Neurology® Podcast

American Academy of Neurology
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The Neurology Podcast provides practical information for neurologists and clinicians to practice the best possible medicine for patients. Examining methods and findings in peer-reviewed journals, the show provides insights that impact clinical practice and patient care. From the journal Neurology and the American Academy of Neurology, providing education and expert analysis since 2007.

  1. 2d ago

    The Future of Child Neurology Residency Training

    Dr. Dara Albert talks with Dr. Bruce Cohen about the future of child neurology residency training, exploring current models, consensus areas, and challenges in evolving the curriculum to meet future healthcare needs. Read the related article in Neurology® Education. Disclosures can be found at Neurology.org.

  2. 5d ago

    Pharmacologic Treatment for Migraine Prevention in Adults Practice Guideline Recommendations

    Dr. Tesha Monteith talks with Dr. Tamara Pringsheim about the updated American Academy of Neurology (AAN) and American Headache Society (AHS) guidelines on pharmacologic treatment for migraine prevention in adults.  Read the related article in Neurology®. Disclosures can be found at Neurology.org.  Show transcript:  Dr. Jose Merino (00:08): This is Jose Merino, editor-in-chief of the Neurology Family of Journals. The Neurology Podcast provides practical information to neurologists and other clinicians to help them provide better care for their patients. Thanks for listening and have a great week. Dr. Tesha Monteith (00:23): Hi, this is Tesha Monteith with the Neurology Podcast. I'm excited to talk to you today about the update in Migraine Guideline: Pharmacologic Treatment for Migraine Prevention in Adults: Practice Guideline Recommendations, a report of the American Academy Neurology Guidelines Subcommittee, and the American Headache Society. Since the last guideline in 2012, there's been a lot of new advances, including the introduction of CGRP inhibitors for acute and preventive treatment. (00:53): With me to discuss is the lead author, Tamara Pringsheim, a neurologist at the Department of Clinical Neurosciences, Psychiatry, Pediatrics, and Community Health Sciences at the University of Calgary. How are you, Tamara? Dr. Tamara Pringsheim (01:06): Great. Thank you for asking me to talk to you about this. Dr. Tesha Monteith (01:09): Why don't you tell me a little bit about yourself and how you got involved in this work? Dr. Tamara Pringsheim (01:14): Sure. I've been working as a methodologist for the American Academy of Neurology Guidelines Subcommittee for a number of years, since 2015. Prior to that, I was a member of the guideline development subcommittee from 2011. I've worked on a number of different guidelines across neurological conditions. Dr. Tesha Monteith (01:36): Great. So how do these new guidelines compare, just broadly speaking, with the older guidelines? Dr. Tamara Pringsheim (01:43): I guess since the last guidelines were published more than 10 years ago, we've had changes to our methodological process. We had a major update to our guideline process manual in 2017, and guideline methodology has continued to evolve over that time period. And as well, a number of targeted treatments for migraine have come out. So there's been an explosion of evidence, particularly in the last five to seven years. And so we have a whole new class of medications available for migraine prevention, which really target our underlying understanding of the condition, whereas most of the other medications were discovered through serendipity. Dr. Tesha Monteith (02:33): So I know that you reviewed over 200 randomized controlled trials. And so how was the quality or confidence of the evidence determined? Dr. Tamara Pringsheim (02:47): With our process, we start by rating risk of bias for every article. This basically gets at a number of different features related to the clinical trial methodology and reporting, and it helps us determine how confident we are in the evidence. In order for us to be highly confident that the results that we are seeing reflect the truth, we typically need to have at least two Class 1 studies for any intervention outcome pair. The effect size estimate also has to meet a certain threshold in terms of the effect size and the precision surrounding that estimate. So if we feel that based on what the panel decides in terms of what is the minimal clinically important difference between an intervention and placebo, that will help us determine our confidence in the evidence. (03:51): So there's this critical coming together of the number of studies, the quality of studies, the effect size, and the precision of the evidence that helps us determine our confidence in the evidence. And all of this is done behind the scenes using a very algorithmic approach so that these rules are faithfully applied across the different interventions we're looking at. This complexity makes it hard for people to understand why certain drugs land in a certain area, but it's one of the things that we do to make this process standardized and rigorous. Dr. Tesha Monteith (04:37): So I do want to talk to you about that, where drugs have landed. One newer thing was that the review was not just episodic migraine, but also chronic migraine. Dr. Tamara Pringsheim (04:47): Yes. Dr. Tesha Monteith (04:48): Were there important differences in the strength of evidence between these populations? Dr. Tamara Pringsheim (04:53): One thing that's really important to remember is that the use of the term chronic migraine is fairly new. So a lot of the trials of the older headache preventive medications were done in the 80s and the 90s. And at this time, there wasn't a definition which distinguished chronic migraine in particular. So a lot of the trials for amitriptyline, for example, were not done in a purely episodic or chronic migraine population. And so this really contrasts with the newer studies where these populations were well-defined. And so we're going to have higher quality evidence or evidence specifically for chronic migraine with the new drugs, whereas for the old drugs, we won't have that. Dr. Tesha Monteith (05:50): Let's get into the preventive treatments that had the strongest level of evidence for episodic migraine. Dr. Tamara Pringsheim (05:57): We had high confidence in the evidence for two of the CGRP medications, erenumab and galcanezumab. Again, these high confidence in the evidence statements are based on the fact that for both these drugs, there were multiple Class 1 studies showing that they were efficacious. And the effect size was in the range that was pre-specified. So the lower level of the 95% confidence interval was clearly higher than what we decided was the minimal clinically important difference. Both these drugs, one had two Class 1 studies, one had three Class 1 studies, so we could be very highly confident that these two medications were efficacious. (06:50): Now for the moderate confidence drugs, we have a longer list for episodic migraines. So it includes atogepant, eptinezumab, fremanezumab, propranolol, rimegepant, topiramate, and valproate, and then a slightly longer list for the low confidence drugs. So amitriptyline, bisoprolol, flunarizine, fluoxetine, levetiracetam, metoprolol, nifedipine, pizotifen, and telmisartan. (07:18): And for this outcome, I'm specifically talking about episodic migraine headache days. Now, one of the layers of complexity, again for this guideline, is that we had a few different outcomes that we were looking at. So the two main outcomes we were looking at were the headache frequency, the change in the number of headache days, but also the 50% responder rate. That's the proportion of people in the treatment group who had at least a 50% reduction in their headache frequency. And some drugs would make it for one endpoint, but not the other. And this is an important nuance that, again, adds complexity to our data synthesis. Dr. Tesha Monteith (08:06): And what about for chronic migraine? Dr. Tamara Pringsheim (08:08): So for chronic migraine, for the number of headache days, we had high confidence for fremanezumab, galcanezumab and onabotulinumtoxinA, and moderate confidence for atogepant, eptinezumab, erenumab, topiramate, rimegepant, and valproate. We didn't have any medications that were in the low confidence in the evidence category. Dr. Tesha Monteith (08:33): Oftentimes in the newer clinical trials, we're looking at change in monthly migraine days, but interesting that you looked at headache days. Dr. Tamara Pringsheim (08:42): Yeah. So another difficulty is that there's not always consistency in what's reported. So some trials would report headache days and some trials would report migraine days per month. Wherever possible, we use the change in the number of days with migraine. And where this was not present, we would use headache days. Dr. Tesha Monteith (09:08): Now, a drug that we use very often in clinical practice is rimegepant, which has a dual benefit of acute attack treatment as well as prevention. And that was rated as low confidence, but in a recent International Headache Society, Italian guidelines, that was noted as moderate quality evidence, strongly in favor of. What do you think that discrepancy was about? Is that a matter of outcomes or? Dr. Tamara Pringsheim (09:38): This guideline includes clinical trials that were published up until June of 2024. And so at that time, the only trial of rimegepant versus placebo that was published was in a population of patients that had episodic or chronic migraine. The population was combined. And so we only have one study. And as I was explaining at the beginning, in order for us to have high confidence in the evidence, we have to have at least two Class 1 studies and the minimal clinically important difference has to meet a certain threshold. So for rimegepant in June of 2024, there's only one study published versus placebo. So the highest possible confidence in the evidence we could have for rimegepant based on the fact that just one study would be moderate. (10:38): The reason why it's not listed in recommendation 3A as high or moderate confidence is because while we had moderate confidence in the evidence for rimegepant on the number of headache days, we had low confidence in the evidence for the 50% responder rate. And that's because for the 50% responder rate, it did not meet the pre-specified cutoff with respect to the minimally clinically important difference. (11:11): So again, it's a small nuance in the evidence, but for an evidence-based guideline, we really pay attention to these things. I know it makes it complex and hard for people who are not immersed in the evidence to understand. This is part of the rigor. There's a temptation to ove

  3. Sep 24

    Resolution of PML after Treatment with Virus-Specific T Cells and HCT

    Dr. Justin Abbatemarco talks with Dr. Irene Cortese about recent advances in the treatment of progressive multifocal leukoencephalopathy (PML), focusing on immune-based therapies like virus-specific T cells and immune checkpoint inhibitors.  Read the related article in The New England Journal of Medicine.  Disclosures can be found at Neurology.org.  Show transcript:  Dr. José Merino: This is José Merino, editor-in-chief of the Neurology Family of Journals. The Neurology Podcast provides practical information to neurologists and other clinicians to help them provide better care for their patients. Thanks for listening, and have a great week. Dr. Justin Abbatemarco: Hello and welcome. This is Justin Abbatemarco with the Cleveland Clinic here with Irene Cortese to discuss an update on progressive multifocal leukoencephalopathy treatment in light of a New England Journal of Medicine correspondence, Resolution of PML After Treatment with Virus-Specific T Cells and HCT. Irene directs the Experimental Immunotherapeutics Unit at NINDS. Hello and welcome. Dr. Irene Cortese: Hi, thank you for the invitation to join you today. Dr. Justin Abbatemarco: It's a pleasure to have you on and to talk about this expanding space in rare disease. And maybe if we could start off, can we just take an overview on how PML usually presents and why does it remain so difficult to treat? Dr. Irene Cortese: PML, or progressive multifocal leukoencephalopathy, is an opportunistic infection of the brain that is caused by the JC virus. And most of us carry this virus lifelong and without any symptoms, and it really only causes disease when the immune system is significantly compromised and loses the ability to keep it in check. And so when that happens, the virus can gain the ability to infect oligodendrocytes, and this can lead to the rapidly progressive demyelinating infection called PML. These lesions that develop in PML are typically located in the white matter, and they are most often multifocal. And this leads to the clinical manifestation of a combination of cortical and subcortical symptoms that evolve over weeks to months. And, unfortunately, if immune competence can't be restored quickly, then the disease is fatal within just a few months. And so that's really the core of the problem here, is that there is no effective direct antiviral treatment. And the only thing that works is restoring the immune system ability to control it, but that's often very difficult to do. When it's even possible, it's frequently just not even fast enough. And so you can see this even in situations where you'd think that we'd have an advantage, for example, in HIV-associated PML, where we do have effective antiretroviral therapy. Even there, restoring immune competence can sometimes just take too long relative to how quickly PML progresses. And so on top of all that, PML is really quite rare and is also remarkably heterogeneous because it can occur in very different patient populations from HIV to hematological malignancy to genetic immune deficiencies. And this rarity and heterogeneity really make both the diagnosis difficult and also treatment development quite difficult. Dr. Justin Abbatemarco: It's such a interesting story, and these different backgrounds really present different challenges. But at these last few years, this has been a success story in some way because we've seen so much effort and research into this rare disease space, which is encouraging. We mentioned this at the top, but there are immune checkpoint inhibitors that have at least been trialed for this T cell exhaustion to see if we can boost the immune system, and then more recently with your work around allogeneic-specific T cells to help clear the infection. What have you taken away from those updates? Dr. Irene Cortese: The biggest takeaway is that these two approaches, checkpoint inhibitors and Virus-Specific T Cells, have really transformed the way that we think about PML. So for decades, our only option was really to try to reverse the underlying immune suppressive condition and just hope that the immune system caught up in time. And now we have these two active strategies to try to speed this process up. Importantly, both these strategies have validated the same core hypothesis that even without a direct antiviral agent, we can improve PML outcomes by restoring effective antiviral immunity. And that said, each of these approaches has real limitations. So first of all, they don't work in all patients. And we have best estimates of success rates somewhere in the 50 to 60% range overall. With checkpoint inhibitors, the fundamental issue is that you're trying to unleash an immune response that has to already be there in some latent or exhausted form. For example, in patients with very advanced immune compromise where the T-cell compartment is essentially absent, there's just nothing left to invigorate, and so checkpoint blockade is really unlikely to help. And even when they do work, there is a real risk of exacerbating underlying autoimmune disease as well as the risk of leading to immune reconstitution inflammatory syndrome, or IRIS, where inflammation in the central nervous system of this immune system waking up and attacking the infection can actually lead to severe morbidity and even death in some patients. Virus-Specific T Cells have a whole different set of limitations. These are mostly practical and logistical at this point. Access is really the big one because there are only a handful of centers worldwide that can manufacture Virus-Specific T Cells. And so this just isn't something you can easily do everywhere or quickly. And also, biologically, every virus-specific T-cell product which is made from a different donor is essentially a different drug. And so it's really hard to predict how any given cell product will actually behave in a given patient. I should also mention that for both these approaches, they truly are still experimental. We don't have any controlled studies, and so most of what we're working from is really retrospective series and case reports. And we definitely have no head-to-head data. And so while we apply general principles estimating residual immune capacity or weighing the risk of exacerbating immune-mediated adverse events, we're really making individualized judgment calls rather than following an evidence-based algorithm. Dr. Justin Abbatemarco: And could you talk about those Virus-Specific T Cells? It's not something we use commonly in neurology. How do those work? And have they been used in other spaces successfully that we've been able to maybe apply some of those principles here? Dr. Irene Cortese: Yeah. So Virus-Specific T Cells were really first developed in the transplant setting, and they were essentially a way to bridge patients immediately following myeloablation. And in the period of time it took them to fully immune reconstitute a brand new immune system, it was a way to protect them from the common viral infections mostly that can develop in this time period and that led to such high morbidity and even mortality. And so the way this is done is that you basically take healthy lymphocytes from a healthy donor, and you can train them in vitro by ex vivo expansion and stimulation to basically become professional killers of the particular virus of interest so that, at the end of this expansion period, you basically have a enriched antiviral product that can be adoptively transferred to the patient recipient. And they may not last for a very long time, however, they can, especially with repeated infusions, provide the necessary immunity to bridge until definitive immune reconstitution is achieved. And so the initial experience with Virus-Specific T Cells was really against the various viruses that are so common in the post-transplant setting, like CMV, EBV, adenovirus, and also BK virus, which is a cousin, let's say, of the JC virus. And over time, the process for manufacturing Virus-Specific T Cells has become more and more streamlined. And so back as in 2015, 2017, we started to realize that perhaps these types of cell products might even be used to treat an acute infection and not just to administer in the setting of a planned transplant. And so essentially we've done exactly this, basically copied these manufacturing methods from the transplant world to make Virus-Specific T Cells against the JC virus and can then use them to treat PML. I should mention that BK virus is very similar in structure to the JC virus. And for that reason, what we learned early on when we started to apply Virus-Specific T Cells to the treatment of PML was that we could actually use Virus-Specific T Cells that were made against BK virus and successfully treat PML. More recent years, groups have been manufacturing JC virus-specific BST, but those BK Virus-Specific T Cells can still be used to treat PML. Dr. Justin Abbatemarco: That's really incredible. And it's so cool when we borrow things from these other fields to help inform rare diseases within neurology space. Maybe it's a perfect segue into the cases report in New England Journal of Medicine where you had two cases with inborn errors of immunity. You've utilized the strategy and then stem cell transplant. Walk us through those cases. What did you see? What did we learn from these that we can apply more broadly? Dr. Irene Cortese: Our paper really told the story of our experience of treating these two young men. Both of them had developed PML in the setting of an inborn error of immunity. One of them had DOCK8 deficiency, and he also had Sézary syndrome as a comorbid condition. And the second patient had a CD40 ligand deficiency. And for both these patients, we basically adopted the same strategy, which was to first try to gain control of the JC viral infection. And once that infection was actually under control, then we went ahead and proceeded to definitive

  4. Sep 21

    Primary Motor Cortex Involvement and Seizure Risk in Patients With Brain Metastases

    Dr. Kait Nevel talks with Drs. Ayal Aizer and Clara Baselga-Garriga about the link between primary motor cortex involvement in brain metastases and increased seizure risk, highlighting implications for patient management and future research directions.  Read the related article in Neurology®. Disclosures can be found at Neurology.org.

  5. Sep 17

    Marijuana Rescheduling: What It Means for Neurology Research and Care

    Dr. John Ney talks with Dr. Daniele Piomelli about the evolving role of cannabis in neurology, exploring its history, current research, and potential future applications. Read the related article in The New England Journal of Medicine.  Disclosures can be found at Neurology.org.

  6. Sep 14

    Integrating, Educating, and Implementing Systems of Care Around Brain Health - Part 2

    In part two of this two-part series, recorded at this year's AAN Annual Meeting, Dr. Gregg Day talks with Drs. Joel Salinas and Sarah Song about imperfect but practical brain health metrics, patient-centered assessment strategies, and future directions in brain health assessment.  Visit the newly launched BrainHealth.com to access trusted brain health information and stay informed.  Disclosures can be found at Neurology.org.    Show transcript:  Dr. Jose Merino: This is Jose Merino, Editor-in-Chief of the Neurology Family of Journals. The Neurology Podcast provides practical information to neurologists and other clinicians to help them provide better care for their patients. Thanks for listening, and have a great week. Dr. Stacey Clardy: Hi, this is your Podcast Editor, Stacey Clardy. Today we feature part two of the brain health discussion that took place at the AAN annual meeting a few months ago. If you have not yet, take a listen to part one from this past Thursday's podcast. For this episode, we pick up with the discussion focusing on plans for how to implement and measure effectiveness of brain health interventions, the sort we can all undertake easily in our clinic visits. And then, we wrap up the episode with comments and questions from the audience who were present at the Brain Health Talk. I hope you take away some inspiration and some ideas on how to encourage your patients to be proactive about protecting their brain. Thanks. Enjoy. Dr. Gregg Day: Hello, this is Gregg Day from Mayo Clinic, and welcome to this special conversation. Today's episode is recorded live at the Brain Health Hub during this year's AAN Annual Meeting in Chicago. Because it was recorded on site, the audio may sound a little different from our usual episodes, but bear with us because it's absolutely worth it. This panel discussion is totally aligned with AAN's mission of bringing brain health to all, and on point with the release of brainhealth.com, AAN's new website, bringing together our resources for clinical practice and for research in this space. We hope you enjoy this panel discussion as much as we enjoyed recording it. One thing that we acknowledge on the Brain Health Committee, one thing that the AAN is committed to fix as we move forward, there's a lack of validated brain health metrics and biomarkers when we talk about brain health. So what does it mean to be healthy? Or maybe a better question, what does it mean to be healthier than I was a year ago headed in the right direction or trending in the right direction? Joel, your thoughts, what should neurologists measure today, even if it's imperfect, that can help us move brain health from concept to more of an accountable practice? Dr. Joel Salinas: This point about imperfect is actually really critical. I think when we're thinking about measurements, there's a trap that we tend to fall into, which is trying to identify the perfect measurement. And I often see that as an excuse to not measure at all. And so, thinking about what is it that you can most practically take into account today. And there's so many different measures for so many different elements, and I would just encourage you to think about what's most relevant to the patient in that moment, and that would be the ideal tool. There's things like the PHQ-9. There's all these cognitive screening assessments. There's different measures related to cardiovascular risks that are out there. Even though none of those are perfect, right? None of those are perfect, we've been able to move healthcare forward quite a lot using these imperfect measures. So I would encourage you to find what is your toolkit of measures that are most helpful for you. Actually, one of my favorite measures, going back to sleep, is actually not metric itself. It's actually just asking, how are you sleeping? And getting that qualitative data because we forget that metrics don't have to be quantitative, they can be qualitative as well. We often will collect things like the GAD-7, the PHQ-9. There's a UCLA 3-item Loneliness Scale. But when I'm in clinic, I'll often just ask, "Have you been feeling lonely?" Or, "How often are you feeling lonely?" And that in and of itself gives you a lot of really valuable information. Dr. Gregg Day: Simply asking that question about physical, mental, social well-being and where do you think you are compared to last year? We've spent a lot of money, a lot of investment to try to develop a tool that performs better than asking someone directly, "Do you feel depressed?" It's hard to do that. So yeah, let's not forget our patients in the room as maybe the greatest arbitrators of that progress. Sarah, any other things that you're thinking of along these lines? Dr. Sarah Song: I still go back to what Joel was saying earlier about individualizing it to the patient and getting more details on something that they happen to mention about if they're feeling lonely or if they mention their sleep, and then delving further into that. As a stroke neurologist, what's really easy for me is I always ask how they're sleeping, I ask how their mood is, and I just go into the markers of depression that we all learn about that are not necessarily just mood. But I ask, obviously, how they're sleeping, how they're eating, do they have energy, what exercise are they doing, what therapy are they doing? And those for me are natural as part of the conversation of post-stroke, but that they touch upon a lot of the elements of brain health already. That's what's really key. Brain health isn't something new, it's actually something that we're already measuring and we're already looking for and we're already asking. Being able to put any sort of, I know it's not qualitative, but putting any sort of number to it or any sort of marker that we can use to measure it and even asking, "Last year you mentioned that you weren't sleeping very well. Do you think that you're sleeping better now or is it worse?" or, "What changed?" Right? Dr. Gregg Day: I think we're talking about setting goals with our patients that we can then ask, "Are we attaining those goals? Are we maintaining those goals?" We can begin that process together. That's really important, very practical. Thank you, guys. We talk about brain health, we talk about quality, and quality of evidence here, and we can appreciate that really matters and is challenged by the multitude of sources of evidence and various levels of quality that we have. Joel, you hit the nail on the head with this encouragement to not let perfect become the enemy of good. And so recognizing that, how do we navigate some of these challenges when we're talking about interventions that patients are bringing forward or maybe that we're interested in trying out? We think there might be some role for those, albeit imperfect. So how do we navigate the uncertainty while maintaining credibility and building trust with our patients about making these recommendations towards brain health? Dr. Joel Salinas: Neurology, in particular, we all develop an expertise in navigating uncertainty. When it comes to brain health, it's just bringing some of those tools and perspectives into that space as well, right? Because we're always talking about prognosis and what to expect and building trust with patients. They're not really looking for you to be certain. Right? They're looking for you to be honest about that uncertainty. The more you're able to actually very clearly articulate to them, "This is what we know about this, this is what we don't know, and this is directionally what we think is helpful." And that applies within the brain health space as well. Right? We don't have huge randomized clinical trials around all the different intervention. The U.S. POINTER study from last year was really helpful in pointing in that direction. From all the literature that we have, we do have a sense of direction. Maybe we don't know the magnitude of effect quite yet, but we can at least point people in the right direction towards things that can be most helpful for them. And then, couch it within how certain we are based off of the evidence. And I will say, most of the time that I bring up issues of uncertainty, patients will respect and trust more me as a clinician than I'm being honest about what I know and what I don't know, and how we're navigating things together. Dr. Gregg Day: Excellent advice. Do you want to add anything to that? Dr. Sarah Song: Neurology is a field that inherently has a lot of uncertainty. We have to be honest and truthful, and we have to listen to our patients. And ideally, we want to be able to promise just good things. Right? I always do caveat with strokes. I'm like, "We're going to do everything we can to help prevent another stroke. Nothing brings the risk down to zero, but we're going to do everything we can to move that needle in your favor." And being honest and truthful does go a long way, but you should never assume that you're God, and that you can fix everything. Nobody can. Dr. Gregg Day: There's that element of humility that we're all expressing here, which is very important. This is a great opportunity to hear from you guys. It can be a question for the panel, that's totally fine. It can be a story that you want to share, your own experience to brain health. Maybe it's the challenges that you're dealing with in clinic. Or maybe it's a success and just an incremental move in the right direction, something that you've already seen. So if you would like to share something, you just put up your hand, and be prepared to catch because this square is coming your way. That's the goal. So we're really hoping we get to see somebody actually catch this. Oh, here we go. Our first candidate, Dr. Lazar. Yes. Dr. Lazar: Hi, everyone. So PGY-3, neurology resident. And I recently did my rotation in Generative Psychiatry, and it was a very important case. We have a demented

  7. Sep 10

    Integrating, Educating, and Implementing Systems of Care Around Brain Health - Part 1

    In part one of this two-part series, recorded at this year's AAN Annual Meeting, Dr. Gregg Day talks with Drs. Joel Salinas and Sarah Song about the evolving landscape of brain health, practical approaches to incorporating brain health assessments into routine care, and the importance of collaboration across specialties. Visit the newly launched BrainHealth.com to access trusted brain health information and stay informed.  Disclosures can be found at Neurology.org.    Show transcript:  Dr. Jose Merino: This is Jose Merino, editor-in-chief of the Neurology Family of Journals. The Neurology Podcast provides practical information to neurologists and other clinicians to help them provide better care for their patients. Thanks for listening and have a great week. Dr. Gregg Day: Hello, this is Gregg Day from Mayo Clinic, and welcome to this special conversation. Today's episode was recorded live at the Brain Health Hub during this year's AAN Annual Meeting in Chicago. Because it was recorded on site, the audio may sound a little different from our usual episodes, but bear with us because it's absolutely worth it. In this conversation, our panel explores the evolving landscape of brain health, including growing use of wearables, digital tools, direct to consumer tests, and artificial intelligence. We discuss how neurologists can help patients to navigate brain age scores, consumer health data, and emerging technologies while integrating brain health into everyday clinical care. This panel discussion is totally aligned with AAN's mission of bringing brain health to all, and on point with the release of brainhealth.com, AAN's new website, bringing together our resources for clinical practice and for research in this space. We hope you enjoy this panel discussion as much as we enjoyed recording it. We appreciate people joining this special session on integrating, educating, and implementing systems of care around brain health for the practicing neurologist. I've got a great team of practicing neurologists here as well. We're looking forward to sharing some of this discussion with lots of opportunities for questions as well. And we're going to kick into the contact right away. I'm Gregg Day. I'm a behavioral neurologist at Mayo Clinic in Florida. I'm joined by Joel Salinas and Sarah Song. I'm going to let them introduce themselves and then I'll provide a bit of scope for our discussion. Dr. Joel Salinas: Great. Thank you, Gregg. So I'm Joel Salinas. I'm a behavioral neurologist, and then I'm also a clinical associate professor of neurology at NYU Langone Health. Dr. Sarah Song: My name is Sarah Song. I'm a stroke neurologist here at Rush University in Chicago, and my favorite job is at the editor-in-chief of Brain and Life, soon to be brainhealth.com. Dr. Gregg Day: Over the past few years, the AAN has definitely taken a clear and very intentional position. Brain health is part of the central nervous system of our academy. It is not meant to be on the periphery, and it's going to become increasingly central to what we do in our practice. And so along with that call, we're really seeing this shift in our field being called to move beyond simply episodic disease management towards a launch of a comprehensive brain health platform and a development of a shared definition of brain health, which we want to conceptualize as this continuous state of attaining and maintaining optimal neurological function to meet the needs of our patients. So this vision raises some real questions in clinical practice. What does preventive neurology look like when we integrate it into our clinic visit? How do we integrate health screening into the clinic visit? We all have time constraints and we're going to be honest and open about that. And what's the future? How do we start educating people on how to actually do this in practice? And maybe even a little bit more challenging, how do we address some of those social structural problems that are often a bit beyond our immediate control, but we all know are critically important here? So today we're going to talk about some of these questions head on. We do want this to be a bit of a dialogue. We want to invite perspectives. We want to hear other perspectives from the audience as well. And we're not here to debate whether brain health is important. I'm going to argue if you're sitting here joining us, you already know why it's important. And if you don't think it's important, you're in the wrong place, but that's okay. Instead, we're going to focus on some of the realistic challenges and maybe strategies to address this. And this key question, what's the AAN going to look like if we're successful in this mission moving forward? So I've asked Joel and Sarah not just to share successes here, but we're going to be candid about the challenges. And so some of these things we just don't know yet about, but we do recognize what we need to be doing to move things forward. And we're going to begin by reframing the neurologist's role in brain health and what that shift means for the people that we care for. So as we've said, the AAN has a definition of brain health. It's changing our view on clinical practice on research and education. So love to hear from Sarah first on your perspective on how this definition has changed or maybe challenged your role as a neurologist in day-to-day practice. Dr. Sarah Song: So I think as a stroke neurologist, my biggest challenge was moving from a reactive to a proactive preventive situation. So I see people on their worst day when they're having a stroke in the hospital, in the ER. I show up and the effects of whatever they've been doing to their brain has ultimately reached some sort of conflict. I think in that sense I was always, okay, how do we prevent a recurrent stroke? But less so thinking on the front end, less so thinking about the lifespan. When we talk about brain health, it starts from prenatal all the way to senescent. It doesn't start when you're 75 and you show up in the ER and I meet you. It should really be starting before you have disease. What can we do upfront? What can we tell your mother before you're even born? So that was the biggest takeaway for me was thinking not just reactive, but proactive, preventive. Dr. Gregg Day: Expanding the scope for sure. Joel, what would you like to add to that? Dr. Joel Salinas: Yeah, with this definition of brain health, which bears repeating again, and it's like over here on one of the posters over here, it's a continuous state of attaining and maintaining the optimal neurologic function that best supports one's physical, mental, and social wellbeing through every stage of life. And as a neurologist, I'm coming from the lens of a behavioral neurologist, it can seem a little overwhelming to feel like you have to now tackle all these different elements of a person's care, but it's really just more than anything reframing something that we've already been doing in practice, which is really claiming responsibility over helping to prevent disease, prevent risks, managing those risks, really being much more proactive. And it's a little bit more of a public health framing, but it's helpful to really claim that responsibility of things that happen before the patient presents in the hospital in the acute state. And there's so much that we can do, which I know we'll get to, but it's an important framing for neurologists in particular to own. Dr. Gregg Day: And this emphasis on prevention, obviously very important. That's the best way to manage disease is going to be to prevent it, certainly best for our patients. But Sarah, as you pointed out, the lifespan perspective isn't within any one of our reaches. So of course the importance of working as a team. Thankfully, we have amazing representation of neurologists here at the AAN, and we all have our own contacts, people that we work with, and so can broaden this mission. Thinking about preventive neurology though, this implies this earlier, broader, sometimes non-traditional interventions to improve our patient's ability to maintain and attain the function that they need. So Sarah, what aspects of brain health promotion feel most natural for you in your clinical environment? Maybe which are some of the areas where you think as a field or as a neurologist, we're going to have more struggles or we're going to hesitate? Dr. Sarah Song: So think as a stroke neurologist, the first thing that really comes up is risk factor management. You both were essential in creating the safest brains, and I'll just refer to some of it. I'll let you guys talk more about that. But for me, it's blood pressure. Above and beyond anything, blood pressure causes strokes of hemorrhagic and ischemic strokes. So talking about risk factor control, especially blood pressure. And then the other one that among risk factor control, just there are so many other risk factors that contribute to stroke. More interesting to me though is the other end, the things that I don't think neurologists are comfortable with. So the addressing mental health, for example. Mental health is something that we learn about, of course, in neurology. We do psychiatry rotations, but we're not necessarily equipped with all of the medication wherewithal or the social strategies that we can use to help so with mental health. And I also think in that same sense, we're not necessarily given the tools to deal with the disparities in health, so socioeconomic disparities that really do affect brain health outcomes as we've learned. So approaching those sorts of situations that we're not comfortable and finding a solution upfront, whether in training or whether in CME or something like that, that we can become more proficient in will actually help us to become more of a well-rounded brain health practitioner. Dr. Gregg Day: And you referenced the safest brains. And Joel, thank you for joining the team in w

  8. Sep 7

    Bridging the Artificial Intelligence Training Gap

    Dr. Justin Abbatemarco talks with Drs. Sara Marceglia and Alberto Priori about the use of artificial intelligence in neurology training, highlighting the need for formal curricula, ethical considerations, and practical applications in clinical practice. Read the related article in Neurology® Education. Disclosures can be found at Neurology.org.

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About

The Neurology Podcast provides practical information for neurologists and clinicians to practice the best possible medicine for patients. Examining methods and findings in peer-reviewed journals, the show provides insights that impact clinical practice and patient care. From the journal Neurology and the American Academy of Neurology, providing education and expert analysis since 2007.

Information

  • Creator
    American Academy of Neurology
  • Years Active
    2007 - 2026
  • Episodes
    1.4K
  • Rating
    Clean
  • Copyright
    © 2019
  • Show Website
    Neurology® Podcast

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