Monthly Archives: April 2012

Today marks the end of the 2012 American Academy of Neurology annual meeting. I spent this past week (also my final week of vacation as a junior neurology resident) attending courses and lectures, perusing posters, meeting other neurologists, and trying to absorb as much neurology as possible in this short amount of time. AAN hosts the largest conference for neurologists around the world and is typically attended by 10,000 to 20,000. While some of the more advanced and groundbreaking science may gravitate toward the specific subspecialty society conferences (e.g. stroke, epilepsy, etc.), this conference is a fantastic opportunity for neurology residents to broaden their perspectives on the field.

These are the highlights from my week at the AAN annual meeting:

[1] Acute Central Nervous System Infections – Infectious Diseases – This course organized by Larry David of the U. of New Mexico provided a brief overview of acute meningitis and encephalitis, the approach to diagnosis and treatment of these diseases, and the practical wisdom and experience used to help one differentiate between various syndromes. In particular, I found value in the emphasis on poor sensitivity of the classic signs of meningitis in elderly patients, the relatively high incidence of undetected nosocomial and multi-drug resistant meningitis in ICU patients with fever and altered mentation, the use of fluid resuscitation in preventing cerebral ischemia in meningitis, and an outlining of an approach to selecting diagnostic tests in encephalitis.

[2] Stroke in Children and Neonates – Vascular Neurology – This course organized by Lori Jordan of Vanderbilt University spanned the current body of knowledge on pediatric stroke as well as provided insight on the interventional trials being pursued, including the use of intravenous thrombolysis in acute stroke in children. While this course was primarily for the benefit of my wife (who is training as a pediatric neurologist), it was interesting to see what lessons the pediatric neurologists drew from the experience of adult stroke neurologists. In particular, the notion that stroke units (one of two interventions in acute stroke that has evidence for outcome benefit, the other being intravenous thrombolysis) were developed as a result of the use of IV tPA (a medication with limited effectiveness and very limited use throughout the country) is an interesting perspective.

[3] Catching up with Tulane’s Neurology department – It was nice having a few hours to catch up with Sheryl Martin-Schild (the director of the Stroke Program at Tulane University Medical Center) and some of the residents and attendings of the Neurology department, the program within which my interest in neurology initially developed. When I was a student, the department was in a state of recovery but appears to be growing quite nicely now. Perhaps not entirely surprisingly (given the high number of acute stroke and hemorrhage cases), several of the residents are pursuing further training in critical care.

[1] Presidential Plenary Session – Stroke Prevention – While there were several interesting talks at this session, the one of greatest relevance and interest to me was a relatively straightforward statement by Ralph Sacco who recently stepped down as the President of the American Heart/Stroke Association, the first neurologist to hold that position. He spoke at length about both medical and lifestyle risk factors for stroke. He made the logical statement that racial/ethnic disparities in long-term stroke outcomes can be eliminated by addressing these risk factors, and he showed the evidence to prove this.

[1] Neurotoxicology – General Neurology, Neuromuscular – This was a very interesting talk organized by Herbert Schaumberg of the Albert Einstein College of Medicine that introduced me to several clinical entities I was not well aware of before including cobalt neurotoxicity from metal-on-metal hip prostheses, drug-induced myoclonus in end stage renal disease (including with gabapentin, morphine, and even propofol), bismuth myoclonic encephalopathy, and fibrous myopathy from intramuscular injections. I also finally learned how to differentiate between ciguatera and scromboid toxins.

[2] Contemporary Issues Plenary Session – Immunology, Vascular Neurology – 500 cases of NMDA encephalitis, Imaging in Acute Stroke – Any talk claiming data on the outcomes for over 500 patients with NMDA encephalitis can easily capture the interest of a room full of neurologists, which this one did – a very, very large room. The other talk that caught my interest was a brief discussion by Maarten Lansberg of Stanford University of the current imaging modalities used in acute stroke. While this talk did not provide much new data, it was refreshing to have a focused review of the current recommended approach to using noncontrast CT scans, perfusion imaging, vessel imaging, and MRI in the acute setting.

[3] Neuro-Ophthalmology and Vestibular Lab – The examination of the eyes is one of the hardest parts of the neurologic examination, and I recognize this as one of the areas where I need a great deal more practice and refinement. Fortunately, this session was there to serve this need. While the lab/workshop sessions are relatively expensive, this provided me with very useful practical knowledge and skills, more so than any other session during this conference. The workshop had about a dozen stations where those taking the course could work directly with experienced neuro-ophthalmologists to refine examination skills, develop methodical approaches, and pick up a few new maneuvers. For me, I was able to refine confrontational visual field testing, the head impulse maneuver, the Dix-Hallpike and Epley maneuvers, and pupillary reaction testing, and I furthermore learned a few new methods of demonstrating psychogenic vision loss.

[1] Neurologic Complications of Medical Disease – General Neurology, Neuromuscular, Vascular Neurology – This course organized by Neeraj Kumar of the Mayo Clinic was a very neat and extensive session covering a variety of medical conditions. I took this course knowing that next year as a senior neurology resident I will be running the consult services and will have greater involvement in directing the care of patients without primary neurologic disease but with severe neurologic deficits and symptoms related to the dysfunction of other organ systems. The course provided overviews of rheumatologic diseases causing peripheral nervous system dysfunction, neurosarcoidosis, nutrient deficiencies, gastrointestinal diseases with neurologic symptoms, systemic malignancies and cancer treatments causing neurologic dysfunction, and finally systemic diseases causing ischemic stroke and intracerebral hemorrhage.

[1] Practical Issues with Botulinum Toxin Use in Neurology – Movement Disorders – I have had no direct experience thus far as a resident with the use of botulinum toxin in neurologic conditions, so I took this course with the hope of having an introduction to its use. Furthermore, as a junior resident with predominantly inpatient ward duties, I have minimal exposure to neurologic movement disorders (which is an outpatient subspecialty within neurology). One major caveat for this course was that the various speakers all had several financial conflicts of interest related to the pharmaceutical companies that manufacture formulations of botulinum toxin; many off-label uses of the medications were discussed. Nonetheless, I particularly found value in the introduction to various dystonias and an overview of the different presentations of spasticity after stroke. Listening to one of the principal investigators for the trials related to botulinum toxin as a therapy for chronic migraine was also very interesting, particularly in his discussion of the pathophysiology and the distinctions he made between chronic migraine and other types of chronic headache (chronic tension-type headache, rebound analgesia).

I presented at AAN two years ago as a medical student. I only had enough time and money to present my work and did not get to explore much to the conference’s many educational resources. This time, my goals were focused entirely on education and broadening my own perspectives, with regards to differential diagnosis (learning about less common clinical entities), approaches to diagnosis and treatment, and the development of a career pathway. For numerous reasons, I wish that all residency programs would send their residents to AAN every year as it is a fantastic opportunity for growth and learning.

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