Artificial intelligence in neurology: opportunities, challenges, and policy implications.

Neurological conditions are the leading cause of disability and mortality combined, demanding innovative, scalable, and sustainable solutions. Brain health has become a global priority with adoption of the World Health Organization's Intersectoral Global Action Plan in 2022. Simultaneously, rapid advancements in artificial intelligence (AI) are revolutionizing neurological research and practice. This scoping review of 66 original articles explores the value of AI in neurology and brain health, systematizing the landscape for emergent clinical opportunities and future trends across the care trajectory: prevention, risk stratification, early detection, diagnosis, management, and rehabilitation. AI's potential to advance personalized precision neurology and global brain health directives hinges on resolving core challenges across four pillars-models, data, feasibility/equity, and regulation/innovation-through concerted pursuit of targeted recommendations. Paramount actions include swift, ethical, equity-focused integration of novel technologies into clinical workflows, mitigating data-related issues, counteracting digital inequity gaps, and establishing robust governance frameworks balancing safety and innovation.

Global synergistic actions to improve brain health for human development.

The global burden of neurological disorders is substantial and increasing, especially in low-resource settings. The current increased global interest in brain health and its impact on population wellbeing and economic growth, highlighted in the World Health Organization's new Intersectoral Global Action Plan on Epilepsy and other Neurological Disorders 2022-2031, presents an opportunity to rethink the delivery of neurological services. In this Perspective, we highlight the global burden of neurological disorders and propose pragmatic solutions to enhance neurological health, with an emphasis on building global synergies and fostering a 'neurological revolution' across four key pillars - surveillance, prevention, acute care and rehabilitation - termed the neurological quadrangle. Innovative strategies for achieving this transformation include the recognition and promotion of holistic, spiritual and planetary health. These strategies can be deployed through co-design and co-implementation to create equitable and inclusive access to services for the promotion, protection and recovery of neurological health in all human populations across the life course.

The Neurology-Stability-Epidural compression assessment: A new score to establish the need for surgery in spinal metastases.

OBJECTIVE: The aim of this study was to translate new evidence about management of spinal metastases in a practical and reliable score for surgeons, radiation oncologists and oncologists, able to establish the need for surgery regardless the available technology and settings. PATIENTS AND METHODS: Three main items were identified and graded: Neurological status (0-5 points), Stability of the spine according to the Spinal Instability Neoplastic Score (SINS) Score (0-5 points), and Epidural compression according to the Epidural Spinal Cord Compression (ESCC) scale (0-3 points). Patients were considered suitable for surgery with ASA score < 4 and ECOG score <3. A retrospective clinical validation of the NSE score was made on 145 patients that underwent surgical or non surgical treatment. RESULTS: Agreement between the undertaken treatment and the score (88.3% of patients), resulted in a strong association with improvement or preservation of clinical status (neurological functions and mechanical pain) (p < 0.001) at 3 and 6 months. In the non-agreement group no association was recorded at the 3 and 6 months follow-up (p 0.486 and 0.343 for neurological functions, 0.063 and 0.858 for mechanical pain). CONCLUSION: Functional outcomes of the study group showed that the proposed NSE score could represent a practical and reliable tool to establish the need for surgery. Agreement between the score and the performed treatments resulted in better clinical outcomes, when compared with patients without agreement. Further validation is needed with a larger number of patients and to assess reproducibility among surgeons, radiation oncologists, and oncologists.

Rapid implementation of virtual neurology in response to the COVID-19 pandemic.

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 neurologic 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.

Teleneurology during the COVID-19 pandemic: A step forward in modernizing medical care.

BACKGROUND: The COVID-19 pandemic mandated rapid transition from face-to-face encounters to teleneurology visits. While teleneurology is regularly used in acute stroke care, its application in other branches of neurology was limited. Here we review how the recent pandemic has created a paradigm shift in caring for patients with chronic neurological disorders and how academic institutions have responded to the present need. METHOD: Literature review was performed to examine the recent changes in health policies. Number of outpatient visits and televisits in the Department of Neurology was reviewed from Yale University School of Medicine and Johns Hopkins School of Medicine to examine the road to transition to televisit. RESULTS: The federal government and the insurance providers extended their supports during the COVID-19 pandemic. Several rules and regulations regarding teleneurology were revised and relaxed to address the current need. New technologies for video conferencing were incorporated. The transition to televisits went smoothly in both the institutions and number of face-to-face encounters decreased dramatically along with a rapid rise in televisits within 2 weeks of the declaration of national emergency. CONCLUSION AND RELEVANCE: The need for "social distancing" during the COVID-19 pandemic has created a major surge in the number of teleneurology visits, which will probably continue for the next few months. It may have initiated a more permanent transition to virtual technology incorporated medical care.

A Simple, Objective, and Mathematical Grading Scale for the Assessment of Facial Nerve Palsy.

OBJECTIVES: It is imperative to acquire a simple, objective, and mathematical method for the assessment of facial nerve palsy which can be universally accepted and implemented. A grading scale which is convenient, continuous and economical was attempted for the first time for global and region-specific assessment of facial nerve palsy. STUDY DESIGN: Hospital-based observational study. SETTING: Medical college hospital. PATIENTS: Ten normal subjects and 51 patients with facial paralysis. INTERVENTIONS: Patients with facial nerve palsy were graded according to the revised version of House-Brackmann grading system (HBGS-2) and a newly proposed grading system. MAIN OUTCOME MEASURES: The results of the present study were compared with the HBGS-2. Data were analyzed using SPSS-17 (IBM Corporation, New York) for descriptive statistics, normality test, Wilcoxon signed-rank test, and Mann-Whitney U test. RESULTS: The mean time spent on recording measurements was 288 seconds. For the new method and HBGS-2, the modes were graded 3 and 4, corresponding to incomplete facial paralysis. The Kolmogorov-Smirnov normality and Wilcoxon signed rank tests were found significant. In Mann-Whitney U test, probability value indicated that grades of new scale were similar to grades of HBGS-2. CONCLUSION: The proposed simple, objective and mathematical (SOM) method of grading facial nerve palsy is convenient and provides global and regional continuous percentage that can monitor the progress and classify the patients with facial paralysis into six-point grades based on severity. This system was having substantial compatibility with HBGS-2 grading. For further validity, multi-center study with a larger sample of patients would be required.

Assessing Deaf patients in the neurology clinic.

There are over 87 000 Deaf people in the UK with British Sign Language (BSL) as their first language.1 Few healthcare professionals receive training in Deaf awareness or in BSL, and missed diagnoses and inadequate treatment of Deaf patients are estimated to cost the National Health Service £30 million per year.2 Neurologists are likely to encounter Deaf BSL users in their practice, but without prior experience may find consultations challenging, especially within the time constraints and pressure of a standard clinic. In this article, we provide guidance on consulting with Deaf people in a neurology clinic, drawing on experience from our cognitive clinic for Deaf BSL users where effective communication is essential.

The establishment of in-house neurology driven therapeutic plasma exchange infrastructure in a resource-limited public hospital in Malaysia: Adopting and integrating evidenced-based health care technology through time.

There has been an increase in the use of therapeutic plasma exchange (TPE) in immune-mediated neurological disorders in recent years. However, accessibility and availability of TPE remains low and costly, especially for a country with limited healthcare funding like Malaysia. With expanding clinical indications in neurological disorders, and increasingly expensive conventional immunomodulatory treatment such as intravenous immunoglobulin and monoclonal antibodies, TPE remains an effective part of first or second-line treatment. In this article, we detailed the historical aspects of the use of TPE in neurological disorders in Malaysia over the last four decades and discussed the challenges behind the establishment of the first in-house neurology-driven TPE service in the country. Local TPE database from a national neurology centre in Kuala Lumpur over the past 20 years was analyzed. We observed a remarkable three folds increase in the use of TPE at our center over the past 10 years (total 131 TPE treatments) compared to a decade prior, with expanding clinical indications predominantly for central nervous system demyelinating disorders. Besides using membrane filtration method, centrifugal technique was adopted, providing new opportunities for other clinical beneficiaries such as a neurologist driven "in-house TPE unit". However, there were real world challenges, especially having to provide services with limited funding, human resources, and space. In addition, much has to be done to improve accessibility, availability, and sustainability of TPE services at our center and nationwide. Nevertheless, even with limited resources and support, it is possible with concerted efforts to work within the confines of these limitations to establish a safe, successful, and sustainable TPE service.

[Questionnaire for the assessment of the voice self-concept in a neurological practice : Applicability for the identification of patients with high consultation needs]. / Fragebogen zur Erfassung des stimmlichen Selbstkonzepts in einer Nervenarztpraxis : Anwendbarkeit zur Identifikation von Patienten mit hohem Beratungsbedarf.

INTRODUCTION: Hoarseness occurs as a symptom of a multitude of neurological diseases. The importance people attribute to their voice differs greatly and it seems advisable to take this into account during consultation. The Questionnaire for the assessment of the voice self-concept (FESS) is able to measure this importance. The aim of this study was to determine the applicability of the FESS in a neurological and psychiatric medical practice. MATERIAL AND METHODS: A total of 556 patients of a neurological and psychiatic medical practice completed the FESS and the severity of hoarseness was measured objectively by means of the Acoustic Voice Quality Index (AVQI). Another 75 patients only completed the questionnaire. The value distribution of the questionnaire, the correlation with age and gender, the voice quality as well as the daily strain on the voice were investigated. RESULTS: The value distribution ranges of all three scales of the FESS are completely utilized. Floor and ceiling effects do not play a relevant role. Gender and age do not seem to be of significance. The influence of the measurable voice quality is minor. In contrast a correlation between voice self-concept and the daily voice strain was detected. DISCUSSION: The FESS has the potential to be an interesting instrument for the measurement of the subjective importance of a patient's voice. Here reference values are generated, against which individual results can be correlated. The AVQI provides an inexpensive fast instrument for the objective measurement of hoarseness in a neurological and psychiatric medical practice.

An Electrophysiology Protocol to Measure Reward Anticipation and Processing in Children.

We present a protocol designed to measure the neural correlates of reward in children. The protocol allows researchers to measure both reward anticipation and processing. Its purpose is to create a reward task that is appropriate for young children with and without autism while controlling reward properties between two conditions: social and nonsocial. The current protocol allows for comparisons of brain activity between social and nonsocial reward conditions while keeping the reward itself identical between conditions. Using this protocol, we found evidence that neurotypical children demonstrate enhanced anticipatory brain activity during the social condition. Furthermore, we found that neurotypical children anticipate social reward more robustly than children with autism diagnoses. As the task uses snacks as a reward, it is most appropriate for young children. However, the protocol may be adapted for use with adolescent or adult populations if snacks are replaced by monetary incentives. The protocol is designed to measure electrophysiological events (event-related potentials), but it may be customized for use with eye-tracking or fMRI.

Exome sequencing in adult neurology practice: Challenges and rewards in a mixed resource setting.

OBJECTIVE: To share the experience of next-generation sequencing (NGS) in delineating molecular basis of neuro-genetic disorders in adults of Indian origin. PATIENTS AND METHODS: Adults (aged ≥18 years) evaluated in a single neurology unit at a tertiary-care teaching hospital between August 2014 and September 2016, underwent NGS for (i) sporadic occurrence of neurological disorder where an extensive search did not reveal an acquired cause or (ii) familial or sporadic, uncommon, seemingly genetic disorder where single monogenic cause could not be ascertained based on phenotype. Presence of pathogenic/ likely-pathogenic variants, novel genetic variants, and novel phenotype associations were noted. RESULTS: Clinical phenotypes included: neuromuscular (n = 14), extrapyramidal (n = 8), ataxia (n = 7), leukoencephalopathy (n = 6), spastic paraplegia (n = 5), stroke (n = 4), progressive myoclonic epilepsy (n = 1) and epilepsy with developmental delay (n = 1). Fifty-eight variants were identified in 43 genes in 34 patients, that included 15 (25.9%) reported variants. Genetic diagnosis could be established in 14 (30.43%) subjects. Six probands (13%) harboured previously unreported variants in a clinically relevant gene. Nine probands harboured unreported variants in two or more different genes associated with the clinical phenotype. In three probands we noted novel associations between the phenotype and genetic variation. In all patients, genetic diagnosis impacted treatment and prognostication. CONCLUSIONS: We present data of NGS in adults with suspected neuro-genetic disorders from India and this is the first report of its kind. It sets a platform for further basic science research to validate 'novel' variants and those of 'uncertain significance' as pathogenic or otherwise with specific reference to Indian ethnicity.

Neuro-ophthalmologic assessment and investigations in children and adults with cerebellar diseases.

In this chapter, we present the bedside assessment and laboratory tests that are available for the neuro-ophthalmologic evaluation of children and adults with cerebellar diseases. In the evaluation of a patient with cerebellar dysfunction, recognizing the pattern of ocular motor and / or vestibular impairment is often a key step to the correct diagnosis. The cerebellum is very important in processing a wide range of different eye movements, including angular vestibulo-ocular reflexes, otolith-ocular reflexes, fixation and gaze holding, smooth pursuit eye movements, saccadic eye movements, optokinetic response, ocular alignment, and vergence. Quantitative eye movement recording is now widely available in specialized clinics and medical practices, especially for testing the vestibulo-ocular reflexes. We describe the approach for assessing specific eye movements linked to cerebellar function, discuss appropriate eye movement laboratory tests, and summarize recent related research findings. In addition, for each laboratory test, we discuss its advantages, disadvantages, indications, and interpretations. Furthermore, we provide differential diagnoses for specific ocular motor and vestibular abnormalities such as slow saccades or impaired vestibulo-ocular reflexes.

The Global Neurological Burden of Tuberculosis.

Central nervous system (CNS) involvement of tuberculosis (TB) is the most severe manifestation of TB and accounts for approximately 5 to 10% of all extrapulmonary TB (EPTB) cases and approximately 1% of all TB cases. TB meningitis (TBM) is the most common form of CNS TB, though other forms occur, often in conjunction with TBM, including intracranial tuberculomas, tuberculous brain abscesses, and spinal tubercular arachnoiditis. CNS TB often presents with nonspecific clinical features that mimic symptoms of other neurological conditions, often making diagnosis difficult. Defining neuroimaging characteristics of TBM include thick basal meningeal enhancement, hydrocephalus, and parenchymal infarctions most commonly involving the basal ganglia and internal capsule. Traditional cerebrospinal fluid sample analysis frequently requires lengthy times-to-result and have low sensitivity. Given the pitfalls of conventional CNS TB diagnostic methods, various molecular-based methods, including immunoassays and polymerase chain reaction (PCR)-based assays have emerged as alternative diagnostic tools due to their rapidity, sensitivity, and specificity. Expert panels on TBM have recently emphasized the need for standard research procedures with updated case definitions and standardized study methods, which will hopefully pave the way for more robust multicenter international studies. In this article, we review the epidemiology, diagnosis, molecular factors associated with disease presentation and outcome, and treatment of CNS TB.

Impact of Stroke Call on the Stroke Neurology Workforce in the United States: Possible Challenges and Opportunities.

BACKGROUND: The Stroke & Vascular Neurology Section of the American Academy of Neurology was charged to identify challenges to the recruitment and retention of stroke neurologists and to make recommendations to address any identified problems. The Section initiated this effort by determining the impact of stroke on-call requirements as a barrier to the recruitment and retention of vascular neurologists. METHODS: This is a cross-sectional survey of a sample of US Neurologists providing acute stroke care. RESULTS: Of the 900 neurologists who were sent surveys, 313 (35%) responded. Of respondents from institutions providing stroke coverage, 71% indicated that general neurologists and 45% indicated that vascular neurologists provided that service. Of those taking stroke call, 36% agreed with the statement, "I spent too much time on stroke call," a perception that was less common among those who took less than 12-hour shifts (P < .0001); 21% who participated in stroke call were dissatisfied with their current job. Forty-six percent indicated that their stroke call duties contributed to their personal feeling of "burnout." CONCLUSIONS: Although the reasons are likely multifactorial, our survey of neurologists providing stroke care suggests that over-burdensome on-call responsibilities may be contributing to the vascular neurology workforce burnout and could be affecting recruitment and retention of vascular neurologists. Strategies to reduce the lifestyle impact of stroke call may help address this problem.

Working plan for the use of patient-reported outcome measures in adults with brain tumours: a Response Assessment in Neuro-Oncology (RANO) initiative.

The Response Assessment in Neuro-Oncology-Patient-Reported Outcome (RANO-PRO) working group is an international multidisciplinary collaboration that provides guidance on the use of patient-reported outcome (PRO) measures in clinical trials and practice for adult patients with brain tumours. Findings from both PROs and traditional outcome measures, such as survival, and clinical or radiological response, are essential to inform the research community, policy makers, physicians, and patients in the treatment decision-making process. Previous initiatives in oncology have focused on guidelines concerning the collection, analysis, interpretation, and reporting of PRO data. However, we recommend the application of appropriate PRO instruments, with respect to its content and measurement properties (ie, research question, content validity, and other measurement properties), in brain tumour research. PROs should be well defined and reliable to generate high-quality evidence, and our recommendations on the use of specific PRO measures could help to improve the quality of PRO evidence derived from neuro-oncological studies, and might add a new dimension in how the value of therapeutics is assessed in patients with brain tumours. In this Policy Review, we present the RANO-PRO working plan for the use of PROs in adults with brain tumours.

Telehealth applications for outpatients with neuromuscular or musculoskeletal disorders.

Telehealth describes the provision of medical services remotely through technology, and may enhance patient access to specialty care services. Although teleneurology has expanded widely since the introduction of telestroke in 1999, telehealth services for outpatients with neuromuscular or musculoskeletal disorders are less widespread. In this narrative review, we will describe the current technology, applications, outcomes, and limitations of this dynamically growing field. Evidence for telehealth applications related to neuromuscular diseases, palliative care, specialized multidisciplinary services, and musculoskeletal care are reviewed. With growing demand for specialized services and finite resources, telehealth provides a promising avenue to promote access to high-quality care, decrease the cost and burden of travel for patients, and with the expansion of software to personal computing and mobile devices, offer flexible, low-overhead practice opportunities for clinicians. Providers embarking on careers in telehealth should be aware of current legal restrictions impacting care to minimize risk and avoid liability. Muscle Nerve 58: 475-485, 2018.