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Background: In-person didactic education in residency has numerous challenges including inconsistent availability of faculty and residents, limited engagement potential, and non-congruity with clinical exposure. Methods: An online curriculum in movement disorders was implemented across nine neurology residency programs (six intervention, three control), with the objective to determine feasibility, acceptability, and knowledge growth from the curriculum. Residents in the intervention group completed ten modules and a survey. All groups completed pre-, immediate post-, and delayed post-tests. Results: Eighty-six of 138 eligible housestaff (62.3%) in the intervention group completed some modules and 74 completed at least half of modules. Seventy-four, 49, and 30 residents completed the pre-, immediate post-, and delayed post-tests respectively. Twenty-five of 42 eligible control residents (59.5%) completed at least one test. Mean pre-test scores were not significantly different between groups (6.33 vs. 6.92, p = 0.18); the intervention group had significantly higher scores on immediate post- (8.00 vs. 6.79, p = 0.001) and delayed post-tests (7.92 vs. 6.92, p = 0.01). Residents liked having a framework for movement disorders, appreciated the interactivity, and wanted more modules. Residents completed the curriculum over variable periods of time (1–174 days), and at different times of day. Discussion: This curriculum was feasible to implement across multiple residency programs. Intervention group residents showed sustained knowledge benefit after participating, and residents took advantage of its flexibility in their patterns of module completion. Similar curricula may help to standardize certain types of clinical learning and exposure across residency programs. Highlights: Interactive online tools for resident didactic learning are valuable to residents. Residents learn from interactive online curricula, find the format engaging, and take advantage of the flexibility of online educational tools. Beginner learners appreciate algorithms that help them to approach a new topic.

Background Common peroneal nerve (CPN) compressive neuropathy is the most common lower-extremity entrapment neuropathy. Materials and Methods A retrospective review of a prospectively maintained single-institution database of all patients with CPN palsy who underwent decompression and neuroplasty over a 5-year period was performed. Results Thirty patients underwent a neuroplasty of the CPN over a 5-year period (2010–2015) at our institution. The median age was 45 years, and there was a male preponderance. The average time between first onset of symptoms to surgery was 122.9 weeks and between first clinic visit and surgery was 21 weeks. The etiology of the CPN neuropathy was as follows: in 12 patients, it followed a surgical procedure and in 14 patients, it occurred after a trauma to the lower extremity. In 2 patients, it occurred as a result of a mass lesion compromising the nerve and in 1 patient, a local infection predisposed to CPN palsy. Right and left lower extremities were equally involved. The median body mass index was 28.6. The most common presentation was weakness of the tibialis anterior (TA) and extensor hallucis longus (EHL) and loss of sensation in the distribution of the CPN or one of its major branches. Pain was a presenting symptom in 16 patients. Only 12 of the 30 patients had a positive Tinel's sign at the site of compression over the lateral fibular neck. Preoperative electrophysiologic confirmation of CPN neuropathy was available in all patients. Mean follow-up was 52 weeks. Prone positioning and selective use of the operating microscope provided excellent visualization and surgical exposure of the CPN from the lower popliteal region to the peroneal tunnel. Average operating room time was 170 minutes and average skin-to-skin time 91 minutes. Clinical improvement after surgery in terms of motor function was noted in 24 of the 26 patients who presented with a motor deficit. The most consistent improvement was noted in the TA and EHL; a trend toward greater improvement with shorter time to surgery was noted. No complications related to the surgical site or CPN were encountered, and no patient had a decline in their neurologic examination as a consequence of the surgery. One patient developed a positioning-related right upper-extremity brachial plexus neuropraxic injury after surgery that recovered completely. Conclusions Common peroneal neuropathy usually presents with weakness of the TA and EHL and decreased sensation or pain in the distribution of the CPN. Microscope-assisted surgical neuroplasty of the CPN at the lateral fibular neck with the patient in a prone position allows decompression of the nerve from the lower popliteal region to the peroneal tunnel. Significant improvement in motor strength after surgery, particularly of the TA and EHL, was observed in this series.

Normal neurologic function requires a constantly balanced environment of electrolytes. Normal hepatic and renal function is critical in maintaining this balance while removing toxins, maintaining a physiologic pH and regulating the excretion of electrolytes. Nutritional intake provides essential nutrients but deficiencies can lead to characteristic syndromes such as Wernicke's encephalopathy and pellagra and exposure to neurotoxic substances such as heavy metals can lead to encephalopathy. Thyroid and adrenal dysfunction are common endocrine causes of encephalopathy and symptoms can often improve rapidly with treatment. A subset of idiopathic encephalopathy is increasingly being recognized as having an autoimmune basis, often presenting as a paraneoplastic process, and having a constellation of symptoms which can aide in the diagnosis. Timely recognition and treatment of the autoantibodies which target neural structures, with immunosuppressive therapy, can improve outcome in these patients. This review contains 4 figures, 3 tables, and 42 references. Key words: osmotic demyelination syndrome,hepatic encephalopathy, renal failure, triphasic waves, dialysis disequilibrium syndrome, Wernicke encephalopathy, Korsakoff syndrome, myxedema coma, Hashimoto encephalopathy

Encephalopathy can range from the acute confusional state to frank coma, and is broadly defined as a constellation of symptoms and signs reflecting diffuse cerebral dysfunction. The potential causes of encephalopathy are vast requiring a thorough initial assessment and systematic diagnostic approach. Obtaining a comprehensive history may be challenging and ancillary sources of information are often helpful in narrowing the differential diagnosis. The general examination may provide hints as to the cause of encephalopathy and the neurologic examination can guide both acute management and focus the diagnostic investigations on specific etiologies which fit the clinical presentation. The systemic manifestations of infection and toxic exposures are common causes of encephalopathy. In sepsis, not only is brain perfusion compromised, multi system dysfunction is common and additional factors related to the specific infection such as hypoxia in pneumonia or secondary CNS involvement can complicate management. An understanding of the common physical examination findings of toxic exposures can aid in the diagnosis and rapid treatment of reversible toxic encephalopathies such as narcotics, benzodiazepines or environmental toxins. Cardiopulmonary dysfunction can lead to hypoxic-ischemic encephalopathy and advances in critical care, and particularly targeted temperature management following cardiac arrest, have improved the neurologic outcome in these patients. This review contains 2 figures, 3 tables, and 25 references. Key words: encephalopathy, delirium, ascending reticular activating system, acute confusional state, subclinical seizures, Glasgow Coma Scale, Full Outline of Unresponsiveness (FOUR) Score , hypoxic-ischemic encephalopathy, neuroleptic malignant syndrome, serum neuron-specific enolase

Background Good medical care relies on communication as much as technical expertise, yet physicians often overestimate the efficacy of their patient communication skills. Teaching communication skills can be cost- and time-intensive, and efforts have rarely focused on challenging situations, such as conveying the news of a patient's brain death to a family member. Objective We developed a resource-sensitive simulation program to teach residents how to diagnose brain death and how to show empathy in discussing the diagnosis with the patient's family. Methods From 2015 to 2017, 3 cohorts of incoming neurology residents participated in the 3-day training exercise. The 2-hour preintervention assessment involved making the diagnosis of brain death and sharing the news with an actor portraying the patient's family member. The scoring via checklists consisted of 15 clinical skills, 9 apnea test–related skills, and 37 verbal skills related to family discussion. The 5-hour didactic intervention focused on technical aspects of the brain death examination and lessons in communication with role-playing. The 2-hour postintervention assessment repeated the brain death examination and family discussion simulations. Data were analyzed using the Wilcoxon signed rank test. Results A total of 18 residents (100%) were assessed, with significant differences between preintervention and postintervention testing across all areas, including clinical assessment (45%–76%, P Conclusions The findings suggest a benefit in simulation training for brain death examination, apnea testing, and the subsequent family discussion regarding the patient's diagnosis.

Introduction: An in-hospital stroke emergency demands timely decision making and prioritization of tasks by the stroke team nurse. Simulation-based medical education (SBME) focuses on obtaining clinical skills in psychomotor, cognitive and affective domains and is superior to the traditional style of education with improved outcomes of knowledge, skills and behaviors and demonstrable effects for patient-related outcomes. A stroke simulation study at our center showed significant improvements in the cognitive and affective domain of new residents and this next phase aims at incorporating members of the multidisciplinary stroke team. Hypothesis: SBME improves stroke emergency performance, particularly for inexperienced stroke team members. Methods: Eight neuro ICU nurses participated in a high fidelity patient simulation of an in-hospital ischemic stroke eligible for IV tPA. The nurse independently managed every nursing task including a focused patient assessment, verifying and evaluating vitals and treating appropriately, expediting labs, managing common obstacles and coordinating care with the stroke team. Nurses completed an affective survey, pre- and post-test cognitive assessment and debriefing with feedback. An evaluator completed a real-time checklist of pre-defined tasks and the subject participated in a review of their performance with the stroke team. Results: Subjects showed a 19.4% improvement in the cognitive assessment post-simulation (p=0.02). The affective survey showed nurses were confident in their ability to perform the NIHSS. While there was no significant change in the affective domain post simulation due to the subject groups being too small for statistical comparison, recognition of normal parameters (labs and vitals) for treatment of stroke showed an improvement of 6.25%. Conclusion: SBME can facilitate the acquisition of technical skills and non-technical skills such as team work, communication, decision-making and cognizance of personal limitations. This pilot demonstrated that nurses can benefit in the cognitive domain through simulation and feedback indicated that a stroke simulation with increased interaction among stroke team members, with defined roles would add to the fidelity of the simulation.

The neurocutaneous disorders (NCDs) embrace an extensive group of developmental disorders associated with involvement of the skin, central nervous system (CNS), and/or the peripheral nervous system (PNS). The neurocutaneous manifestations relate to the common ectodermal origin of these organs. This review intended for the practicing clinical neurologist focuses on selected aspects of the NCDs primarily those associated with cerebrovascular disease. Our emphasis is primarily on those NCDs with genetic heterogeneity and their neurological manifestations.

Background: Residents’ funduscopy skill is an important topic for medical education. Objective: To provide a snapshot of the performance of direct funduscopy (DF) as part of the initial clinical assessment among different faculty physicians and residents from Internal Medicine (IM), Emergency Medicine (EM) and Neurology (N). Methods: Retrospective study of 200 randomly reviewed charts of patients (> 18 years) presenting either to the ED, inpatient units or outpatient clinics from January 2001 to July 2013, with corresponding ICD-9 codes for headaches, altered mental status and visual changes. Results: Whereas the Neurology Service was the one who performed most DF upon initial evaluation, DF is infrequently done throughout services independent of inpatient or outpatient location. More than half of patients (66%) presenting with visual symptoms had evaluation done by Ophthalmology. Conclusions: A more robust teaching of DF should be included among the basic clinical competencies during Medical School and Neurology Residency training.

We report a case of pathologically confirmed tumefactive multiple sclerosis (MS) followed shortly thereafter by the diagnosis of an oligoastrocytoma. The complexity of diagnosis and management of concomitant presence of tumefactive MS and glial cell tumors is discussed.

INTRODUCTION: An ED-based “stroke code” demands timely decision making and prioritization of tasks by the stroke team neurologist while coordinating care with ED staff, radiology and pharmacists. Simulation-based medical education (SBME) focuses on obtaining clinical skills belonging to the psychomotor, cognitive and affective domains. SBME is superior to the traditional style of medical education and has shown improved outcomes of knowledge, skills and behaviors and moderate effects for patient-related outcomes in other emergency based scenarios including ACLS and procedure-based learning. HYPOTHESIS: To describe the rationale and design for a novel hospital based stroke simulation. SBME can improve stroke code efficiency particularly for inexperienced stroke team members. METHODS: Six incoming PG2 neurology residents participated in a pilot study using a high fidelity patient simulation of an acute ED-based stroke code at week 1 and 3 of orientation. The trainee independently managed every step from activation of the stroke pager including a focused patient assessment, ordering and interpreting labs and imaging, managing common obstacles, staffing with the on-call attending, working with ancillary staff and appropriate treatment as indicated. Residents completed an affective survey, pre- and post-test cognitive assessment and debriefing with feedback, as well as real time checklist and review of videotaped assessment of their performance. RESULTS: Subjects showed a 16.1% improvement in the cognitive assessment from week 1 to week 3 (p=0.02). The affective survey showed residents were moderate to highly confident in their ability to perform a history and physical prior to participation, yet they had low confidence utilizing the NIHSS and managing medications for acute stroke in the ED prior to participation. CONCLUSION: SBME can facilitate the acquisition of technical and non-technical skills such as leadership, team work, communication, situational awareness, decision-making, cognizance of personal limitations important for patient safety and a learning cycle of debriefing and feedback. Post-test and affective survey results demonstrate improvements in the cognitive domain and resident confidence respectively.

The lymphomas and leukemias are a heterogenous group of hematologic malignancies with protean manifestations. Neurologic sequelae of the diseases have been recognized since the time the conditions were first described in the mid-1800s. Although our understanding of the various presentations of these blood disorders evolved along with our knowledge of malignancies, accurate diagnosis can still be difficult. It is critical for neurologists to have a high index of clinical suspicion to appropriately recognize their heralding features. This review’s focus is the relevant clinical neurologic features and diagnostic studies that identify leukemias and lymphomas affecting the nervous system.

Cardiac arrest is a common and serious medical emergency affecting upwards of 450 000 Americans on an annual basis. It causes a substantial strain on the physical and financial resources of the medical system. The optimal management of patients requires the close collaboration of multiple specialists, including first responders, intensivists, cardiologists, and neurologists. The role of the neurologist for the post-arrest patient is to assist in management to minimize brain injury as well as to prognosticate long-term outcomes to help guide therapy decisions of families and physicians. This review focuses on epidemiologic data, current management recommendations, clinical and ancillary testing to suggest long-term prognosis, and common complications of cardiac arrest. Particular attention has been paid to updates, including therapeutic hypothermia, since this topic was last reviewed in 1993.

The lymphomas and leukemias are a heterogenous group of hematologic malignancies with protean manifestations. Neurologic sequelae of the diseases have been recognized since the time the conditions were first described in the mid-1800s. Although our understanding of the various presentations of these blood disorders evolved along with our knowledge of malignancies, accurate diagnosis can still be difficult. It is critical for neurologists to have a high index of clinical suspicion to appropriately recognize their heralding features. This review's focus is the relevant clinical neurologic features and diagnostic studies that identify leukemias and lymphomas affecting the nervous system.

Cardiac arrest is a common and serious medical emergency affecting upwards of 450000 Americans on an annual basis. It causes a substantial strain on the physical and financial resources of the medical system. The optimal management of patients requires the close collaboration of multiple specialists, including first responders, intensivists, cardiologists, and neurologists. The role of the neurologist for the post-arrest patient is to assist in management to minimize brain injury as well as to prognosticate long-term outcomes to help guide therapy decisions of families and physicians. This review focuses on epidemiologic data, current management recommendations, clinical and ancillary testing to suggest long-term prognosis, and common complications of cardiac arrest. Particular attention has been paid to updates, including therapeutic hypothermia, since this topic was last reviewed in 1993.

Multiple sclerosis (MS) is one of the most common neurologic disorders that affects young people. The disorder has long been associated with clinical relapses and a disabling course. However, there has been a rapid expansion in the available treatment options for MS, and new insights into existing therapies, as decades of research has begun to produce tangible treatment results leading to newly approved an emerging therapies.

The leukemias and lymphomas represent a heterogenous group of hematologic malignancies with protean manifestations. Neurologic sequelae of the diseases have been recognized almost since the time the conditions were first described in the mid-1800s. Although our understanding of the various presentations of these blood disorders has evolved along with our knowledge of the malignancies, accurate diagnosis can still be difficult. It is critical for neurologists to have a high index of clinical suspicion to appropriately recognize the heralding features. This review focuses on the relevant clinical neurologic features and diagnostic studies to identify leukemias and lymphomas affecting the nervous system.