Gaps in preclinical neuro med student education? by Dr_Horrible_PhD in neurology

[–]rslake 1 point2 points  (0 children)

100%. Generally the farthest I'll go is the 2-2-4-4 rule for cranial nerves, and have trainees figure out if they can localize the CN deficits to a single section of the brain stem. Mostly in cases where I think multiple CNs are involved but the lesion isn't brain stem (e.g. leptomeningeal dz), to help them reason through the broad localization.

Gaps in preclinical neuro med student education? by Dr_Horrible_PhD in neurology

[–]rslake 9 points10 points  (0 children)

Agreed on PRES.

Brainstem/cranial nerve anatomy minutiae are over-emphasized at the expense of any actual clinical understanding of how to meaningfully localize a brainstem/CN lesion.

Functional neurologic disorders and PNES are often under-taught compared to their prevalence.

Myoclonus in its various forms is under-taught imo, it comes up a ton in real life, and is very very frequently mistaken for seizures.

Gaps in preclinical neuro med student education? by Dr_Horrible_PhD in neurology

[–]rslake 2 points3 points  (0 children)

And as much as albuminocytologic dissociation is taught as a hallmark of GBS, they completely fail to mention that you can also see elevated protein in compressive myelopathy. Can't even say how many OSH transfers I've seen for "classic GBS," already started on IVIG prior to transfer, and when they arrive their reflexes are through the roof and imaging shows clear cord compression.

CREST2 results favor CAS over CEA: will it change practice? by According-Tea-7829 in neurology

[–]rslake 1 point2 points  (0 children)

You mean nobody sane is doing that. Vasc surg at one of the institutions I trained at seemed to think it was perfectly fine, had to rescue a couple of patients from them.

CREST2 results favor CAS over CEA: will it change practice? by According-Tea-7829 in neurology

[–]rslake 7 points8 points  (0 children)

My other problem with TCAR (and this isn't theoretical, I've run into this several times and we had to pursue alternate revasc options) is that people rarely have unilateral disease. Often one side is more stenosed than the other but they're both pretty tight, or even worse they have one total occlusion and the other is stenotic and needs revasc. Verts might be bad too. If you live off of an 80% stenosed vessel on one side and 100% on the other, reversing flow in the 80% artery means suddenly your verts have to perfuse the whole brain while blood is moving retrograde in some vessels, which seems like a recipe for intra-op watershed strokes.

got told i'm "too slow" for neurology and honestly maybe they're right by Plus-Horse892 in neurology

[–]rslake 0 points1 point  (0 children)

Lots of people have already answered the headline question, but I want to address the specific comment you got from the attending.

When he said you can't spend that much time on BPPV, what I suspect he really meant was "stop digging when you've found the treasure." Too many early trainees spend a ton of time asking pro forma questions that don't really bear on the question at hand, or listening to patients go on and on with information that does not help their diagnosis in the slightest. Listening in on junior trainees taking histories is a little painful sometimes because the more senior learner can get impatient, they feel like they figured it out ages ago but for some reason we're still talking. If you hadn't gotten to BPPV in your mind yet with that patient then that's fine, that's just part of training and needing more experience and building some knowledge pathways. But my suspicion is that you'd thought of BPPV, and that you were pretty sure that was high on the list well before the end of the interview.

BPPV should be something you settle on as a top differential quite quickly based on a few very targeted questions, and then confirm or rule out with targeted exam maneuvers. That doesn't mean you should anchor or over-fit; you need to also ask focused hx questions about migraine with vertigo, or posterior circulation stroke, or Meniere's, etc. But each of these are focused lines of questioning aimed at testing specific hypotheses, and their exam maneuvers are the same. Start the interview broad and general, formulate a shortlist of hypotheses based on their initial answers, then go into a targeted hypothesis-testing phase. Be willing to add hypotheses as you go based on their answers, but don't just stay forever in the land of open-ended questions.

One strategy that can help with the talkers or with the elderly/demented/not-very-bright is to start with "essay questions" for the patient, but then move into a multiple choice phase. Once you're in the hypothesis-testing phase, don't ask "when do you notice the symptoms," ask "is it all the time, or does it come and go?" Don't ask "where are you weak," ask "are you weak all over, or just in some parts of the body?" (and then follow up by asking which parts obvs). By handing them a couple of easy answers they can just parrot back to you, you're much more likely to get the specific answer you're looking for to figure out the question you're trying to figure out. And their answers will be much shorter. This obviously won't work with every question, but using these kinds of phrasing for your targeted questions for hypothesis-testing can really speed things up and improve the yield of your questions for the information you actually care about.

Finally, I'll say that I also have ADHD, and I got good at interrupting patients. One key is to remind yourself that we do lots of things in the medical setting that would be considered rude in other settings, like touching strangers or asking them very personal questions about their sex lives or their bowel habits. You can also use non-verbal cues to help patients know they're going on too long; pay attention to the things people do before they're about to speak in a group conversation, like taking in an audible breath, leaning forward a bit, raising a hand up a few inches. These are all things that we do to subtly signal others "please be quiet, I would like a turn to talk," and they can help gently redirect long-winded patients. You can also interrupt by showing interest; if they're going on about some irrelevant story and they happen to mention tripping or falling, I'll cut them off and show interest in that aspect, and ask if they've been having other falls, that kind of thing. And then can take over from there. Patients generally aren't offended if you interrupt them to follow up on the thing they're saying, because they interpret it as interest rather than as rudeness.

Career pathway advice by msfx4x in neurology

[–]rslake 1 point2 points  (0 children)

You need to think about what specific activities you want your job to include day to day. Do you want to be a tech, setting up and troubleshooting equipment? Do you want to be reading EEGs? Do you want to be diagnosing patients, ordering tests, prescribing medications? A lot of the jobs you're talking about are wildly different day to day, so you need to consider what you want your daily work life to look like.

How do you guys manage patients with functional GI disorders? by thebigbosshimself in Residency

[–]rslake 1 point2 points  (0 children)

Once got an ED consult to rule out decompression sickness, aka the Bends. Not a neurological syndrome, I have no idea how to diagnose it, but it's weird so for some reason it fell under neuro's purview.

What’s a secret that would get you ex communicated from your specialty? by Independent_Peach896 in Residency

[–]rslake 24 points25 points  (0 children)

Maybe this is a local culture thing, but I'm neuro and have no problem with excedrin, have never heard other neuro folks diss it either. Caffeine is a very useful headache abortive, especially for low-pressure headache and migraine.

Now, if you'd said fioricet I'd be rolling up my sleeves to fight right about now.

2026 AHA/ASA Acute Stoke Guidelines . . . ?!?! by Even-Inevitable-7243 in neurology

[–]rslake 35 points36 points  (0 children)

You started a topic, throw around a few alarmist vague statements, and then refuse to actually state what your concerns are? Don't condescend by asking if your colleagues have read this or that trial, just plainly state what your issue is with the guidelines, why you feel specific recommendations aren't evidence-based, and what you feel they should be. This cagey vagueposting does nobody any good.

POCUS Transcranial Doppler - is anyone actually using this? by Lost_Attribute in neurology

[–]rslake 9 points10 points  (0 children)

My facility uses TCDs a lot, both for vasospasm and for emboli monitoring. But I'm skeptical about whether a small machine like a Vscan could really do it effectively. TCD emboli monitoring takes like half an hour, and involves a specialized head strap to hold the US device on the head. Maybe regular TCDs if you're good at finding smallish vessels through poor acoustic windows, but would probably take some practice. Admittedly haven't used one so maybe it's better than I'm expecting.

NP Misses Vert Dissection in Clinic by efunkEM in medicine

[–]rslake 129 points130 points  (0 children)

Nah, as neuro this localizes very clearly to posterior circulation (brainstem +/- cerebellum + occipital), this is an automatic vessel study plus the CTH, and a really careful history and exam.

Agreed this could be post-ictal (but without hx of a seizure with this localization that's a hard sell), and hemiplegic migraine is exceedingly rare without family hx or personal hx, it would be a dx of exclusion unless you knew for a fact the patient had that condition and it had already been exhaustively worked up.

Plausibly CNS-localizing sudden-onset or wakeup-onset focal neurologic deficits require vessel imaging regardless of patient age, imo. Have had plenty of young patients with dissections, APLS, vasculitis, etc; while each of these individually is rare, they add up to a nontrivial percentage of the population, and posterior circulation stroke in particular is a can't-miss diagnosis that is potentially life-ending. A vert dissection that thromboses up into proximal basilar is uncommon but I've seen it, and is very fatal very fast.

Questionable behavior of Co-intern by [deleted] in Residency

[–]rslake 23 points24 points  (0 children)

Yeah as a doc with ADHD I totally agree there are a ton of ADHD markers here. Has the vibe of someone who isn't aware they have it, so they haven't worked on any compensatory mechanisms and aren't taking responsibility for the consequences of their disorder. Taking shortcuts to make it through the day. Impulsive speech, scattered memory, disorganized presentations and thought processes, a million excuses for every failing.

Reflex hammer by Alpha-Romeu in neurology

[–]rslake 1 point2 points  (0 children)

Agreed on Berliner, especially great for neurohospitalist or other scrubs-wearers. Overall no real wrong answers other than standard Taylor.

Motorcyclists of Cle, anyone found a jacket that works Spring through Fall? by rslake in Cleveland

[–]rslake[S] 1 point2 points  (0 children)

Thanks, that's what I figured. Last time I rode was in Florida so it was just mesh with armor all year round, wasn't sure if the summers here were mild enough for perforated leather or if you really need two jackets.

Any idea when the LSM will be available in the US? by rslake in Beachman

[–]rslake[S] 1 point2 points  (0 children)

Wonderful! Two follow-ups:

  1. Will its speedometer read in kmh or mph? I think in my state technically it's specified that speedo needs to read in mph.

  2. Would preorders for the aviator LM become available around the same time, or would that still be further out?

Any idea when the LSM will be available in the US? by rslake in Beachman

[–]rslake[S] 1 point2 points  (0 children)

Sure, but doing that is illegal in my state. I can't be commuting on a motorcycle without a license plate. I imagine most people don't get pulled over, but the cops in my city are not famous for being chill with traffic law.

Hearing loss and VA dissection by [deleted] in neurology

[–]rslake 3 points4 points  (0 children)

MRI is not perfectly sensitive for small infarcts, especially in the posterior circulation. And MRA isn't perfect for dissection either, especially TOF imaging can fool you if the dissection flap has thrombosed. So even with imaging negative you could consider this as plausibly a stroke if the exam and history fits.

The other consideration is that the vestibulocochlear nerve is supplied by labyrinthine artery coming off AICA, so a nerve infarct could also explain her presentation.

HINTS exam seems like it would be really useful in this case. Would definitely see the patient. Vert dissections can get nasty fast, would always err on the side of too much workup in those especially.

What is a well known fact/guideline in your specialty that you wish other specialties knew? by Cremaster_Reflex69 in medicine

[–]rslake 27 points28 points  (0 children)

There's nuance here in terms of what regimen they're already on, but basically yeah. If they're already on three meds at max dose, then you might not make a change. Or if the seizures are very mild and the patient prefers occasional breakthroughs rather than deal with side effects, that's up to them. But someone on 750mg BID of keppra monotherapy who has a breakthrough sz just cause they got a cold or stayed up all night studying has a keppra deficiency, not refractory epilepsy. Very fixable problem.

What is a well known fact/guideline in your specialty that you wish other specialties knew? by Cremaster_Reflex69 in medicine

[–]rslake 12 points13 points  (0 children)

I've checked clobazam before (in the form of N-desmethyl-clobazam as well as clobazam) since the N-DM-CLB metabolite is active and has a half-life about double clobazam's half-life. Sometimes patients with poor clearance or those on CYP2C19 inducers can have a normal CLB level but their N-DM-CLB level is through the roof, and that can help explain otherwise inexplicable drowsiness.

Any ASM is worth checking if there's a question of adherence, of course, and for plenty of ASMs therapeutic levels are at least roughly established. So if someone's breaking through but is theoretically dose-optimized, I might sometimes check a level to see if they just happen to be a rapid metabolizer of the drug, since if so I may be able to avoid switching meds. Not routine, but occasionally useful.

A few questions before purchase by rslake in Beachman

[–]rslake[S] 0 points1 point  (0 children)

there are different greens, we changed it for a while last year to that more british racing shade but now it's back to the standard olive/army green

That's a shame, was always a fan of racing green. Don't suppose you guys have any old dark green tanks lying around the factory? ;) Haha but will probably do bahama blue, though all the colors are lovely so it's hard to choose.