To outline features of the neurologic examination that can be performed virtually through telemedicine platforms (the virtual neurological examination [VNE]), and provide guidance for rapidly pivoting in-person clinical assessments to virtual visits during the COVID-19 pandemic and beyond.

The full neurologic examination is described with attention to components that can be performed virtually.

A screening VNE is outlined that can be performed on a wide variety of patients, along with detailed descriptions of virtual examination maneuvers for specific scenarios (cognitive testing, neuromuscular and movement disorder examinations).

During the COVID-19 pandemic, rapid adoption of virtual medicine will be critical to provide ongoing and timely neurological care. Familiarity and mastery of a VNE will be critical for neurologists, and this article outlines a practical approach to implementation.

The optimal timing of anticoagulation after ischemic stroke in atrial fibrillation (AF) patients is unknown. Our aim was to demonstrate the feasibility and safety of initiating dabigatran therapy within 14 days of transient ischemic attack (TIA) or minor stroke in AF patients.

A prospective, multi-center registry (NCT02415855) in patients with AF treated with dabigatran within 14 days of acute ischemic stroke/TIA (National Institutes of Health Stroke Scale (NIHSS) ≤ 3) onset. Baseline and follow-up computed tomography (CT) scans were assessed for hemorrhagic transformation (HT) and graded by using European Cooperative Acute Stroke Study criteria.

One hundred and one patients, with a mean age of 72.4 ± 11.5 years, were enrolled. Median infarct volume was 0 ml. Median time from index event onset to dabigatran initiation was 2 days, and median baseline NIHSS was 1. Pre-treatment HT was present in seven patients. No patients developed symptomatic HT. On the day 7 CT scan, HT was present in six patients (one progressing from baseline hemorrhagic infarction type 1). Infarct volume was a predictor of incident HT (odds ratio = 1.063 [1.020–1.107], p < 0.003). All six (100%) patients with new/progressive HT were functionally independent (modified Rankin Scale (mRS) = 0–2) at 30 days, which was similar to those without HT (90%, p = 0.422). Recurrent ischemic events occurred within 30 days in four patients, two of which were associated with severe disability and death (mRS 5 and 6, respectively).

Early dabigatran treatment did not precipitate symptomatic HT after minor stroke. Asymptomatic HT was associated with larger baseline infarct volumes. Early recurrent ischemic events may be clinically more important.

The current American Heart Association guidelines for acute ischemic stroke reserve Grade 1A recommendation for the use of endovascular thrombectomy (EVT) for patients with an Alberta Stroke Program Early Computed Tomography Score (ASPECTS) of ≥6.

We aim to determine the safety and efficacy of EVT for large vessel occlusion ischemic stroke patients with low ASPECTS (5 or less).

Medline, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov were searched for studies appraising the outcomes of EVT for low ASPECTS ischemic stroke. A meta-analysis of proportions compared the clinical outcomes of patients undergoing EVT and those receiving best medical therapy only.

Nine studies (1,196 patients) were included. There was a trend (p = 0.11) toward a higher rate of symptomatic intracranial hemorrhage (sICH) in the EVT group (9.2%; 95% CI 6.1–13.6; I2 53.37%) compared to the medical group (5.5%; 95% CI 3.7–8.1; I2 0%). There was no difference (p = 0.41) in the pooled 90-day mortality of EVT patients (30.7%; 95% CI 21.7–41.5; I2 84.23%) and medical patients (36.6%; 95% CI 26.4–48.1; I2 76.2%). EVT patients had better (p = 0.001) 90-day outcomes, with 27.7% (95% CI 21.8–34.5; I2 62.08%) of patients attaining a modified Rankin Scale of 0–2 compared to only 3.7% (95% CI 2.3–5.9; I2 87.21%) in the medical group.

This meta-analysis demonstrates a trend in higher sICH among low ASPECTS patients undergoing EVT. Despite this, a significant proportion of this subset of patients still achieved good functional outcomes at 90 days. Randomized trials are necessary to substantiate this result as significant bias is inherent in the observational studies included in this review.

Although cognitive deficits are frequent in multiple sclerosis (MS), screening for them with tools such as the Montreal Cognitive Assessment (MoCA) test is usually not performed unless there is a subjective complaint. The Multiple Sclerosis Neuropsychological Questionnaire (MSNQ) is among the instruments most commonly used to assess self-reported subjective complaints in MS. Nonetheless, it does not always accurately reflect cognitive status; many patients with cognitive deficits thus fail to receive appropriate referral for detailed neuropsychological evaluation. The objective of this study was to examine the validity of the MoCA test to detect the presence of objective cognitive deficits among patients with MS without subjective complaints using the Minimal Assessment of Cognitive Function in MS (MACFIMS) as the gold standard.

The sample included 98 patients who were recruited from a university hospital MS clinic. The MSNQ was used to select patients without subjective cognitive complaints who also completed the MACFIMS, MoCA test and MSQOL-54.

23.5% of patients without subjective cognitive complaints had evidence of objective cognitive impairment on the MACFIMS (z score < -1.5 on two or more tests). The MoCA had a sensitivity of 87% and a specificity of 68% for detecting objective cognitive impairment in this patient population using a cut-off score of 27.

A significant proportion of patients without self-reported cognitive impairment do have evidence of cognitive deficits on more exhaustive cognitive assessment. The MoCA is a rapid screening test that could be used to target patients for whom a more detailed neuropsychological assessment would be recommended.

Post-cardiac surgery patients exhibit a higher incidence of postoperative delirium (PD) compared to non-cardiac surgery patients. Patients with various cardiac diseases suffer from preoperative sleep disorder (SPD) induced by anxiety, depression, breathing disorder, or other factors.

To examine the effect of sleep disorder on delirium in post-cardiac surgery patients.

We prospectively selected 186 patients undergoing selective cardiac valve surgery. Preoperative sleep quality and cognitive function of all eligible participants were assessed through the Pittsburgh Sleep Quality Index (PSQI) and the Montreal Cognitive Assessment, respectively. The Confusion Assessment Method for Intensive Care Unit was used to assess PD from the first to seventh day postoperatively. Patients were divided into two groups according to the PD diagnosis: (1) No PD group and (2) the PD group.

Of 186 eligible patients, 29 (15.6%) were diagnosed with PD. A univariate analysis showed that gender (p = 0.040), age (p = 0.009), SPD (p = 0.008), intraoperative infusion volume (p = 0.034), postoperative intubation time (p = 0.001), and intensive care unit stay time (p = 0.009) were associated with PD. A multivariate logistic regression analysis demonstrated that age (odds ratio (OR): 1.106; p = 0.001) and SPD (OR: 3.223; p = 0.047) were independently associated with PD. A receiver operating characteristic curve demonstrated that preoperative PSQI was predictive of PD (area under curve: 0.706; 95% confidence interval: 0.595–0.816). A binomial logistic regression analysis showed that there was a significant association between preoperative 6 and 21 PSQI scores and PD incidence (p = 0.009).

Preoperative SPD was significantly associated with PD and a main predictor of PD.

The purpose of this study was to examine the effectiveness, satisfaction, and acceptance of a low-cost Lombard-response (LR) device in a group of individuals with Parkinson’s disease (IWPD) and their communication partners (CPs).

Sixteen IWPD and hypophonia and their CPs participated in the study. The IWPD wore a LR device that included a small MP3 player (Sony Walkman) and headphones playing a multi-talker noise audio file at 80 dB during lab-based speech tasks and during their daily conversational speech over a 2-week device trial period. Outcome measures included average conversational speech intensity and scores on a questionnaire related to speech impairment, communication effectiveness, and device satisfaction.

Conversational speech intensity of the IWPD is increased by 7 to 10 dB with the LR device. Following a 2-week trial period, eight of the IWPD (50%) gave the LR device moderate-to-high satisfaction and effectiveness ratings and decided to purchase the device for long-term daily use. At the 4-month follow-up, none of the IWPDs were still using the LR device. Device rejection was related to discomfort (loudness), headaches, interference with cognition, and difficulty controlling device.

Short-term acceptance and satisfaction with the LR device was moderate, but long-term acceptance, beyond 4 months, was absent. Future studies are required to determine if other types of low-cost LR devices can be developed that improve long-term efficacy and device acceptance in IWPD and hypophonia.

To examine whether sociodemographic characteristics and health care utilization are associated with receiving deep brain stimulation (DBS) surgery for Parkinson’s disease (PD) in Ontario, Canada.

Using health administrative data, we identified a cohort of individuals aged 40 years or older diagnosed with incident PD between 1995 and 2009. A case-control study was used to examine whether select factors were associated with DBS for PD. Patients were classified as cases if they underwent DBS surgery at any point 1-year after cohort entry until December 31, 2016. Conditional logistic regression modeling was used to estimate the adjusted odds of DBS surgery for sociodemographic and health care utilization indicators.

A total of 46,237 individuals with PD were identified, with 543 (1.2%) receiving DBS surgery. Individuals residing in northern Ontario were more likely than southern patients to receive DBS surgery [adjusted odds ratio (AOR) = 2.23, 95% confidence interval (CI) = 1.15–4.34]; however, regional variations were not observed after accounting for medication use among older adults (AOR = 1.04, 95% CI = 0.26–4.21). Patients living in neighborhoods with the highest concentration of visible minorities were less likely to receive DBS surgery compared to patients living in predominantly white neighborhoods (AOR = 0.27, 95% CI = 0.16–0.46). Regular neurologist care and use of multiple PD medications were positively associated with DBS surgery.

Variations in use of DBS may reflect differences in access to care, specialist referral pathways, health-seeking behavior, or need for DBS. Future studies are needed to understand drivers of potential disparities in DBS use.

Contrast-enhanced magnetic resonance imaging (CEMRI) of the head is frequently employed in investigations of sensorineural hearing loss (SNHL). The yield of these studies is perceptibly low and seemingly at odds with the aims of wise resource allocation and risk reduction within the Canadian healthcare system. The purpose of our study was to audit the use and diagnostic yield of CEMRI for the clinical indication of SNHL in our institution and to identify characteristics that may be leveraged to improve yield and optimize resource utilization.

The charts of 500 consecutive patients who underwent CEMRI of internal auditory canal for SNHL were categorized as cases with relevant positive findings on CEMRI and those without relevant findings. Demographics, presenting symptoms, interventions and responses, ordering physicians, and investigations performed prior to CEMRI testing were recorded. Chi-squared test and t-test were used to compare proportions and means, respectively.

CEMRI studies revealed relevant findings in 20 (6.2%) of 324 subjects meeting the inclusion criteria. Pre-CEMRI testing beyond audiometry was conducted in 35% of those with relevant positive findings compared to 7.3% of those without (p < 0.001). Auditory brainstem response/vestibular-evoked myogenic potentials were abnormal in 35% of those with relevant CEMRI findings compared to 6.3% of those without (p < 0.001).

CEMRI is a valuable tool for assessing potential causes of SNHL, but small diagnostic yield at present needs justification for contrast injection for this indication. Our findings suggest preferred referral from otolaryngologists exclusively, and implementation of a non-contrast MRI for SNHL may be a better diagnostic tool.

To determine whether optic disc hemorrhages (ODH) and cotton wool spots (CWS) at presentation are associated with worse visual outcomes in pediatric patients with idiopathic intracranial hypertension (IIH).

Retrospective institutional review of 100 eyes of 50 consecutive pediatric IIH patients (aged 16 years or less) who had baseline optic disc photographs before or within 30 days of their diagnostic lumbar puncture and initiation of medical treatment. Optic disc photographs were independently graded by three ophthalmologists in a standardized manner. Visual function was assessed using visual acuity (VA) and visual field grade (VFG).

At least one ODH was found in 41% of eyes, at least one CWS was found in 27% of eyes, and 20% of eyes had both ODH and CWS. At presentation, Frisén grade was associated with the presence of CWS (p = 0.013) and showed no association with ODH (p = 0.060). When controlling for Frisén grade, ODH and CWS were not associated with worse VA or VFG at final follow-up. Severe ODH were associated with worse VA and VFG at presentation (p < 0.03), but not at final follow-up. Severe CWS at presentation was strongly associated with a worse Humphrey mean deviation of 5.0 dB (95% confidence interval 1.6–8.3) at final follow-up (p = 0.002).

When controlling for the severity of papilledema, ODH do not provide any additional prognostic value in pediatric IIH patients. Frisén grade and severe CWS at presentation were independently associated with worse visual outcomes at the final follow-up.

Many neurosurgeons pursue graduate degrees as part of their training. In some jurisdictions, graduate degrees are considered a necessary condition of employment in academic neurosurgery. However, the relationship between possession of a graduate degree and eventual research productivity is not well established. We used bibliometric methods to analyze publications from academic Canadian neurosurgeons, with an emphasis on level of graduate training.

All neurosurgeons holding academic appointments at Canadian institutions from 2012–2016 were included. Over that time frame, Scopus was used to quantify the number of papers, number of citations, 5-year h-index and 5-year r-index, CiteScore, authorship position, and paper type (clinical or basic science). Publication output was compared between neurosurgeons grouped as MD-only, MD-Masters, or MD-PhD.

In total, 2557 abstracts from 131 Canadian neurosurgeons were analyzed. We found that MD-Masters neurosurgeons published significantly more total papers, clinical papers, and first/last author papers than MD-only neurosurgeons. MD-PhD neurosurgeons had the same findings, in addition to more basic science papers, in journals with a higher CiteScore, 5-year h-index, and 5-year r-index than both other groups. These results were preserved even with significant outliers removed. There was no difference if graduate degrees were obtained before or after starting residency. There was no correlation with career length and number of recent papers published.

The attainment of a graduate degree has an important association with future publication productivity for academic neurosurgeons. These data should be useful for hiring committees considering the value of graduate degrees from applicants for positions in academic neurosurgery.

To explore what elective students learn about the specialty of Neurology.

A prospective qualitative study using pre- and post-elective written questionnaires.

Analysis concentrated on three main themes: What did students learn about the specialty of Neurology? What would they change about their experience? Did their opinions change? Major findings were (i) pre- and post-elective the most frequent response for “what is the best thing about Neurology?” was the “process of localization” and (ii) post-elective students were less likely to cite the challenge or problem-solving aspect of Neurology as the best thing while more emphasized the importance of the physical exam and the variety of cases. (iii) Students were most surprised by the scope of neurological practice. (iv) They would diversify the setting of their elective to include less time spent in the emergency room and more time in clinic. (v) The perception of Neurology as a specialty in which patients have a poor prognosis was the opinion that changed the most.

Showcasing the diversity of cases and careers in Neurology may be a useful strategy to increase interest in the specialty and reduce neurophobia. Lectures or small groups early in medical school should concentrate on clear examples of common neurological conditions and emphasize the role of general neurologists and subspecialists involved in patient care. Whenever possible students should rotate through different clinics and not concentrate exclusively on emergency room and in-patient cases.