Professor of Neurology @MayoClinic. Editor-in-chief @ContinuumAAN. Proud @AANMember. Improving systems of care and healthcare value for our patients
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Feb 15 • 7 tweets • 2 min read
The 71 year old patient in your office has had progressive imbalance and falls
She has brisk reflexes on exam, so you order an MRI. Results below (T2 left, T1 with contrast right)
What’s going on here??
What is your next move for this patient? #ContinuumCase
Jan 26 • 8 tweets • 2 min read
A 77 year old woman comes in following a seizure. Her imaging shows a nonenhancing T2 hyperintense right medial temporal lesion
Biopsy shows mild hypercellularity suspicious for low grade glioma
What next? Hint: you might’ve done something different just a few years ago
The patient is otherwise healthy and lives independently. She has a normal neurologic exam and is tolerating her antiseizure medication
What do you do next in this #ContinuumCase?
Jan 6 • 8 tweets • 2 min read
A 39 year old woman with relapsed, refractory B-cell lymphoma undergoes CAR T-cell therapy
On day 5: mild fever and headache
On day 14: somnolent, then unresponsive. CT below
You’re the neurologist on call.
What do you see?
What’s going on?
What do you do?
Patients undergoing CAR T therapy are medically complex: underlying malignancy, conditioning chemotherapy, risk of infection, and the treatment itself
Differential for encephalopathy in these patients is broad: metabolic, infectious, and other causes
What about the CT?
Nov 18, 2023 • 7 tweets • 2 min read
A 24 year old man had progressive painless weakness and numbness over 4 months
EMG: Demyelinating polyradiculoneuropathy
CSF: protein 398, no cells
✅ Diagnosis: CIDP. Started IVIG and steroids. Mission accomplished.
Here’s the problem: he didn’t get better
A #ContinuumCase
You take a closer look.
On exam he has diffuse weakness, length-dependent sensory loss, and areflexia
You review his electrophysiology. Moderate slowing of velocities + conduction block (74% block of amplitude on this tibial motor study⬇️)
All still fits CIDP
Nov 3, 2023 • 11 tweets • 3 min read
The 62 year old man in your office clearly doesn’t want to be there. “My family made me come in.”
After working outside on a hot day, he had a brief loss of consciousness. Neuro exam showed mild sensory loss in his feet. ECG below
How would you approach this #ContinuumCase?🧵
More about the spell: he felt lightheaded beforehand, no abnormal movements, and immediately returned to normal thereafter. He has occasional brief lightheadedness on standing
He has a history of coronary disease, treated hypertension, and diabetes
What’s your next move?
Oct 28, 2023 • 11 tweets • 3 min read
A 75 year old woman comes to the ED with 3 days of low back pain, imbalance, and tingly feet
She has diabetes and melanoma. “I just finished my first round of chemo last week!”
She has moderate lower limb weakness & absent reflexes
How would you approach this #ContinuumCase?🧵
New spine pain and neurologic deficit in the setting of active malignancy is an emergency!
Fortunately, her spine MRI showed no sign of cord or cauda equina compression. So what’s going on here?
Let’s think it through
Sep 15, 2023 • 8 tweets • 2 min read
A 48 year old woman comes to clinic with her teenage children. The reason:
“Mom wakes up screaming at night, and it scares us.”
What do you do next for this patient?
A things-that-go-bump-in-the-night #ContinuumCase🧵
The episodes occur several times per week and consist of screaming, sitting up in bed, followed by confusion. Once, she ran from the room.
She appears frightened during the events, and has a vague sense of recall for being chased.
Her neurologic exam is normal.
What’s next?
Sep 2, 2023 • 7 tweets • 2 min read
A 52 year old woman comes in for evaluation of daily headaches. They’ve been present for about 2 years, occur on awakening, and resolve after her morning coffee.
Her neurologic exam is completely normal.
What do you do next for this patient?🧵#ContinuumCase
She has a history of migraine and mild hypertension. She’s a light snorer, and gets up 3x a night for the bathroom. She does not have excessive daytime sleepiness, and she has no systemic symptoms (eg weight loss) but she is fatigued
Which of the following will you recommend?
Jul 28, 2023 • 6 tweets • 2 min read
Because you read Continuum and follow #ContinuumCases, your reputation as a neurologic detective has grown.
You get paged with a curbside:
MICU: “Hi, neurology, we have a diabetic patient with uncontrolled movements, we’re worried he’s in status and…”
You: “I’m on my way.”
At the bedside you see a 57 year old man who is drowsy but oriented following IV lorazepam and levetiracetam. He has low-amplitude writhing movements of all limbs.
After reviewing his MR (non-con T1), which blood test are you most interested in obtaining?
Jul 14, 2023 • 6 tweets • 2 min read
A 47 year old woman developed imbalance and falls 1 year after gastric bypass surgery. Good diet and takes a vitamin. Her cervical MRI is below
Here’s the twist: serum B12, ceruloplasmin, folate, and urine copper were all NORMAL. What’s going on here?! #ContinuumCase
Her exam showed severe proprioceptive sensory loss and gait ataxia, so the “inverted V” T2 hyperintensity in the dorsal columns is no surprise. Another clue: her EMG showed an axonal peripheral neuropathy
What next?
Jul 7, 2023 • 9 tweets • 2 min read
A #ContinuumCase conundrum:
A 52 year old develops abrupt left face and arm weakness. DWI below
The case seems straightforward until you notice on exam, in addition to somnolence and left hemiparesis, he has bleeding gums…
Time to solve a mystery, #neurotwitter!🧵on 🧠&🩸
First the imaging: his DWI shows an acute right hemispheric ischemic cerebral infarction. SWI shows a convexal subarachnoid hemorrhage, and subcortical microhemorrhages
What next?
Jun 30, 2023 • 8 tweets • 3 min read
#ContinuumCase!
A 48 year old is found unresponsive by her family. She was intubated for respiratory depression with no response to naloxone. She was comatose with intact brainstem reflexes
Urine drug screen was negative. MRI below (DWI⬆️/FLAIR⬇️)
What’s the diagnosis???🧵
The MRI shows restricted diffusion and T2 hyperintensity in the cerebellum, temporal lobe, and basal ganglia.
A few possibilities here, what do you think is most likely?
A 28 year old PGY2 neurology resident is asked by her attending to review 2 scans and determine the diagnosis: Alzheimer disease (AD) or dementia with Lewy bodies (DLB).
What should she say, #neurotwitter?🧵
How would you respond?
A 56 year-old developed progressive imbalance and dream enactment behavior. On exam he had an ataxic dysarthria and prominent limb dysmetria
In addition to cerebellar atrophy on his brain MR, you notice a subtle abnormality. What’s going on, #neurotwitter? 🧵
Which of the following diagnoses are associated with the “hot cross bun” sign on MRI?
A 41 year old man had 4 days of pain and severe right vision loss. Exam showed a right APD and normal eye movments. Fundoscopy and contrasted T1 below.
He recovered well after IV steroids. What’s going on, #neurotwitter? Poll in 🧵
What is the most likely diagnosis in this patient?
Jun 30, 2022 • 9 tweets • 3 min read
Time to solve this case, #neurotwitter
➡️ What’s going on?
➡️ How do these images solve the mystery for this patient?
➡️ Why is ALS the wrong diagnosis? 1/9
➡️ Lower motor neuron signs in upper limbs (atrophy, fasciculations)
➡️ Upper motor neuron signs below (brisk reflexes)
➡️ Could it be a diffuse process like ALS? Sure, but a cervical cord lesion fits too
➡️ Chronic + Focal = Degenerative? 2/9
Jun 17, 2022 • 8 tweets • 4 min read
Solving the Case of the Vanishing Leg:
“My right leg is disappearing.”
➡️ 48 years old
➡️ Whole right lower limb weakness, atrophy
➡️ Progressive
➡️ Painless
What’s going on? 🧵1/8
As always, start with the patient (before the data). Where does this localize?
Weakness and atrophy often localize to nerve (motor neuron especially when no sensory symptoms)
➡️ BUT, some asymmetric myopathies can present similarly
Usually generated in UMN >>> LMN
Many causes: epileptic, neurodegenerative, toxic (opioids), physiologic
July 1: look out for hypnic myoclonus (sleep jerks) on hour 6 of rounds
Jun 30, 2021 • 5 tweets • 3 min read
How to Quality:
Delivering high value care to patients has to start with an understanding of quality of care. Extremely proud of this team’s first report of quality of neurologic care in the US, using Axon Registry data @AANMember@GreenJournal 1/ n.neurology.org/content/early/…
This analysis is the culmination of years of development, millions of patient encounters, and hundreds of neurologist and staff volunteers dedicated to high quality care.
But it still represents an early step in improving outcomes 2/