The Role of the Neurological Examination in Primary Care Referrals to Neurology.

Low confidence with the neurological examination may contribute to primary care physicians' discomfort with neurology and a low threshold to refer patients. We surveyed primary care physicians in Quebec about their last three referrals to neurology to evaluate what role the neurological examination played in their decision. Twenty-six physicians answered concerning 73 patient referrals. We found that primary care physicians use the neurological examination to reinforce their decision but rarely depend on the findings. Our results suggest that improving history-taking rather than examination skills may have more impact on neurology referrals, influencing quality of referral information above quantity of referrals.

Education Research: Qualitative Assessment of Virtual Teaching of the Neurological Examination to Students Reveals Importance of Technique, Process, and Documentation.

Introduction: Virtual teaching sessions during the coronavirus disease 2019 pandemic were challenging for students and teachers but were also an opportunity to find creative ways to teach physical examination skills, including the neurologic examination. We examined expert opinions of the pros and cons that arise using a virtual platform to teach the neurologic examination and strategies to best address these challenges. Methods: This was a qualitative study incorporating a focus group of faculty and resident neurologists. Data were coded using conventional content analysis. An interpretivist, social constructionist approach was used to look for interesting or novel ideas, rather than testing a specific hypothesis. Three independent auditors performed a dependability and confirmability audit to confirm that the themes accurately reflected the data. Results: A single focus group was used. Four of the 6 participants were faculty neurologists and 2 were neurology residents. Five themes were identified: (1) learning the neurologic examination is complex, (2) lack of physical contact is the most important drawback of virtual teaching, (3) virtual teaching can effectively emphasize the organization of the examination, (4) virtual sessions can facilitate combined teaching of technique and demonstration of abnormalities, and (5) virtual platforms do not necessarily imply reduced participation. Conclusion: Teaching the neurologic examination is a multifaceted process that should emphasize not only technique but also an overall approach to performing and documenting the examination. Many aspects of the neurologic examination can be appropriately taught virtually using various strategies, although there may always be some limitations. Virtual education can play a useful role for future curriculum design and global education.

Insular Involvement in Cases of Epilepsy Surgery Failure.

BACKGROUND: Epilepsy surgery failure is not uncommon, with several explanations having been proposed. In this series, we detail cases of epilepsy surgery failure subsequently attributed to insular involvement. METHODS: We retrospectively identified patients investigated at the epilepsy monitoring units of two Canadian tertiary care centers (2004-2020). Included patients were adults who had undergone epilepsy surgeries with recurrence of seizures post-operatively and who were subsequently determined to have an insular epileptogenic focus. Clinical, electrophysiological, neuroimaging, and surgical data were synthesized. RESULTS: We present 14 patients who demonstrated insular epileptic activity post-surgery-failure as detected by intracranial EEG, MEG, or seizure improvement after insular resection. Seven patients had manifestations evoking possible insular involvement prior to their first surgery. Most patients (8/14) had initial surgeries targeting the temporal lobe. Seizure recurrence ranged from the immediate post-operative period to one year. The main modality used to determine insular involvement was MEG (8/14). Nine patients underwent re-operations that included insular resection; seven achieved a favorable post-operative outcome (Engel I or II). CONCLUSIONS: Our series suggests that lowering the threshold for suspecting insular epilepsy may be necessary to improve epilepsy surgery outcomes. Detecting insular epilepsy post-surgery-failure may allow for re-operations which may lead to good outcomes.