Faculty Bibliography

The COVID-19 pandemic is causing world-wide social dislocation, operational and economic dysfunction, and high rates of morbidity and mortality. Medical practices are responding by developing, disseminating and implementing unprecedented changes in health care delivery. Telemedicine has rapidly moved to the frontline of clinical practice due to the need for prevention and mitigation strategies; these have been encouraged, facilitated, and enabled by changes in government rules and regulations and payer-driven reimbursement policies.We describe our neurology department's situational transformation from in-person outpatient visits to a largely virtual neurology practice in response to the COVID-19 pandemic. Two key factors enabled our rapid deployment of virtual encounters in neurology and its subspecialties. The first was a well-established robust information technology infrastructure supporting virtual urgent care services at our institution; this connected physicians directly to patients using both the physician's and the patient's own mobile devices. The second is the concept of one patient, one chart, facilitated by a suite of interconnected electronic medical record (EMR) applications on several different device types.We present our experience with conducting general teleneurology encounters using secure synchronous audio and video connections integrated with an EMR. This report also details how we perform virtual neurological examinations that are clinically meaningful, and how we document, code and bill for these virtual services. Many of these processes can be used by other neurology providers, regardless of their specific practice model. We then discuss potential roles for teleneurology after the COVID-19 global pandemic has been contained.

OBJECTIVE:To present the clinical, radiologic, and pathologic findings of a patient with carotid intimal sarcoma. METHODS:Detailed medical interview, neurologic examination, and diagnostic evaluation including CT angiography head and neck, MRI brain and neck, digital subtraction angiography, and biopsy of the mass were performed. RESULTS:We report a patient who presented with symptoms of multifocal, bilateral strokes over weeks caused by an enlarging tumor thrombus associated with an intimal sarcoma of the carotid artery. The presence of a carotid space mass encasing the left internal carotid artery was initially not recognized on imaging and was mistakenly attributed to soft atheromatous plaque rather than tumor thrombus. Rapid disease progression resulted in multiple intracranial metastases from tumor embolization. CONCLUSION/CONCLUSIONS:Clinical and radiologic findings of intimal sarcoma may be similar to those of thrombotic disease. However, patients with sarcoma may show an associated perivascular soft tissue mass and an unusual distribution of vessel stenosis. Reevaluation of imaging should be considered in patients presenting with initial imaging findings suggestive of rapidly progressive thrombotic disease who have a poor response to antithrombotic therapy and do not follow an expected clinical course.

OBJECTIVE:The Mobile Universal Lexicon Evaluation System (MULES) is a test of rapid picture naming that captures extensive brain networks, including cognitive, language and afferent/efferent visual pathways. MULES performance is slower in concussion and multiple sclerosis, conditions in which vision dysfunction is common. Visual aspects captured by the MULES may be impaired in Parkinson's disease (PD) including color discrimination, object recognition, visual processing speed, and convergence. The purpose of this study was to compare MULES time scores for a cohort of PD patients with those for a control group of participants of similar age. We also sought to examine learning effects for the MULES by comparing scores for two consecutive trials within the patient and control groups. METHODS:MULES consists of 54 colored pictures (fruits, animals, random objects). The test was administered in a cohort of PD patients and in a group of similar aged controls. Wilcoxon rank-sum tests were used to determine statistical significance for differences in MULES time scores between PD patients and controls. Spearman rank-correlation coefficients were calculated to examine the relation between MULES time scores and PD motor symptom severity (UPDRS). Learning effects were assessed using Wilcoxon rank-sum tests. RESULTS: = 0.37, P = .02). Learning effects were greater among patients with PD (median improvement of 14.8 s between two MULES trials) compared to controls (median 7.4 s, P = .004). CONCLUSION/CONCLUSIONS:The MULES is a complex test of rapid picture naming that captures numerous brain pathways including an extensive visual network. MULES performance is slower in patients with PD and our study suggests an association with the degree of motor impairment. Future studies will determine the relation of MULES time scores to other modalities that test visual function and structure in PD.

Introduction: Natalizumab treatment in patients with early relapsing-remitting multiple sclerosis (RRMS) may improve clinical outcomes. STRIVE is a completed, 4-year, multicentre, observational, open-label, single-arm study of anti-JC virus antibody negative patients starting natalizumab < 3 years after RRMS diagnosis.
Objective(s): To examine 4-year, end-of-study no evidence of disease activity (NEDA) status, disability worsening and improvement, and cognitive performance of natalizumab-treated patients with early RRMS.
Method(s): Clinical NEDA, the primary endpoint, was defined as no relapses or Expanded Disability Status Scale (EDSS) worsening (score increase of >=1.5 from a baseline [BL] of 0.0, >=1.0 from a BL of 1.0-5.5, or >=0.5 from a BL >=6.0, confirmed over 24 weeks). MRI NEDA was defined as no gadolinium-enhancing or new/enlarging T2-hyperintense lesions. Overall NEDA encompassed both clinical and MRI NEDA. Annualised relapse rates (ARRs) were analysed with a negative binomial regression model. The Kaplan-Meier method estimated time to 24-week-confirmed EDSS worsening or improvement (score decrease of >=1.0 from a BL >=2.0). The Symbol Digit Modalities Test (SDMT) change from BL to year 4 was analysed via a Wilcoxon signed-rank test.
Result(s): At BL (N=222), patients had active disease, a mean (standard deviation [SD]) of 1.4 (1.2) relapses in the prior year, and a mean (SD) EDSS score of 2.04 (1.13). At study end, 100 of 169 patients (59.2%) achieved cumulative clinical NEDA, and 72 of 143 (50.4%) and 45 of 163 (27.6%) had MRI and overall NEDA, respectively. In year 4, 101 of 134 patients (75.4%) had overall NEDA. ARRs decreased by 90.2%, from 1.43 in the year before natalizumab to 0.14 on natalizumab (P< 0.0001). Cumulative probabilities of EDSS worsening and improvement over 4 years were 19.3% and 43.9%, respectively. At study end, the mean (SD) EDSS score was 1.77 (1.55). From BL to year 4, patients had significant improvement in SDMT score (n=174; mean change from BL: 4.6 [95% confidence interval: 2.9-6.2]; P< 0.0001). Serious adverse events were reported in 25 of 222 patients (11.3%), with no cases of progressive multifocal leukoencephalopathy.
Conclusion(s): Natalizumab treatment over 4 years was associated with NEDA achievement, a 43.9% probability of disability improvement, a 19.3% probability of disability worsening, and significantly improved cognitive performance. These results support natalizumab's long-term effectiveness in early RRMS patients