in patients presenting with symptoms of acute stroke before 6 hours?

7 Answers available

What blood pressure targets do you enforce in the first 24-48 hours in a patient who develops an intracranial hemorrhage after mechanical thrombectomy?

Blood pressure targets for ischemic stroke and intracerebral hemorrhage are described in several guidelines. However, in patients with acute stroke wh...

Would you discontinue romosozumab in a patient who develops a hemorrhagic stroke while on therapy?

What is your approach to secondary stroke prevention in patients with atrial fibrillation and intracranial stenosis (>70%)?

When do you recommend hyperacute MRI for patients with wake-up stroke?

Would you recommend a CT venogram or MR venogram in patients with concern for venous sinus thrombosis?

How does your treatment approach differ in patients with acute visual loss due to central retinal artery occlusion versus retinal vein occlusion?

How do you approach management of patients with lupus and transverse myelitis not responding to pulse dose steroids?

Do you typically load DAPT in patients with ICAD?

How do you apply the 2HELPS2B score into clinical decision making for determining duration of cEEG testing?

What imaging do you recommend for patients with suspected CSF leak?

How would you determine the safety of anticoagulation in patients with evidence of cerebral microhemorrhages who present with acute stroke secondary to cardioembolism?

Would you consider starting dual antiplatelet therapy in a patient with evidence of petechial hemorrhage post-stroke secondary to ICAD?

What is the expected timeframe one would expect to see paroxysmal sympathetic hyperactivity/sympathetic storming persist post-traumatic brain injury?

For example, in the setting of TBI, how do you guide the duration of the medical treatment?

Would you consider skipping intravenous thrombolysis in patients with tandem occlusions who qualify for endovascular thrombectomy?

Is there a good rationale for using vasopressors/induced hypertension in a patient with fluctuating neurologic deficits from symptomatic intracranial stenosis?

When do you consider stenting in patients with recurrent stroke with ICAD?

What is the preferred approach to managing non-occlusive or partially occlusive venous sinus thrombosis?

What is your approach to the management of asymptomatic intracranial atherosclerosis discovered during the workup of an acute stroke?

Does it influence your choice of antithrombotic therapy? Do you perform serial follow-up imaging?

When do you consider patients with acute stroke with large vessel occlusion with very low ASPECTS scores (less than 3) for endovascular thrombectomy?

In light of meta-analysis data showing favorable outcomes in this normally excluded subset of patients (Katsanos et al., PMID 37775318).

How would you manage a CVST secondary to a traumatic brain injury with the presence of intracranial hemorrhage?

When would you consider using anticoagulation and for how long?

In which patients do you recommend craniectomy-watch after acute stroke?

How often is a contrast-enhanced brain MRI truly normal in the setting of spontaneous intracranial hypotension?

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?

What do you advise regarding the timing and safety of major surgery in patients with moderate to severe intracranial atherosclerosis?

Does your approach differ if the stenosis is symptomatic or flow-limiting?

Would you recommend TNK or DAPT in patients with stroke-like symptoms and NIHSS less than 5 presenting within 4.5 hours?

When is brain biopsy useful/warranted as part of the diagnostic work-up in patients with suspected primary CNS angiitis?

Regarding CVST, what protocol of heparin dosing do you regularly use and does it change depending on clot burden/ICH status?

Is there any evidence supporting the use of heparin boluses?

Would you administer IV thrombolysis in a patient presenting with disabling stroke symptoms while on anti-amyloid therapy?

When do you use MRI to evaluate patients with spontaneous subdural hemorrhage?

In light of the evidence associating cerebral amyloid angiopathy (CAA) with subdural hemorrhage; Rivier et al., PMID 38147345.

Do you typically use NOACs or Lovenox in patients with stroke due to hypercoagulability from malignancy?

What is your treatment approach to neurological Sjogrens disease with both peripheral neuropathy and transverse myelitis?

Do you repeat a lumbar puncture in a patient living with HIV diagnosed with and treated for neurosyphilis and if so, when?

In patients being evaluated for brain death, which abnormal movements are definitively known to still be consistent with brain death and which are possibly consistent with brain death but lack definitive evidence?

What are the sources for this and are they reliable by today’s standards? Numerous case series report various abnormal movements but how reliabl...

In a patient with presumed autoimmune encephalitis, would treating them with IVIG before getting a brain biopsy alter the pathological changes in a meaningful way?

When do you re-image patients with a diagnosis of venous sinus thrombosis?

What is your approach to monitoring the neurologic status of a patient with a traumatic brain injury requiring burst suppression for status epilepticus?

E.g., a patient has an intracranial hemorrhage after TBI with convulsive status epilepticus.

How do you manage patients with status dystonicus?

When do you consider treating intracerebral hemorrhage associated with cerebral amyloid angiopathy as an inflammatory CAA?

How would you treat it?

Is there a role for routine EEG in the diagnostic evaluation of critically ill comatose patients or should these patients always receive long-term continuous video EEG monitoring?

How does the 2HELPS2B scoring tool play a role in your decision-making?

How do you approach patients with recurrent TGA in the emergency room?

How do you manage incidentally found venous sinus thrombosis?

Would you consider dual antiplatelet therapy for stroke prevention for ICAD in patients with a history of SAH?

What criteria are used to choose a specific dose of aspirin in ischemic stroke?

We have seen 81 vs 162 vs 325 mg up to 1300 mg.

Would you give TNK or IVT to a patient with proximal occlusion and an NIHSS of 0-3 (non-disabling)?

How about a distal occlusion? The patient was initially symptomatic but symptoms improved or mostly resolved.

How many times one can use IVIG in GBS?

Plasmapheresis first or IVIG first in GBS? What other treatment options are there for severe disabling GBS?

What is the normal range of spinal tap opening pressure?

Are there variations with different patient populations?

How do you prescribe ketamine for treatment of refractory status epilepticus, and what is its efficacy?

Is there a role for inpatient EMG/NCS in patients who present with rhabdomyolysis with unclear etiology?

How do you acutely manage a free-floating thrombus in a major artery in a patient with a stroke as a result of it?

How do you work up incidentally found papilledema in the emergency room?

Would you attempt a brain MRI in patients who present to the ER with subacute presentation of obstructive hydrocephalus?

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?

Do you start an anti-seizure medication in a patient with a first unprovoked nocturnal seizure with a normal exam, imaging, and EEG; or wait until the second seizure?

11 Answers available

Which patients presenting with spontaneous ICH should be considered for a diagnostic cerebral angiogram/DSA?

How do you counsel patients with postmedian sternotomy plexopathy?

What would be the clinical benefit of multiphase CTA over CTP?

Should MTCTA be standard for anyone with LKN>=6h?

Does management of NMDA receptor encephalitis change in a patient with HIV/AIDS?

How would you work up and manage an isolated CN3 deficit with anisocoria?

MRI Orbits with possible mild enhancement of unilateral CN3; Brain MRI chronic microvascular disease, mild atrophy.

Is there a utility in getting repeat antibody testing on GBS patients after PLEX?

Can this guide further treatment/prognosis?

When should one consider obtaining a cardiac MRI in ischemic stroke patients?

What is the utility of it?

How do you approach the management of EBV Meningoencephalitis (CSF pleocytosis and CSF PCR positive for EBV)?

When do you restart antiplatelet therapy in patients with hemorrhagic conversion of stroke?

Do you think repeated routine EEG is sufficient for cardiac arrest patients or should we be always using continuous EEG?

Many recent studies cast doubt on continuous vs repeated routine EEG.

When do you consider plasmapheresis instead of (or in addition to) IV steroids for patients with acute MS exacerbation?

What are some commonly missed diagnoses that should be considered in cases of otherwise seronegative yet steroid-responsive autoimmune encephalitis?

What workup do you recommend on patients with suspected ischemic cranial nerve six palsy?

For patients with acute ischemic stroke and BP >185/110, at what point do you consider persistently elevated BP too refractory to safely give thrombolysis?

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 ...

What is the recommended approach for extracranial bleeding after tPA?

Fibrinogen level >200.

For patients with ischemic stroke status-post decompressive hemi-craniectomy, when should they start aspirin for secondary stroke prevention?

For patients with ischemic stroke status-post decompressive hemi-craniectomy, when should they start aspirin for secondary stroke prevention? POD 5? P...

Is intracranial hemorrhage a contraindication for valproic acid?

How do you manage patients with post spinal tap headaches?

Are there any diagnostic tests or imaging that you recommend?

How do you approach a patient with atrial fibrillation on apixaban who has a new cardioembolic stroke?

In patients with Afib on anticoagulation and concurrent intracranial atherosclerotic disease, would you consider adding an anti-platelet to anticoagulation if there are recurrent events that could be related to the ICAD?

How do you manage and treat post stroke alien hand syndrome?

In patients with embolic stroke and a PFO, how often do you go beyond venous Doppler of the lower extremities to screen for DVT (e.g. MRV or CTV abdomen and pelvis)?

Would you anticoagulate if this screening is negative pending PFO closure?

When can you utilize external ventricular drains (EVDs) in the management of posterior fossa strokes?

Do all malignant posterior fossa infarcts need sub-occipital craniectomy or are there a subset of cases that can be managed with EVD?

Do you typically recommend anti-epileptic medication in patients with acute multi-compartmental intracranial hemorrhage?

What is your approach to the management of worsening dystonic spasms that are painful and refractory to standard dystonia medications?

In a patient who is already on a standing regimen of baclofen, tizanidine, trihexyphenidyl, clonidine, and diazepam and who is taking additional diaze...

Is there a difference in treatment of status epilepticus from alcohol withdrawal vs other causes?

Is there a role for using an external ventricular drain (EVD) trial in the workup of normal pressure hydrocephalus?

This applies to using EVD either in addition to or instead of a large volume lumbar puncture.

What is the diagnostic yield of working up suspected autoimmune encephalitis in patients with new onset behavioral disturbance without overt neurological deficits?

Anecdotally, the diagnostic yield in these patients seems quite low, yet autoimmune encephalitis is often invoked in such patients, particularly in th...

What are some alternatives to dexamethasone for brain edema in patients who are allergic, have an intolerance, or refuse the medication?

How do you manage autonomic storming in patients with increased intracranial pressure?

Under which clinical scenarios do you consider an inpatient EMG?

How do you target therapy before the EEG is connected in a patient who comes to the ED in super refractory generalized convulsive status epilepticus once the convulsions resolve?

If the patient is in burst-suppression once EEG is connected, how long do you keep patient in burst-suppression before weaning sedation?

What blood pressure goals do you typically target for patients in the immediate post thrombectomy period?

Do you perform apnea testing prior to ancillary tests in patients with suspected brain death who are unable to undergo complete brainstem testing?

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...

Do you consider a severe ICA stenosis (70-99% narrowing per NASCET criteria) symptomatic if a lacunar stroke attributable to small vessel disease occurs in the perforating arteries (e.g. lenticulostriate) downstream from the stenosis?

Do you offer this person a vascular intervention (i.e., CEA or stenting)?

How do you approach treatment of myoclonic status epilepticus from anoxic brain injury?

Or love to share personal experiences/articles?

Is there a role to continue aspirin in patients with myeloproliferative disorders who have never had a thrombotic event that are starting DOAC for stroke prophylaxis with newly diagnosed atrial fibrillation?

How long do you wait before foley or IV placement in patients who have recieved TNK or TPA?

What are current strategies to treat severe symptomatic basilar stenosis failing medical therapy?

How do you manage patients with a diagnosis of AIDP who do not respond to initial IVIg?

How do you complete brain death testing in patients who cannot tolerate apnea testing and are unable to transport for ancillary testing?

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...

Can Guillain-Barre syndrome present with intact reflexes?

When do you recommend treating stimulus-induced generalized periodic discharges (GPDs)?

What antithrombotic regimen do you recommend prior to and in anticipation of CEA for patients with symptomatic carotid stenosis?

Would you give IV thrombolysis to a patient presenting with acute disabling stroke symptoms after a TAVI procedure?

When do you start anticoagulation in patients with endocarditis and evidence of mycotic aneursym?

Do you typically recommend four factor prothrombin complex concentrate versus fresh frozen plasma for INR correction in patients with vitamin K antagonist associated spontaneous ICH?

How do you approach ictal-interictal continuum in patients with presumed toxic/metabolic etiology?

For example, a patient with 2 Hz GPDs with hepatic or uremic encephalopathy.

Is angioedema secondary to IV tPA considered an absolute contraindication for tPA in future?

When are steroids indicated in the treatment of strep pneumo meningitis?

Does timing relative to initiation of antibiotics matter?

In what clinical situations do you treat triphasic waves on EEG?

What are some high-yield instances where triphasic waves on electroencephalogram (EEG) are more than just harmless markers of gross toxic-metabolic en...

When would you add acyclovir for treatment of Bell's Palsy in addition to steroids and symptomatic care?

How do you evaluate and treat patients with cerebral edema secondary to hyperammonemia?

What modality do you prefer?

Do you recommend pre-emptive anti-epileptic treatment for patients with spontaneous ICH?

If so, for how long?

Would you favor restarting anticoagulation or pursuing left atrial appendage closure in a patient with hemorrhagic stroke on anticoagulation for non-valvular atrial fibrillation?

In what subset of traumatic brain injury/concussion patients would you consider use of N-Acetyl Cysteine?

When do you redose IVIG in GBS patients who were under-treated and are worsening?

Is there any data supporting this?

How do you approach the workup of a patient with incidentally found pachymeningitis?

What factors influence whether you treat a suspected flare of NMOSD (neuromyelitis optica spectrum disorder) with pulse dose steroids versus plasmaphereis?

What is your practice for the timing of resumption of oral anticoagulation after ICH?

Do you order any imaging beforehand? Are there other studies that you order?

What symptomatic management do you recommend in patients with post LP headaches?

When do you consider a blood patch?

Under what circumstances would you recommend using the 2HELPS2B score to decide whether or not to pursue long-term cEEG?

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 you typically recommend platelet transfusions in patients with spontaneous ICH?

Do you have a particular cutoff?

What is the utility and yield of CSF studies for orbital apex syndrome?

Although probably more familiar to ophthalmologists, orbital apex syndrome refers to the consequence of any kind of swelling or mass effect within the...

When do you recommend MRA in patients with spontaneous ICH and negative CTA?

Do you ever recommend any specific sequences on MRA?

Do you typically recommend CT angiogram and CT venogram to assess for patients with lobar spontaneous ICH?

How do you approach a mildly positive finding on an autoimmune encephalitis panel when there is no other evidence of encephalitis (such as elevated CSF protein, abnormal imaging, or EEG findings)?

For example, a GAD65 Ab of 0.07 when the cut-off is 0.02. Does this answer change if you consider adult vs pediatric populations?

For a patient with high suspicion for NMDA receptor encephalitis, is there a role for giving rituximab along with methylprednisolone & IVIG (all three together) while the CSF anti-NMDAR antibodies are still pending?

Instead of waiting for the antibody test to result, if you have a high suspicion for NMDAR encephalitis, is there a role for giving rituximab alongsid...

Do you always pursue stroke work up in patients diagnosed with transient global amnesia?

For patients clinically presenting with Transient Global Amnesia and no other focal neurologic deficits, do you always pursue work up to rule out stro...

8 Answers available

What is your decision process on decreasing the sodium goal for patients with cerebral edema?

Would you consider anticoagulation for a young patient with a recent embolic stroke and newly diagnosed global cardiac hypokinesis with ejection fraction of less than 25%?

No thrombus detected on echocardiogram and no evidence of atrial fibrillation is present.

When do you prescribe a steroid taper after the high dose IV course for a multiple sclerosis exacerbation?

Would you recommend short-term dual antiplatelet therapy for a patient who received tPA, and is otherwise eligible for dual antiplatelet therapy per POINT or SAMMPRIS trial?

Do you counsel patients against driving who presents with transient global amnesia?

What is your approach for a patient with an acute ischemic stroke caused by an aortic thrombus?

For patients with generalized tonic-clonic seizures lasting > 2 minutes without IV access, what alternative medications can be used?

Do you routinely obtain an EEG in patients who are admitted with traumatic intra-cerebral hemorrhage?

How do you manage acute exacerbations of trigeminal neuralgia?

What effective modalities have you found for acute exacerbations of trigeminal neuralgia including in patients who present to the ED?

How do you decide between TCAR vs. carotid stenting for patients unstable for CEA?

How do you approach the treatment of SREAT (steroid-responsive encephalopathy with autoimmune thyroiditis) after initial pulse dose steroids?

When do you start anticoagulation in a patient with cardioembolic CVA secondary to new onset atrial fibrillation with hemorrhagic conversion?

How do you determine timing and frequency of stability scans for a patient with spontaneous, non-aneurysmal intracerebral hemorrhage?

What factors influence your thinking?

When do you use plasmapheresis after IVIG in patients with Guillain-Barre Syndrome?

Do you frequently encounter asterixis in patients with UTI associated encephalopathy?

The most frequently taught cause of asterixis is hepatopathy and of course hepatic encephalopathy, and has other close associations (ie, uremia), I ha...

Do you use a combination of anticoagulant and antiplatelet therapy for treating intraluminal internal cerebral artery thrombus causing stroke?

For what duration do you use therapy?

How do you approach the management of a large vessel stroke if you anticipate the development of malignant cerebral edema?

Is there any benefit to starting hyperosmolar therapy prior to the development of depressed level of consciousness or midline shift?

Do you treat cerebral vein thrombosis with parenchymal hemorrhage using full dose heparin protocol rather than the high risk protocol?

Do you start anticoagulation in a patient with infective endocarditis who also has atrial fibrillation and stroke?

How would you approach evaluation and treatment of a patient on pembrolizumab therapy who presents with symmetric, proximal, upper extremity and lower extremity painful weakness without an elevated CK?

How do you treat refractory focal status epilepticus in patients with traumatic bilateral subdural hematomas?

How do you treat refractory focal status epilepticus in an adult with history of alcoholism and traumatic bilateral subdural hematomas who is failing ...

Do you always perform temporal artery biopsy in patients with positive inflammatory markers and high clinical suspicion of GCA?

Is either ESR or CRP more sensitive or specific for the diagnosis of GCA?

Additionally, what is the current role for temporal artery ultrasound in workup for GCA?

How would you approach treatment of a brainstem AVM after hemorrhage in a patient not a candidate for surgery or embolization?

What would be your preferred technique and dose/fractionation?

How do you treat post-IVIG headache that is not responsive to Tylenol or NSAIDs?

Specifically, how do you treat the delayed headache, not the headache that develops during the infusion where pre-hydration and slowing down the rate ...

What is the utility in repeating a temporal ultrasound (US) in a previously US diagnosed positive GCA patient who has received treatment and is presenting with recurrent GCA symptoms?

For patients with atrial fibrillation on DOAC, when should they resume DOAC after a thalamic bleed without intraventricular bleed?

How does presence of intraventricular hemorrhage change your recommendations?

What is the best course of action for a patient with isolated carcinomatous meningitis who is responding well to intrathecal methotrexate but now has MRI findings suspicious for methotrexate leukoencephalopathy?

Can intrathecal methotrexate be continued with close neurologic observation vs switch in treatment now due to findings?

How do you approach patients with suspected CNS lymphoma who have been treated with steroids?

Do you biopsy immediately, stop treatment, biopsy at a later time, or depend solely on the data you already have?

When is follow-up imaging warranted in patients with anoxic brain injury?

What modality do you prefer?

What DHE migraine protocol works best for acute treatment both in terms of dosage and timeframe?

When do you consider middle meningeal artery embolization in patients with recurrent subdural hemorrhages?

In what clinical scenario would you refer a patient for embolization? Are there any contraindications?

At what timepoint do you do an EMG/NCS in patients with suspected GBS?

How long do you wait (from onset of symptoms) to do a EMG/NCS in a patient with GBS?

How to you treat pregnant women who develop Bell's Palsy?

In a patient with suspected Miller Fisher syndrome, would you wait until antibody testing results to start IVIG or treat empirically?

Is there is a particular pattern of extraocular motility restriction in Miller Fisher syndrome?

How do you treat patients with symptoms of acute ischemic stroke who have an allergic reaction to alteplase?

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...

When do you start anticoagulation for secondary prevention in patients with HFrEF and history of embolic strokes?

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 ...

In women of childbearing age with NMDA encephalitis and normal pelvic imaging, is there a role for oophorectomy for possible microteratoma?

If not, how often do you repeat pelvic imaging?

In patients in the ICU who are on the inter-ictal continuum, how do you decide whether or not to treat for potential non-convulsive status epilepticus?

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...

When do you restart anticoagulation in patients with atrial fibrillation who just had an ischemic stroke?

When do you consider starting hypertonic saline solution in patients with an acute ischemic stroke?

How do you approach management of cerebral venous sinus thrombosis in a patient with severe thrombocytopenia?

Is an EMG/NCS required to clinically diagnose Guillain barre syndrome?

Should patients who have had hemorrhagic strokes be restarted on oral anticoagulation?

If so, how do you decide when to restart anticoagulants?

How do you determine the timing of anticoagulation for patients with large MCA strokes secondary to atrial fibrillation?

In what clinical settings is acute ICH clot removal recommended?

In patients with recurrent ischemic infarcts on the same side as an internal carotid artery lesion, is intervention warranted even if there is less than 50% obstruction?

When would you consider stenting or CEA even if there is less than 50 obstruction when no other etiology has been found?

Do you treat HIV/AIDS-associated CNS vasculitis with antiretrovirals alone or in combination with steroids?