The Neurologist Is In

Monthly insights and advice from a stroke specialist, a movement disorder expert, and a neuromuscular physician.

Friday, February 23, 2018

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For most of us, headaches come and go and we usually know how to deal with it: get a massage, take a brisk walk, find some peace and quiet, or swallow a few ibuprofen tablets. If the pain lingers, we take more tablets, get some rest, or ignore it until it subsides.

But what about the headache that persists and doesn't respond to the usual treatments? How do you know when to take it to the emergency department? That question came up one late afternoon a few weeks ago as I was sitting with one of the fellow moms at my son's math competition. Melissa had been experiencing migraines since she was a teenager and was able to manage them with a combination of ibuprofen and rest. More recently she had been prescribed a stronger medication as the headaches often occurred in conjunction with her menstrual period.

For a few months, she had been practically headache free, but today, that familiar feeling of a clamp-like device around her head and pain in her right eyeball was starting to emerge. Except something was different this time. At first, Melissa thought the pain was unfamiliar only because she hadn't felt it in a while.

But when I looked at my friend and saw that she wasn't wearing sunglasses, I knew something was different. Sunlight usually bothered Melissa when she had a headache. Without sounding an alarm. I checked to see if she had any weakness in her arms or legs and asked if she felt dizzy or out of it. I detected no weakness. She said she didn't feel dizzy but her neck bothered her and the headache was quickly becoming one of the worst she'd ever had.

I suggested we go to the emergency department. At the hospital, a CT scan revealed that Melissa's headache was due to a small subarachnoid hemorrhage (SAH), which is bleeding into the space around the brain. Nontraumatic subarachnoid hemorrhages are most often caused by a leaking or ruptured brain aneurysm or blood vessel malformation. Melissa had an aneurysm—a weakness in a blood vessel in her brain that had ballooned and filled with blood—and it had started to leak. Melissa was admitted to the hospital where the aneurysm was successfully treated.  

Melissa was lucky. Her aneurysm was found before it ruptured. Less than a third of people who make it to the ED and get aneurysm surgery in time recover without any neurologic deficits. Sometimes aneurysms come with warning signs, but often, as in Melissa's case they are silent until they leak or rupture. The most common sign of an aneurysm leak or rupture is a headache. If you don't usually get headaches, then a bad headache warrants a trip to the ED. But if you already get migraines, here are some signs to look for:

  1. The headache feels different from any previous headache.
  2. You aren't experiencing typical symptoms such as light sensitivity.
  3. The pain is more severe than anything you've experienced.
  4. You feel numbness or weakness in the face, arms, or legs.
  5. You have a stiff neck.
  6. You are experiencing visual disturbances.
  7. You have a past medical history of HIV, or autoimmune disease.

If you experience any of these, get yourself to the nearest emergency department.

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Dr. Ganti is a board-certified emergency physician with fellowship training in vascular neurology. She is the mother of four boys and one girl and the author of more than a dozen medical textbooks. You can follow her on Twitter at @LathaGanti.

Friday, January 26, 2018



I recently saw one of my patients with epilepsy who is doing really well. He hadn't had any seizures for more than a year. After telling me how things had gone over the preceding months and celebrating his seizure freedom, he asked me what else he could do to continue to be free of seizures.

That kind of patient exchange is ideal for an epilepsy specialist like me: A patient who is excited to learn as much about the disease as possible and willing to take an active role in managing it—because what patients do in their day-to-day lives can significantly affect seizure control.

Here are some of the strategies that will help any epilepsy patient manage his or her disease better. I shared all but the first one with my patient.

1. Consult a specialist. Epilepsy is a chronic disease that can last a lifetime so it's important to establish a relationship with a neurologist who specializes in the disease. He or she will have more detailed knowledge of medications, treatment, and research. If you are not already connected to an epilepsy specialist, the National Association of Epilepsy Centers has a helpful resource to identify an epilepsy center in your area ( You can also visit the American Academy of Neurology's website and use their Find a Neurologist tool to locate an epilepsy specialist near you (

2. Determine the right medication. Treatment is not one-size-fits all. Finding the appropriate medication or treatment for you involves collaborating with your physician. The two of you may need to work with different drugs and dosages until you find the most effective one that causes the fewest side effects.

3. Take your medication as directed. This seems obvious but I can't tell you how many of my patients skip their medication. They may stop taking it if they feel better or if they don't have a seizure for a long time. Or they may simply have busy lives and forget. It's important to understand that taking the medication every day is the key to controlling your seizures. Not only can it help minimize or eliminate seizures, taking your medication regularly also helps reduce the risk of sudden unexpected death in epilepsy (SUDEP). As its name suggests, SUDEP happens suddenly in otherwise healthy people with epilepsy, usually while sleeping and often around the time of a seizure. Some researchers suspect an irregular heartbeat caused by the seizure. Others say people suffocate from impaired breathing, fluid in the lungs, and lying face down in the bed.

4. Don't skimp on sleep. Lack of sleep is a common trigger for seizures. Be sure to allow yourself at least eight hours every night. If you experience insomnia, sleep apnea, or other sleep disorders, consult with a sleep specialist. I try to make a special point to talk to new parents and college students about making sleep a priority—it often can be difficult for both of these groups.

5. Limit alcohol. Drinking too much can interfere with sleep, and it also increases the risk of breakthrough seizures. You may also forget or not bother to take your medication if intoxicated or hung over.

6. Don't be afraid to exercise. Not a lot of data exist on the effect of exercise on epilepsy, but staying active has so many other benefits, including improving sleep and energy. If you are uncertain about what forms of exercise are safe for you, talk to your doctor. Your exercise plan may need to be tailored to fit your epilepsy type and other medical conditions.


Dr. Spencer is professor of neurology and an epilepsy specialist at the Oregon Health & Science University in Portland. He is also a fellow of the American Academy of Neurology (AAN) and author of Navigating Life with Epilepsy, one of the books in the AAN's Neurology Now Books series. For more information about Dr. Spencer's book, go to order Dr. Spencer's book or check out other titles in the series, visit​. 

Thursday, July 6, 2017



Ellen, a vivacious woman in her 80s, experienced a stroke last year that resulted in vision loss on the left side in both eyes. Otherwise, she had regained her strength and was recovering well. However, in the course of a recent clinic visit, she told me she was feeling down. Prior to her stroke she had been an active golfer and swimmer. Since her stroke, she was often too depressed to do either.

I explained to Ellen that depression after a stroke is actually quite common, affecting about one-third of all stroke survivors, especially those who experience physical or mental difficulties. People who have a history of depression or whose social environment is problematic may also be more prone to depression after stroke. And depression isn't just a psychological response. Research suggests biological factors can contribute to mood changes, as well.

Don't Ignore Depression

I commended Ellen for sharing her feelings with me since recognizing and treating depression can improve recovery. Untreated depression can worsen quality of life and even hasten death. When patients report feelings of sadness it allows them and their doctors to discuss treatment. In Ellen's case, I encouraged her to visit the driving range with a friend to practice her golf swing, and to walk in the pool with weights or take a water aerobics class, if she didn't feel like she could swim.

For all my patients I share this additional advice.

Recognize Symptoms

Symptoms of depression can include feeling down, loss of appetite, a lack of interest in activities that used to bring joy, or changes in sleeping patterns, such as sleeping too much or too little. It's important to recognize and treat depression because it can influence how well you recover from stroke, physically and cognitively. The depression can also worsen your quality of life, and even hasten death.

Recognizing depression after a stroke can be difficult because some stroke symptoms can mimic depression. For example, after a stroke, some people experience reduced emotional expression or a "flat affect," which can make them seem depressed. Problems with communication such as difficulty understanding or trouble speaking can limit diagnosis and treatment of depression.

Patients with pseudobulbar affect—sudden outbursts of laughing or crying for no apparent reason—can be mislabeled as having depression. Still, it's essential for doctors to continue to check for symptoms of depression, and for families and caretakers to notice when their loved ones seem sad or depressed.

Important Ways to Manage Depression

1. Check in with yourself daily. Assess how you're feeling. Pay attention to your mood. If you're feeling down, become proactive about trying to improve your mood: Talk to a friend, or participate in an activity that brings you joy. If you're feeling good, share that good mood with others in conversation, or write it down, for a visual reminder of a happy day.

2. Educate yourself and others. Learn the symptoms of stroke—and share them with those you love. Use this opportunity to talk to others about how stroke has impacted your life. Symptoms of stroke can be easily summarized by the acronym FAST: F for face drooping, A for arm weakness or numbness, S for speech problems, such as slurred speech or difficulty finding words, and T for time, to remind you to call 911 if you see stroke symptoms in others or experience them yourself.

3. Learn the difference between anxiety and depression. The two mood disorders can occur at the same time, and make your progress in therapy more difficult. Anxiety includes feelings of worry and fear that can be disabling, and can affect everything from social interactions to participating in therapy. Anxiety must be diagnosed by a physician, as medications for depression may not be effective for anxiety, or may affect people with anxiety differently.

4. Get moving. Hormone regulation may change after a stroke, leading to an increase in cortisol levels. Elevated cortisol levels can make you feel sluggish and fatigued, cause weight gain, affect blood pressure, and lead to emotional lability. Exercise can help counter that. Studies show that even four weeks of exercise could have a beneficial effect on mood.

5. Guard your immune system. Depression can suppress your immune function, so be sure to wash your hands regularly and keep active to help boost immune function.

6. Stay socially engaged. Consider group activities, such as exercise classes, support groups, or book clubs, as a way to interact with those you love or to meet new people.

7. Consider mindfulness activities. Meditation, tai chi, yoga, or gentle stretching can help reduce stress and mental fatigue.

8. Stay in touch with your doctor. Mood disorders can arise at any time after a stroke. You should let your doctor know if you're feeling down.

9. Seek out other stroke survivors. Talking to people going through a similar experience can help allay fears. Look for a support group at, through the American Heart Association website. Also, many local hospitals will have a support group that you can join.

10. Get treatment. Consider medication, counseling, or a combination of the two. Early treatment may have a positive effect on how well you recover from a stroke, not only emotionally, but also physically.

Wednesday, February 1, 2017



The stroke center where I work just got a mobile stroke unit—one of a handful in the country—and I am so excited. This miniature emergency department on wheels lets us bring stroke care right to your door by ambulance, and helps us reduce the time between the appearance of symptoms and medical care. That, in turn, increases the opportunity of administering intravenous (IV) tissue plasminogen activator (tPA), the only FDA-approved medication to treat acute stroke, which must be used four-and-a-half hours after symptoms start. Some patients also require endovascular therapy, a procedure that removes blood clots using a thin catheter and other devices, such as stents, to restore blood flow to the brain. Early treatment with both IV tPA and endovascular therapy decreases the risk of disability in patients who would benefit from clot removal.

Mobile Magic

Everything that happens in the hospital can happen in this special ambulance, which is staffed with a nurse trained in stroke care, a technician proficient in computed tomography (CT) imaging, and a monitor screen connected to a neurologist, who can beam in remotely from almost anywhere via mobile technologies. After picking up the patient, the ambulance driver parks and levels the vehicle using special feet that emerge from below. While the neurologist examines the patient via video screen—asking him or her to smile, read cards, look left and right, and more—the nurse starts intravenous lines, assesses vitals, and draws blood. Once the CT technician is ready, the patient undergoes a CT scan, which is sent to a waiting radiologist, who interprets it and confers with the neurologist.

The patient is treated within minutes and transferred to a primary stroke center if symptoms are less serious, , or to a comprehensive stroke center, if the patient's symptoms are more severe, or if the patient needs endovascular treatment to remove larger blood clots.

Saving Lives

Early evidence shows that mobile stroke units shorten treatment times in half, with the average patient being treated within 30 minutes. Given that patients are more likely to have a better outcome—to walk, return to work, and become more independent—if they receive IV tPA (and endovascular therapy), it is paramount that stroke centers find new and innovative ways to reach patients with stroke more quickly.

With every minute that passes, 1.9 million brain cells are destroyed during an acute stroke! Although expensive—a mobile unit costs just under $1 million plus another $1 million to operate—it's worth it if it helps save more of those precious minutes.

For more about mobile stroke units and stroke care, go to​

Dr. Sarah Song is an assistant professor of neurology at Rush University Medical Center in Chicago, IL, and a member of Neurology Now's editorial advisory board.

Friday, December 2, 2016

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As a dementia specialist who sees many patients with primary progressive aphasia (PPA) and their families, I was immediately interested in reading Where the Light Gets In (Crown Archetype, 2016), a memoir by Kimberly Williams-Paisley about the effect her mother's diagnosis of PPA had on the family. I was struck by Williams-Paisley's candor and frankness about the difficulties of adjusting to her mother's constant shifts in behavior as the disease progressed. Her mother died on November 17, 2016, at age 73, 10 years after her diagnosis. I thought Williams-Paisley's book exactly captured the myriad challenges patients and families face.

The experience of PPA is different for everyone, but it is always a worsening condition. In sharing her family's struggles, Williams-Paisley can help other families prepare for possible changes in the future. Her memoir also reminds us that people with PPA have strengths that can be enriched, enjoyed, and cherished at any stage of the disease. Over time, Williams-Paisley was able to see the light through the darkness of the disease.

Symptoms of Primary Progressive Aphasia

About 55 percent of PPA cases are caused by frontotemporal lobar degeneration (FTLD), a condition marked by the shrinking of frontal and temporal lobes of the brain; about 45 percent are caused by Alzheimer's disease. People with FTLD typically have behavioral problems and trouble with executive function (the ability to perform a sequence of steps to accomplish a task). People with Alzheimer's disease usually have noticeable problems with memory. With PPA, degenerative diseases such as FTLD or Alzheimer's disease start by affecting the language regions of the brain causing aphasia.

Aphasia, or difficulty speaking or understanding words and sentences, can also be caused by a stroke, traumatic brain injury, brain tumors, or infections. PPA starts with trouble finding words or following conversations, then progresses to an inability to communicate or understand conversations. Eventually, other areas of brain function are affected, causing problems with memory and difficulty handling daily activities unrelated to language.

As Williams-Paisley describes in her book, her mother's problems first became evident when she had difficulty reading verses from the Bible during Williams-Paisley's wedding. As months went by, her mother had more trouble finding her words. The disease eventually affected her ability to drive, and she needed more help with activities of daily living.

How to Diagnose

To assess for PPA, I conduct a series of tests to evaluate language functions. For example, I ask the patient to describe a picture, tell me the names of objects, or to repeat words and sentences. I also evaluate whether he or she can comprehend words and sentences, or read and write. In addition, I evaluate memory, attention, problem solving, and visual processing. Patients may undergo imaging tests to see if any irregularities show up in the brain in areas associated with language and cognition or to check for certain spinal fluid proteins, which may indicate whether someone has Alzheimer's disease or not.

Managing Symptoms

At the moment, there is no cure for PPA. Instead, neurologists treat symptoms and offer strategies for managing communication and behavioral problems. If the underlying cause is Alzheimer's disease, I might prescribe medications approved for use with Alzheimer's disease, which may slow progression. If the cause is FTLD, I try to manage the symptoms through speech or language therapy, since no approved drug exists to treat underlying FTLD. In both FTLD and Alzheimer's disease, if psychiatric problems develop, I may prescribe antidepressants or antipsychotics along with recommendations for family members and care partners for how to adjust to behavioral changes.

Addressing Speech Problems

Since trouble speaking is the first symptom in PPA, sessions with a speech pathologist are crucial—either in person or via the internet or telehealth (treatment sessions offered through the internet) if a local speech therapist with PPA expertise isn't available. Evidence suggests that speech therapy interventions can stabilize symptoms for a while. When the ability to speak worsens, the speech pathologist can update or modify exercises accordingly. Check with Northwestern University Cognitive Neurology Center ( and the aphasia laboratory at the University of Texas, Austin (, for specialized treatment programs, as well as the Association for Frontotemporal Dementia ( or the Alzheimer's Association ( for more information.

Maintaining Quality of Life

Physical exercise and social engagement and enrichment may also help slow the decline of PPA. Art or music therapy, for example, may reveal a new interest in or affinity for art or music, which can be an important outlet for emotional expression as the ability to communicate with words declines. Art and music therapy sessions, either one-on-one or in groups, are available through specialized centers.

Supporting the Family

Degenerative diseases are tough for families, especially spouses and adult children or other members closely involved in caregiving. As PPA progresses, families will need help from knowledgeable care partners or assisted living facilities where experts can manage psychiatric symptoms, if they develop. Later in the course of the disease, I may consult with family members about palliative or hospice care, if necessary.

Furthering Research

The search for a cure or better treatment for degenerative diseases continues, with the collaboration of affected individuals, their family members, primary care physicians, neurologists, and clinician-scientists. Active participation in clinical trials is a vital step toward this goal.

Through her book and speaking about PPA, Williams-Paisley helped raise awareness of the condition, which continues to be underdiagnosed in minority and underserved communities. The fight against this disease is possible only if patients and family members collaborate with health care professionals and investigators to better understand the underlying causes and find an effective treatment.

To read our feature on Kimberly Williams-Paisley and her mother, go to​.

Dr. Bonakdarpour, a specialist in primary progressive aphasia, is assistant professor of neurology at Cognitive Neurology and Alzheimer Disease Center, Northwestern University Feinberg School of Medicine in Chicago.​