Brain Diseases From Bench to Bedside Report

April 12-13, 2018, Moscow
By Peter Sandercock

The meeting, organized by Profs. Eugene Gusev and Alla Guekht, focused on the recent developments in translational research and treatment innovations in cerebrovascular diseases, epilepsy, cognitive impairment and dementia, depression, demyelinating diseases, and others. It was held at the Buyanov City Clinical hospital, and was organized in partnership with the following institutions: Ministry of Health of The Russian Federation, Russian Academy of Sciences, Moscow Healthcare Department, Pirogov Russian National Research Medical University, World Stroke Organization, European Stroke Organization, World Federation of Neurology, International League Against Epilepsy, European Federation of Neurorehabilitation, All-Russian Society of Neurologists, Moscow Research and Clinical Center for Neuropsychiatry.

Peter Sandercock

The International Stroke Faculty included Profs. P. Sandercock (WSO, UK), V. Caso (ESO, Italy),  M. Hilz (Germany), L. Østergaard (Denmark), and D. Muresanu, (EFNR, Romania). The WFN had been represented by Prof. M. Freedman (Canada); and the ILAE by Profs. S. Wiebe (Canada), I. Blumcke (Germany), A.Hauser (USA), E. Beghi (Italy), N. Speccio (Italy).

Opening ceremony. Left to right: V. Caso, E. Gusev, A. Guekht, and P. Sandercock.

The conference faculty had a high-level meeting with Prof. V. Skvortsova, Minister of Health for the Russian Federation, to discuss the management of stroke and brain disorders and highlight the priority this should be given both internationally and within the Russian Federation. An action plan on collaborative strategy in brain diseases has been discussed.

The conference proved popular and over 700 delegates from 42 cities of the Russian Federation attended with additional registrants from Belarus, Georgia, Kazakhstan, Tajikistan, Ukraine, and Uzbekistan. The conference attracted a high level of media coverage and both Profs. P. Sandercock and V. Caso gave video interviews for local media organizations.

The stroke session began with an update on controversies in thrombolysis by P. Sandercock, who highlighted the importance of not withholding thrombolysis to patients with ischemic stroke purely on the basis of age over 80.

Meeting with Prof. V. Skvortsova, Minister of Health for the Russian Federation (center). Left to right: M.Hilz, S. Wiebe, N. Specchio, E. Gusev, V. Caso, S.Muraviev, M. Martynov, E. Beghi, L.Østergaard, M. Freedman, A. Hauser, A. Guekht.

V. Caso gave a powerful talk on life after stroke in women. She highlighted the particulars of stroke management during pregnancy and demonstrated how gender inequality results in adverse effects in women’s health care in general and in stroke outcome in particular. M. Hilz gave a detailed overview of autonomic dysfunction in diseases requiring neurological intensive medicine.

V. Parfenov covered management of patients after stroke, highlighting the value of lifestyle changes (quitting smoking, increasing physical activity, and fresh fruit and vegetable consumption) and antithrombotic therapy with aspirin after ischaemic events.

I. Koltunov, N.Pechatnikova, and V. Kakaulina presented their work on cerebrovascular diseases associated with genetic metabolic disorders and demonstrated the program of genetic screening for rare diseases, supported by the Moscow government. A. Pryamikov, A.Mironkov, and O. Sazhina, doctors from the regional stroke center in the host hospital, closed the session with an interesting talk on their experience on carotid endarterectomy and internal carotid artery stenting in acute stroke.

Meeting in the Moscow Research and Clinical Center for Neuropsychiatry.

The clinical stroke-focused session was followed by a translational science session, which covered a broader range of topics.  I. Blumke reported work from the European Epilepsy Brain Bank Consortium: 25 years of interdisciplinary experience with epilepsy surgery in 9,579 children and adults, L. Østergaard presented novel data on the role of capillary pathways in stroke and cognitive decline, N. Gulyaeva highlighted how distant hippocampal damage in brain disorders may be related to corticoid-mediated mechanisms. A. Shpak spoke on neurotrophic factors in neuro-ophthalmology, showing their important role in glaucoma as the model of neurodegenerative diseases. D. Muresanu gave a talk titled, “From Neurobiology to Evidence-Based Medicine: Concepts in Neurorehabilitation After Stroke.”

The session on cognitive and affective disorders was opened by the lecture by M. Feedman focusing on the diagnostic and treatment challenges of frontotemporal dementia. R. Akzhigitov and co-authors gave an overview on depression in neurological diseases, presenting the huge experience of the Moscow Research and Clinical Center for Neuropsychiatry with the effective programs of multidisciplinary management of depressions and cognitive impairment, including post-stroke.

The session on the following day was dedicated to epilepsy. V. Krylov and I. Trifonov presented the results of the epilepsy surgery program, which is successfully developing in Moscow and other cities of the Russian Federation. S. Wiebe gave a thorough overview of the outcomes of epilepsy surgery. He emphasized that the novel way of conceptualizing surgical outcomes highlights the importance of longitudinal data. N. Specchio described special issues of epilepsy surgery in children. A. Hauser demonstrate how TBI and post-traumatic epilepsy represent a substantial societal burden. He reviewed the major risk factors and stated that studying the predictors of epilepsy after TBI should become one of the priorities. The successes and challenges in the implementation of the 68th WHA Resolution on Epilepsy were presented by E. Gusev and A. Guekht. They demonstrated that epilepsy is comorbid to stroke and other major noncommunicable diseases, dramatically increasing their severity and mortality.

The seminar on post-stroke cognitive impairment led by M. Freedman.

The last session was opened by E. Beghi with the talk describing the mechanisms and predictors of falls in neurological diseases, including stroke, Parkinson’s disease, multiple sclerosis, and others. He stressed that stroke can be the cause of balance disorders due to impaired ability to produce fast, accurate, and coordinated muscular patterns. Several interesting talks were presented by Russian colleagues on multiple sclerosis, including the burden of multiple sclerosis (V. Mkrtchyan, N. Pavlov) and therapeutic approaches (N. Khachanova and N. Arzymanian).

The novel techniques and experience of neurostimulation in gait disorders in multiple sclerosis patients were presented by the neurosurgery team of the Buyanov City Clinical Hospital (S. Asratyan). The significant part of the session was dedicated to management of ALS, presented by members of the Russian and foreign faculty.

The interactive video session concluded the conference with presentation of interesting cases in different aspects of neurology and with a lot of discussion.

On the next day, the international faculty and the leading Russian specialists on brain diseases visited the Moscow Research and Clinical Centre for Neuropsychiatry of the Healthcare Department of Moscow, one of the leading institutions for management of patients with post-stroke cognitive impairment, depression and anxiety, suicidal ideations, epilepsy, and other brain diseases. It was the second meeting of the international scientific advisory board of the Research and Clinical Centre, formed in October 2017 during the World Stroke Day Congress in Moscow.

The meeting started with an overview of the more than 100-year history of the center, presented by its director A. Guekht. The scientific achievements, patient management, and educational activity of the center, as well as the state-of-the-art facilities for diagnostics and research were quite impressive.

Prof. N. Gulyaeva (Institute of Higher Nervous Activity, RAS) presented the results of studies in translational neuroscience. Then, completed and ongoing research projects in post-stroke cognitive impairment, epilepsy, depression and suicide, and autonomic disorders were presented by the specialists of the center and of collaborative institutions (Pirogov Russian National Research Medical University, A.I. Yevdokimov Moscow State University of Medicine and Dentistry, Serbsky State Scientific Center for Social and Forensic Psychiatry, Institute of Higher Nervous Activity and Neurophysiology of RAS, N.V.Sklifosovsky Research Institute of Emergency Medicine and Buyanov City Clinical Hospital). The projects were extensively discussed by the faculty, and plans for international publications and new projects had been developed. The true highlights of the meeting were a series of seminars in stroke and other brain diseases led by the eminent members of the international faculty. These seminars were of high educational value for the doctors and researchers from Moscow clinics.

The conference closed with warm thanks from the organizing committee to the supporting organizations, the conference faculty, and conference participants for their efforts in improving the outcomes for people with stroke and brain disorders. The conference strengthens the international collaborative efforts to tackle these disorders, which place such a burden on patients, society and health systems.•

Prof. Peter Sandercock is emeritus professor of neurology at the University of Edinburgh.  He is a member of the Board of Directors of the World Stroke Organization and chairman of the WSO Education Committee.  He is commissioning editor for the World Stroke Academy, the WSO’s online global educational resource.

Palliative Care in Neurology

By David Oliver

There is increasing awareness of the role of palliative care for neurological patients, and this has been emphasized at two recent conferences.

David Oliver

At the Fourth Congress of the European Academy of Neurology in Lisbon, there was a European Association for Palliative Care / EAN Symposium on Palliative Care and Neurology as part of the program.  Over 100 people attended.

During the session, Prof. Raymond Voltz, Dr. Simone Veronese, and Prof. David Oliver spoke on developments within the field. The importance for all neurologists to provide a palliative care approach and to collaborate with specialist palliative care was emphasized, as has been emphasized in the EAN / EAPC Consensus on palliative care and neurology. There was good feedback, and several members of the audience discussed the issues afterward.

Within the same congress, there was a case-based workshop on end-of-life care for the neurological patient, looking at the use of interventions such as gastrostomy or ventilation at the end of life, coping with difficult patient and family situations, and how to be involved in difficult conversations.  Prof. Oliver also spoke at a scientific theater, a presentation within the poster and exhibition area,on the Consensus document on palliative care and neurology.

The 15th International Congress on Neuromuscular Disease (ICNMD) was held in Vienna in early July.  Over 1,400 delegates from 69 countries attended the meeting, which was held in collaboration with the European Federation of Autonomic Societies (EFAS).

Palliative care was included within the program, and the workshop on palliative care was attended by over 40 people who heard about the role of palliative care for neurological patients, the effectiveness of multidisciplinary care approach, the recognition of end of life care, and the experience of an ALS team in Moscow, Russia, in developing a clinic and increasing the availability of both palliative care and morphine use in symptom management.

Prof. Oliver, who is co-chair of the EAN Palliative Care Specialty Panel and chair of the EAPC Reference Group on palliative care and neurology, spoke in two other sessions. There was an “overarching session” on dysphagia, and he spoke on the ethical challenges of the management of dysphagia, including the assessment, use of interventions, discussions with patient and families and consideration of care at the end of life, including the consideration of withdrawal of treatment.  The session allowed a wider discussion of the issues of dysphagia, which may affect many with neuromuscular disease.

Palliative care also was featured in a plenary session on motor neurone disease. Prof. Oliver discussed the ethical issues in the management of motor neurone disease, discussing the telling of the diagnosis, the issues of genetics, cognitive change, nutritional support, ventilator support, and end-of-life issues.  The session was a new development at the congress with palliative care being discussed in the large plenary session, with over 500 people attending.

This was a wonderful opportunity to introduce palliative care and ethical discussions into the care of people with neuromuscular diseases. We are very grateful to Prof. Wolfgang Grissold, the chair of the ICNMD Scientific Committee and the organizers, for facilitating these opportunities to present at this congress. •

Further Information

https://www.eanpages.org/2018/06/17/lisbon-2018-report-on-symposium-4-ean-eapc-palliative-care-and-neurology/

Oliver DJ, Borasio GD, Caraceni A, de Visser M, Grisold W, Lorenzl S, Veronese S, Voltz R. A consensus review on the development of palliative care for patients with chronic and progressive neurological disease. Eur J Neurol 2016; doi:10.1111/ene.12889

Prof. David Oliver is honorary professor at the University of Kent, an EAPC board member, and chair of Reference Group on Neurology and Palliative Care.

Continuum in Haiti

By Aaron Berkowitz, MD, PhD

When I first began working in Haiti with the nongovernmental organization Partners In Health (PIH) and its Haitian sister organization Zanmi Lasante (ZL) in 2012, I was asked to provide CME in neurology for internists, family physicians, and residents in several hospitals. There is only one neurologist in Haiti for 10 million citizens and no neurology training programs. Therefore, physicians training in Haiti have no opportunity to learn about neurologic disease from a neurologist – no preclinical course, no rotation, no CME. And yet, since the majority of patients in Haiti do not have access to the country’s only neurologist, they see these same general practitioners who have had no access to neurology education.

Aaron Berkowitz, MD, PHD

I began providing week-long CME courses on neurologic diagnosis and management of common neurologic conditions, and precepting local physicians in the care of their patients with neurologic disease between lectures.  Our colleagues in Haiti appreciated the courses, and I enjoyed the opportunity to think through challenges in neurologic care and education in resource-limited settings (e.g., should a patient with an acute stroke and no access to CT receive aspirin?).1,2 However, the approach felt diffuse since I was giving lectures for large groups of practitioners at several hospitals, and seeing individual patients with multiple individual providers in different departments at each hospital. After several years, my colleagues in Haiti and I thought we could have a larger and more sustainable impact by focusing on a smaller group.

We decided to start a neurology rotation for the internal medicine residents at a newly opened teaching hospital in rural Haiti, Hôpital Universitaire de Mirebalais (HUM).3 Instead of lecturing in various hospitals and seeing patients with providers in different departments of each hospital, during each trip I worked with the same five PGY-2 internal medicine residents, and they worked only with me.  The volume of consults we saw and the incredible progress in neurologic diagnosis and treatment made by the residents inspired us to start the first neurology training program in Haiti at HUM in 2015.

Three generations of neurology trainees at Hôpital Universitaire de Mirebalais in Haiti with issues of Continuum provided by the AAN-WFN Continuum Education Program. From left to right: Dr. Brégenet Lamour, Dr. Ronald St. Jean, and Dr. Roosevelt François.

We initiated a 2-year fellowship program that accommodates one trainee each year. Applicants must be graduates of internal medicine or family medicine residencies in Haiti. A team of about a dozen U.S.-based neurology faculty spend one to 12 weeks per year in Haiti providing bedside and classroom teaching, precepting the fellows in their care of inpatients and outpatients, and mentoring them to provide CME to their colleagues in other departments and conduct research projects.4

I have always encouraged our visiting faculty to bring a few textbooks in their suitcase for the neurology program’s growing library. One faculty member brought several issues of Continuum. Our fellows loved it:

“I was impressed with the teaching method in Continuum to create such a comprehensive resource on each topic and convey the material so clearly,” said Dr. Roosevelt François, the program’s first graduate (in 2017) and current in-country program director.

“I appreciate how each issue begins with the basics and arrives at the most up-to-date aspects of diagnosis and treatment,” said Dr. Brégenet Lamour, our current second-year fellow and soon-to-be second graduate.

I wanted to subscribe our neurology fellows in Haiti to Continuum, but I had not had good luck mailing things to Haiti; a book donation to a Haitian medical library from a U.S. publisher we had organized was held up in Customs for nearly six months.  I learned about the AAN-WFN Continuum Education Program to assist in neurologic education in low-income countries (Haiti ranks 216 out of 235 countries in GDP per capita5). The coordinators of the program kindly agreed to send the journals to me in the U.S. to transport them in my suitcase to make sure they would arrive expeditiously. Five copies of each issue are provided; we keep one in our library, give one to our first graduate/faculty member, and provide one each to our two fellows. We save one for our next fellow. The fellows use Continuum not only for their own education but as a teaching tool.

Some of my U.S.-based colleagues ask if Continuum is too geared toward high-income settings to be applicable in Haiti, given that there is limited access to many neurodiagnostic tests and modern neurologic treatments in Haiti as in most low-income settings.6

“We don’t think ‘just because we don’t have this in Haiti, we don’t need to know about it.’ No!” Said Dr. Francois. “We need to know the most comprehensive up-to-date information to be prepared for the future when this technology arrives in Haiti.”

“While we await advances in technological resources, we must continue to train our human resources, said Dr. Ronald St. Jean, our current first year trainee. “Neurology existed long before technology.”

“Some of our patients want to travel abroad for diagnostic testing or treatment not available in Haiti, so we need to know how to advise them – is the test or procedure indicated? What are the risks and benefits of the intervention? Otherwise they could waste their time and money,” added Dr. Lamour.

The AAN-WFN Continuum Education Program provides an excellent resource for practitioners in low-income settings who may have limited access to internet in the field to provide up-to-date information on neurologic disorders. In the words of my colleague Dr. Francois, the first neurologist to be trained in Haiti:

“Thank you to my professors for helping me to discover Continuum, this inexhaustible resource of neurologic information, and thank you to the AAN-WFN for providing us with this resource.  Continuum offers an enormous opportunity to continue my neurologic education with the most up-to-date information, and make sure my practice is current. Continuum is a crucial part of the continuity of my neurologic education.” – Dr. Francois •


References

  1. Berkowitz AL, Westover MB, Bianchi MT, Chou SH. Aspirin for acute stroke of unknown etiology in resource-limited settings: a decision analysis. Neurology. 2014 Aug 26; 83(9):787-93
  2. Berkowitz AL. Managing acute stroke in low-resource settings. Bull World Health Organ. 2016 Jul 01; 94(7):554-6.
  3. Berkowitz AL, Martineau L, Morse ME, Israel K. Development of a neurology rotation for internal medicine residents in Haiti. J Neurol Sci. 2016 Jan 15; 360:158-60
  4. Israel K, Strander S, Martineau L, Pierre S, Morse ME, Berkowitz AL. Development of a neurology training program in Haiti. Submitted
  5. The World Bank. GDP per capita 2017 (US$). https://data.worldbank.org/indicator/NY.GDP.PCAP.CD?year_high_desc=true Accessed July 5, 2018
  6. McLane HC, Berkowitz AL, Patenaude BN, McKenzie ED, Wolper E, Wahlster S, Fink G, Mateen FJ. Availability, accessibility, and affordability of neurodiagnostic tests in 37 countries. Neurology. 2015 Nov 03; 85(18):1614-2

Aaron Berkowitz, MD, PhD, is the director of the global neurology program at Brigham and Women’s Hospital, and associate professor of neurology at Harvard Medical School.

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