The Department of Neurology at University of Miami Miller School of Medicine, hosted its first virtual 2021 Neurology Update and Stroke Intensive Review, continuing its tradition of lively and informative presentations and networking among esteemed international faculty and diverse neurological experts.
“The idea of the course, which we have offered for 54 years, is in large part to provide an update on the latest diagnostic and treatment advances in the major subspecialties of neurology. Secondly, though, we focus significantly on stroke, an area in which Miller School neurologists and researchers are national leaders and are doing pivotal epidemiological research,” said course co-director Jose G. Romano, M.D., professor of neurology, executive vice chair of clinical affairs and chief of the Stroke Division, and medical director of the Comprehensive Stroke Program at UM/Jackson Memorial Hospital.
While this goal remains unchanged, the impact of COVID-19 on neurological disorders was spotlighted in presentations across the subspecialties.
“We looked at how it affects the risks for patients with seizures, headaches, migraines, multiple sclerosis, and stroke, and discussed how standard of care in medication and other therapy should be modified,” Dr. Romano said.
This year’s meeting, held June 17-19, provided new and creative models for attendees to connect.
“We missed being face-to-face, but the virtual format worked well for participants, who are now accustomed to sharing with colleagues in this way,” said course co-director Andres M. Kanner, M.D., professor of clinical neurology, director of the International Comprehensive Epilepsy Center and chief of the Epilepsy Division in the Department of Neurology.
“Bread and Butter” Learning
The course was directed to general neurologists and neurology subspecialists, internists, nurses, nurse practitioners, residents, fellows, neuropsychologists, psychiatrists and medical students.
“The focus of this program is largely on the bread and butter of clinical neurology,” Dr. Kanner said. “Today, this includes how to approach the evaluation and treatment of patients with COVID-19 and its neurological complications, research that is on the cusp of changing neurology practice, as well as novel therapies. Participants are here to learn ‘How is this going to affect my daily practice?’ Answering that was the purpose of this meeting.”
Program leaders modified the schedule and session lengths to accommodate the virtual format, using pre-recorded presentations, followed by live roundtable discussions between the presenters and participants. These included case studies around the use of various modalities in diagnosis and disease management.
Here is a roundup of conference highlights by subspecialty:
Among the epilepsy presenters were experts from the Miller School’s level-four Epilepsy Center, who discussed the new antiepileptic medications, and also delved into the use of the common anesthetic, ketamine, in the treatment of status epilepticus. Experts reviewed the indications for use of the three neuromodulation therapies (vagus nerve stimulation, responsive neurostimulation, and deep brain stimulation). Other topics also included the impact of COVID-19 on the development of seizures and guidance on the use of antiepileptic medications in patients considering pregnancy.
The Division of Memory Disorders and the Comprehensive Center for Brain Health have a number of grants for research dedicated to the treatment of Alzheimer's disease and prevention. With this backdrop, presentations explored behavioral markers of neurodegeneration and relationships between dementia and physical disability, and dementia and sarcopenia. Several other presentations sprang from studies supporting the role of specific diets and of resilience and other personality characteristics in protecting brain health.
Migraine presentations covered emerging treatments — including calcitonin gene-related peptide inhibitors and neuromodulation — and reported on several case studies of complicated headache seen during the pandemic. Headaches were spotlighted as a common symptom of COVID-19 infection and Post-Acute Sequela of COVID19, prompting exploration of the etiology. Telemedicine was also discussed as being a viable option for patient access and care. “Providers are reporting overall success using this format for patients with headaches and migraines, both related and unrelated to COVID-19,” Dr. Kanner said.
UM experts discussed the latest surgical treatments and therapeutic solutions for Parkinson's Disease and other movement disorders.
“We dug into factors for early identification and initial treatment strategies, and reviewed the latest thinking on the timing of introducing medication, since it is an area of controversy,” Dr. Kanner said. Presenters also reviewed common complications of treatment and discussed how to strategically move forward from therapy failures to optimal next steps.
COVID-19 factored heavily into the MS presentations, with a discussion of vaccine safety for this population, and how immunotherapy potentially increases the risks of contracting COVID-19 or successfully treating a SARS-CoV-2 infection. As in previous years, the faculty reviewed the new therapies for MS and neuromyelitis optica.
Experts covered the clinical findings on sleep disorders as they relate to differential diagnosis of neurological disorders.
“There was an excellent review of the impact of circadian rhythm in sleep disturbances, and another on how sleep affects risk factors for stroke and other morbidities,” Dr. Kanner said.
The Stroke Intensive
Led by Dr. Romano, the stroke intensive review is the cornerstone of the program each year.
“This intensive meets the Joint Commission requirements to ensure neurologists at primary and comprehensive centers are thoroughly updated on the latest in stroke prevention and acute treatments, so we provide that to the community,” Dr. Romano said.
With COVID-19 infection increasing stroke risk, both during and following active infection, some of the most productive roundtable discussions revolved around emergent treatment for this population. Other presentations covered the newest guidelines and recommendations for the use of anti-platelet medication and new approaches to stroke prevention in atrial fibrillation patients. The powerful effect of catheter-based interventions (thrombectomy) in patients with occlusion of a major artery in the brain was also reviewed.
“Perhaps the biggest news we discussed was the extension of the window for thrombolytic treatment (tPA) from 4.5 hours to 24 in select patients who have salvageable brain tissue,” Dr. Romano said. “Advanced brain imaging has enabled us to discern which patients may benefit. This will make a huge difference in how we treat the common scenario where a patient wakes up with stroke symptoms, having suffered a stroke overnight. Now, in many cases, we can intervene without knowing exactly when the stroke may have occurred in the night.”
Presenters brought the topic of recurrent strokes, which represent one in four strokes, to the forefront, and discussed prevention of cognitive decline from small strokes.
“When a patient has had one or more strokes, we have the concrete knowledge of elevated risk. What we have the power to do to prevent recurrence should be front and center with these patients,” he said.
“Zooming” Toward Enhanced Collaboration
The virtual format enabled robust attendance at a lower cost and allowed participants a streamlined, customizable learning commitment. Beyond that, Dr. Kanner says the virtual interactions over the pandemic have also changed the culture of sharing.
“One of the rare silver linings of COVID-19 is the skyrocketing ability to communicate with our colleagues, not only at a local or national level, but also at an international level,” he said. “Because more of us were engaged in virtual interactions throughout the year, this made for more lively and informed discussions. We were able to extend the learning further as a result.”
Participants can access video presentations and lectures online.