Teaching Video NeuroImage: Alternating Skew Deviation as a Manifestation of Anti-GAD65-Associated Cerebellitis
Bell, Carter; Drummond, Patrick S; Grossman, Scott N
Access to cavernous dAVF via occluded superior petrosal Sinus
Raz, Eytan; Sharashidze, Vera; Grossman, Scott; Ali, Aryan; Narayan, Vinayak; Nossek, Erez; Stein, Evan; Nelson, Peter Kim; Shapiro, Maksim
There are multiple treatment alternatives for cavernous dAVFs, with transvenous routes being most common. Among these routes, occluded inferior petrosal sinus is well-described, and, apart from being imaginative and elegant, it is also safe and effective. Herein we describe the application of this method to reach the fistulous pouch of a cavernous dAVF via an occluded superior petrosal sinus.
Trends in concussion mechanism of injury during the COVID-19 pandemic
Schaffer, Olivia; Xie, Frank; Cheng, Debby; Grossman, Scott N; Galetta, Steven L; Balcer, Laura J
OBJECTIVE:The primary objective was to determine the effect of the COVID-19 pandemic on volume, demographics, and mechanisms of injury (MOI) for patients seen at an urban multidisciplinary concussion center. During the first phase of the pandemic in the United States, stay-at-home orders led to decreased group activities and required cancellation of outpatient appointments or initiation of telemedicine visits. METHODS:This study was a retrospective chart review of 3500 patient electronic medical records (EMR). Patients aged 1-99 years were eligible if they had been seen at New York University Langone Health Concussion Center during March 1-December 31, 2019 (control/pre-pandemic period) or during the same period in 2020 (pandemic period). Injury date, appointment date, age, sex, and MOI were captured; statistical analyses were performed using Stata17 (StataCorp, College Station, TX). RESULTS:There were 48% fewer visits during the COVID-19 pandemic period compared to the 2019 control period. There was a decreased proportion of pediatric patients (15% control, 6% pandemic; p = 0.007, chi-square test). Fewer concussions were related to team sports (21% control, 5% pandemic; p < 0.001), and a greater proportion were caused by bicycle accidents (4% control, 8% pandemic; p = 0.037) and assault/domestic violence (3% control, 9% pandemic; p < 0.001). CONCLUSION/CONCLUSIONS:The relative proportions of concussion MOI, age distributions, and visit volumes were significantly associated with pre-pandemic vs. pandemic periods, suggesting that COVID-19 changed concussion epidemiology during the pandemic period. This study demonstrates how epidemiologic data may inform future resource allocation during public health emergencies.
Where's the Vision? The Importance of Visual Outcomes in Neurologic Disorders: The 2021 H. Houston Merritt Lecture
Patil, Sachi A; Grossman, Scott; Kenney, Rachel; Balcer, Laura J; Galetta, Steven
Neurologists have long-recognized the importance of the visual system in the diagnosis and monitoring of neurological disorders. This is particularly true since approximately 50% of the brain's pathways subserve afferent and efferent aspects of vision. During the past 30 years, researchers and clinicians have further refined this concept to include investigation of the visual system for patients with specific neurologic diagnoses, including multiple sclerosis (MS), concussion, Parkinson's disease (PD) and conditions along the spectrum of Alzheimer's disease (AD, mild cognitive impairment [MCI] and subjective cognitive decline [SCD]). This review, highlights the visual "toolbox" that has been developed over the past three decades and beyond to capture both structural and functional aspects of vision in neurologic disease. While the efforts to accelerate the emphasis on structure-function relationships in neurological disorders began with MS during the early 2000's, such investigations have broadened to recognize the need for outcomes of visual pathway structure, function and quality of life for clinical trials of therapies across the spectrum of neurological disorders. This review begins with a patient case study highlighting the importance utilizing the most modern technologies for visual pathway assessment, including optical coherence tomography (OCT). We emphasize that both structural and functional tools for vision testing can be used in parallel to detect what might otherwise be sub-clinical events or markers of visual and, perhaps, more global neurological, decline. Such measures will be critical as clinical trials and therapies become more available across the neurological disease spectrum.
Vision as a piece of the head trauma puzzle
Bell, Carter A.; Grossman, Scott N.; Balcer, Laura J.; Galetta, Steven L.
Approximately half of the brain"™s circuits are involved in vision and control of eye movements. Therefore, visual dysfunction is a common symptom of concussion, the mildest form of traumatic brain injury (TBI). Photosensitivity, vergence dysfunction, saccadic abnormalities, and distortions in visual perception have been reported as vision-related symptoms following concussion. Impaired visual function has also been reported in populations with a lifetime history of TBI. Consequently, vision-based tools have been developed to detect and diagnose concussion in the acute setting, and characterize visual and cognitive function in those with a lifetime history of TBI. Rapid automatized naming (RAN) tasks have provided widely accessible and quantitative measures of visual-cognitive function. Laboratory-based eye tracking approaches demonstrate promise in measuring visual function and validating results from RAN tasks in patients with concussion. Optical coherence tomography (OCT) has detected neurodegeneration in patients with Alzheimer"™s disease and multiple sclerosis and may provide critical insight into chronic conditions related to TBI, such as traumatic encephalopathy syndrome. Here, we review the literature and discuss the future directions of vision-based assessments of concussion and conditions related to TBI.
MICK (Mobile Integrated Cognitive Kit) app: Feasibility of an accessible tablet-based rapid picture and number naming task for concussion assessment in a division 1 college football cohort
Bell, Carter A; Rice, Lionel; Balcer, Marc J; Pearson, Randolph; Penning, Brett; Alexander, Aubrey; Roskelly, Jensyn; Nogle, Sally; Tomczyk, Chris P; Tracey, Allie J; Loftin, Megan C; Pollard-McGrandy, Alyssa M; Zynda, Aaron J; Covassin, Tracey; Park, George; Rizzo, John-Ross; Hudson, Todd; Rucker, Janet C; Galetta, Steven L; Balcer, Laura; Kaufman, David I; Grossman, Scott N
Although visual symptoms are common following concussion, quantitative measures of visual function are missing from concussion evaluation protocols on the athletic sideline. For the past half century, rapid automatized naming (RAN) tasks have demonstrated promise as quantitative neuro-visual assessment tools in the setting of head trauma and other disorders but have been previously limited in accessibility and scalability. The Mobile Interactive Cognitive Kit (MICK) App is a digital RAN test that can be downloaded on most mobile devices and can therefore provide a quantitative measure of visual function anywhere, including the athletic sideline. This investigation examined the feasibility of MICK App administration in a cohort of Division 1 college football players. Participants (nÂ =Â 82) from a National Collegiate Athletic Association (NCAA) Division 1 football team underwent baseline testing on the MICK app. Total completion times of RAN tests on the MICK app were recorded; magnitudes of best time scores and between-trial learning effects were determined by paired t-test. Consistent with most timed performance measures, there were significant learning effects between the two baseline trials for both RAN tasks on the MICK app: Mobile Universal Lexicon Evaluation System (MULES) (pÂ <Â 0.001, paired t-test, mean improvement 13.3Â s) and the Staggered Uneven Number (SUN) (pÂ <Â 0.001, mean improvement 3.3Â s). This study demonstrated that the MICK App can be feasibly administered in the setting of pre-season baseline testing in a Division I environment. These data provide a foundation for post-injury sideline testing that will include comparison to baseline in the setting of concussion.
Accuracy of clinical versus oculographic detection of pathological saccadic slowing
Grossman, Scott N; Calix, Rachel; Hudson, Todd; Rizzo, John Ross; Selesnick, Ivan; Frucht, Steven; Galetta, Steven L; Balcer, Laura J; Rucker, Janet C
Saccadic slowing as a component of supranuclear saccadic gaze palsy is an important diagnostic sign in multiple neurologic conditions, including degenerative, inflammatory, genetic, or ischemic lesions affecting brainstem structures responsible for saccadic generation. Little attention has been given to the accuracy with which clinicians correctly identify saccadic slowing. We compared clinician (nÂ =Â 19) judgements of horizontal and vertical saccade speed on video recordings of saccades (from 9 patients with slow saccades, 3 healthy controls) to objective saccade peak velocity measurements from infrared oculographic recordings. Clinician groups included neurology residents, general neurologists, and fellowship-trained neuro-ophthalmologists. Saccades with normal peak velocities on infrared recordings were correctly identified as normal in 57% (91/171; 171Â =Â 9 videosÂ Ã—Â 19 clinicians) of clinician decisions; saccades determined to be slow on infrared recordings were correctly identified as slow in 84% (224/266; 266Â =Â 14 videosÂ Ã—Â 19 clinicians) of clinician decisions. Vertical saccades were correctly identified as slow more often than horizontal saccades (94% versus 74% of decisions). No significant differences were identified between clinician training levels. Reliable differentiation between normal and slow saccades is clinically challenging; clinical performance is most accurate for detection of vertical saccade slowing. Quantitative analysis of saccade peak velocities enhances accurate detection and is likely to be especially useful for detection of mild saccadic slowing.
Treatment of Periodic Alternating Nystagmus as a Consequence of Ataxia-Telangiectasia
Jauregui, Ruben; Bhagat, Dhristie; Garcia, Mekka R; Miller, Claire; Grossman, Scott N
Training in Neurology: Objective Structured Clinical Examination Case to Teach and Model Feedback Skills in Neurology Residency
LaRocque, Joshua J; Grossman, Scott; Kurzweil, Arielle M; Lewis, Ariane; Zabar, Sondra; Balcer, Laura; Galetta, Steven L; Zhang, Cen
We describe an educational intervention for neurology residents aimed at developing feedback skills. An objective structured clinical examination case was designed to simulate the provision of feedback to a medical student. After the simulated case session, residents received structured, individualized feedback on their performance and then participated in a group discussion about feedback methods. Survey data were collected from the standardized medical student regarding residents' performance and from residents for assessments of their performance and of the OSCE case. This manuscript aims to describe this educational intervention and to demonstrate the feasibility of this approach for feedback skills development.
The MICK (Mobile integrated cognitive kit) app: Digital rapid automatized naming for visual assessment across the spectrum of neurological disorders
Park, George; Balcer, Marc J; Hasanaj, Lisena; Joseph, Binu; Kenney, Rachel; Hudson, Todd; Rizzo, John-Ross; Rucker, Janet C; Galetta, Steven L; Balcer, Laura J; Grossman, Scott N
OBJECTIVE:Rapid automatized naming (RAN) tasks have been utilized for decades to evaluate neurological conditions. Time scores for the Mobile Universal Lexicon Evaluation System (MULES, rapid picture naming) and Staggered Uneven Number (SUN, rapid number naming) are prolonged (worse) with concussion, mild cognitive impairment, multiple sclerosis and Parkinson's disease. The purpose of this investigation was to compare paper/pencil versions of MULES and SUN with a new digitized format, the MICK app. METHODS:Participants (healthy office-based volunteers, professional women's hockey players), completed two trials of the MULES and SUN tests on both platforms (tablet, paper/pencil). The order of presentation of the testing platforms was randomized. Between-platform variability was calculated using the two-way random-effects intraclass correlation coefficient (ICC). RESULTS:Among 59 participants (median age 32, range 22-83), no significant differences were observed for comparisons of mean best scores for the paper/pencil versus MICK app platforms, counterbalanced for order of administration (PÂ =Â 0.45 for MULES, PÂ =Â 0.50 for SUN, linear regression). ICCs for agreement between the MICK and paper/pencil tests were 0.92 (95% CI 0.86, 0.95) for MULES and 0.94 (95% CI 0.89, 0.96) for SUN, representing excellent levels of agreement. Inter-platform differences did not vary systematically across the range of average best time score for either test. CONCLUSION/CONCLUSIONS:The MICK app for digital administration of MULES and SUN demonstrates excellent agreement of time scores with paper/pencil testing. The computerized app allows for greater accessibility and scalability in neurological diseases, inclusive of remote monitoring. Sideline testing for sports-related concussion may also benefit from this technology.