To determine intermodality (in-person vs. telemedicine examination) and inter-examiner (two tele-examiners) agreement for capturing neuro-ophthalmic manifestations of concussion using the Telemedicine Buffalo Concussion Physical Examination (Tele-BCPE), a 29 item validated instrument for remote evaluation of the neurological manifestations of concussion.

Background and Objectives We determined inter-modality (in-person vs telemedicine examination) and inter-rater agreement for telemedicine assessments (2 different examiners) using the Telemedicine Buffalo Concussion Physical Examination (Tele-BCPE), a standardized concussion examination designed for remote use. Methods Patients referred for an initial evaluation for concussion were invited to participate. Participants had a brief initial assessment by the treating neurologist. After a patient granted informed consent to participate in the study, the treating neurologist obtained a concussion-related history before leaving the examination room. Using the Tele-BCPE, 2 virtual examinations in no specific sequence were then performed from nearby rooms by the treating neurologist and another neurologist. After the 2 telemedicine examinations, the treating physician returned to the examination room to perform the in-person examination. Intraclass correlation coefficients (ICC) determined inter-modality validity (in-person vs remote examination by the same examiner) and inter-rater reliability (between remote examinations done by 2 examiners) of overall scores of the Tele-BCPE within the comparison datasets. Cohen's kappa, kappa, measured levels of agreement of dichotomous ratings (abnormality present vs absent) on individual components of the Tele-BCPE to determine inter-modality and inter-rater agreement. Results For total scores of the Tele-BCPE, both inter-modality agreement (ICC = 0.95 [95% CI 0.86-0.98, p < 0.001]) and inter-rater agreement (ICC = 0.88 [95% CI 0.71-0.95, p < 0.001]) were reliable (ICC >0.70). There was at least substantial inter-modality agreement (kappa >= 0.61) for 25 of 29 examination elements. For inter-rater agreement (2 telemedicine examinations), there was at least substantial agreement for 8 of 29 examination elements. Discussion Our study demonstrates that the Tele-BCPE yielded consistent clinical results, whether conducted in-person or virtually by the same examiner, or when performed virtually by 2 different examiners. The Tele-BCPE is a valid indicator of neurologic examination findings as determined by an in-person concussion assessment. The Tele-BCPE may also be performed with excellent levels of reliability by neurologists with different training and backgrounds in the virtual setting. These findings suggest that a combination of in-person and telemedicine modalities, or involvement of 2 telemedicine examiners for the same patient, can provide consistent concussion assessments across the continuum of care.

Background and Objectives: To better understand patients' and neurologists' assessments of their experiences regarding effectiveness of teleneurology encounters. Methods: Following an audio-video telehealth visit, neurologists asked patients to participate in a survey-based research study about the encounter, and then, the neurologists also recorded their own evaluations. Data were analyzed using standard quantitative and qualitative techniques for dichotomous and ordered-category survey responses in this cross-sectional analysis. Results: The study included unique encounters between 187 patients and 11 general neurologists. The mean patient age was 49 ± 17.5 years. Two thirds of the patients (66.8%, 125/187) were female. One third (33.2%; 62) were patients new to the NYU Langone Health neurology practices. The most common patient chief complaints were headache (69/187, 36.9%), focal and generalized numbness or tingling (21, 11.2%), memory difficulty (15, 8%), spine-related symptoms (12, 6.4%), and vertigo (11, 5.9%). Most patients (94.7%, 177/187) reported that the teleneurology encounter satisfied their needs. Patients and their neurologists agreed that the experience was effective in 91% (162/178) of encounters, regardless of whether the visit was for a new or established patient visit. Discussion: More than 90% of new and established patients and their neurologists agreed that teleneurology encounters were effective despite some limitations of the examination, the occasional need for patient assistance, and technical difficulties. Our results provide further evidence to justify and to expand the clinical use of teleneurology.

Objective: To assess inter-examiner agreement of virtual concussion telemedicine examinations and to determine agreement of virtual and in-person concussion examinations performed by the same physician. Background: We developed a virtual concussion telemedicine examination by adapting several in-office examination methods. The virtual exam was compared to the in-person concussion exam to examine reliability and to validate the use of telemedicine via audio-video conferencing technology. Design/Methods: A virtual concussion examination form with instructions on how to perform this was developed. The standardized examination included 29 elements, such as orthostatic tolerance, ocularmotor exam, and balance tests. We enrolled 21 participants referred for an initial concussion evaluation at the NYU Concussion Center. Two virtual concussion telemedicine examinations were conducted in the office setting following study enrollment; one examination was perfomed by the treating physician and another was compled by another physician. The in-person concussion examination was then performed by the treating physician. We used Cohen's Kappa to determine inter-modality and inter-examiner agreement. Results: We determined Cohen's kappa to assess agreement on dichotomous examination ratings for each of 29 exam elements across 21 participants. Kappa values for inter-examiner agreement ranged from 0.31–1.0, with median kappa=0.76; 45% of exam elements had excellent inter-examiner agreement between the two telemedicine examiners (kappa>0.75), while 75% of exam elements had at least intermediate inter-examiner agreement for telemedicine examiners (kappa>0.40). Within the same examiner for telemedicine vs. in-person examinations, Cohen's kappa values were even higher, with values ranging from 0.48–1.0 overall. Conclusions: We found that the treating physician's virtual and in-person concussion examination findings largely agreed. However, there was less agreement between virtual concussion examinations performed by two different physicians. This suggests that expertise and experience of examining physicians contribute more to variability than do modality or area of the examination. This study sets the stage for investigations of reliability between in-person and teleneurology examinations. Disclosure: Ms. Jack has nothing to disclose. Miss Digney has nothing to disclose. Mr. Bell has nothing to disclose. Binu Joseph has nothing to disclose. Ms. Hyman has nothing to disclose. Dr. Galetta has nothing to disclose. An immediate family member of Dr. Balcer has received personal compensation in the range of $5,000-$9,999 for serving as a Consultant for Children's Hospital of Philadelphia. Dr. Balcer has received personal compensation in the range of $50,000-$99,999 for serving as an Editor, Associate Editor, or Editorial Advisory Board Member for North American Neuro-Ophthalmology Society. Prof. Willer has nothing to disclose. Mr. Haider has received personal compensation in the range of $10,000-$49,999 for serving as a Consultant for BlinkCNS. The institution of Mr. Haider has received research support from NIH. Dr. Saleem has nothing to disclose. Dr. Grossman has nothing to disclose. Dr. Leddy has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Neurolign. Dr. Leddy has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Stage 2 Contract Engineering. Dr. Leddy has received stock or an ownership interest from Highmark Innovations. The institution of Dr. Leddy has received research support from NIH. The institution of Dr. Leddy has received research support from DoD. The institution of Dr. Leddy has received research support from AMSSM. Dr. Busis has received personal compensation in the range of $500-$4,999 for serving as a Consultant for American Academy of Neurology. Dr. Busis has received personal compensation in the range of $0-$499 for serving as an Editor, Associate Editor, or Editorial Advisory Board Member for Neurology Today. Dr. Torres has received publishing royalties from a publication relating to health care.

Background and Objectives: To better understand neurologists' assessments of the experiences and effectiveness of teleneurology encounters. Methods: After completing an audio-video telehealth visit with verbally consenting patients, neurologists recorded their evaluations of the encounter. Data were analyzed using standard quantitative and qualitative techniques. Results: The study included unique encounters between 187 patients and 11 neurologists. The mean patient age was 49 ± 17.5 years. Two thirds of patients (66.8%, 125/187) were female. One third of patients (33.2%; 62) were new patients. The most common patient complaints were headache (69/187, 36.9%), focal and generalized numbness or tingling (21, 11.2%), memory difficulty (15, 8%), spine-related symptoms (12, 6.4%), and vertigo (11, 5.9%). Neurologists reported that they completed a virtual examination that provided enough information for medical decision-making in 94.9% of encounters (169/178, 9 missing responses). Fourteen of 25 examination elements important for medical decision-making could be performed sufficiently during virtual encounters. Examination assistance was needed for 16.4% (30/183) of patients, who were, on average, 17.3 years older than those who did not require assistance (62.9 years vs. 45.6 years, p = 0.0002). In 19.1% (34/178) of encounters, neurologists learned clinically relevant information from seeing patients in their homes. Neurologists' assessments of the effectiveness of encounters were not related to the presence (97.2%, 35/36 effective) or absence (95%, 134/141 effective) of technical difficulties (p = 0.5729) in 177 encounters (10 missing responses). Discussion: Neurologists reported that nearly 95% of teleneurology encounters were effective despite limitations of the virtual examination, occasional need for patient assistance, and technical difficulties.

Objective To develop a brief, focused telehealth physical examination for use in the outpatient setting by sports medicine physicians, pediatricians, neurologists, and primary care physicians. Background Telemedicine has become a key resource for addressing healthcare access limitations for individuals living in rural communities. The COVID-19 pandemic has forced physicians and other healthcare providers to adopt telemedicine practices. Published literature guiding the evaluation of patients with concussion via telemedicine is sparse. Design/Methods The Buffalo Concussion Physical Examination (BCPE) is a practical and pertinent clinical assessment that helps to diagnose concussion and that has prognostic value when repeated over the first weeks after injury. An interdisciplinary team with experience in telemedicine services utilized a modified-Glaser approach to consensus to translate elements of the BCPE into virtual methods enabling clinicians to provide care to patients over the internet. Results The Telehealth version of the BCPE (Tele-BCPE) includes an orthostatic intolerance screen, examination of the cranial nerves, and tests of the oculomotor, vestibular and cervical systems. History and examination templates as well as detailed instructions for performance are included. The Tele-BCPE is meant to be used at initial and follow-up visits for patients acutely after concussion as well as in those with prolonged symptoms. Conclusions We developed a telehealth physical examination to help direct treatment to patients at any stage after concussion and reduce barriers to healthcare access posed by the COVID-19 pandemic and for patients living in rural or underserved areas. Prospective evaluation of the validity and reliability of the Tele-BCPE for the diagnosis and management of patients with concussion is warranted.

To determine the patient and physician perspective of the same teleneurology visit

A 27-year-old man presented to our hospital's emergency department (ED) with an abnormal gait, paresthesias of the lower extremities, and lower back pain that had progressed over 2 weeks. He reported no medical history and a family history notable only for poor folic acid absorption in his father (etiology unknown).

OBJECTIVE: To report a unique case of bihemispheric complex partial whistling seizures in a 60-year-old man following a motorcycle accident. BACKGROUND: Automatisms are common manifestations in seizures. However, musical semiology is rare and infrequently described in the literature. Five prior cases of whistling seizures have been reported (Tan 1990, Lazzarino 1982, Loring 1994, Raghavendra 2010) with only two studied by video-EEG (Raghavendra 2010). Therefore, the lateralization and localization of whistling seizures are poorly understood. DESIGN/METHODS: Clinical presentation, imaging, video-EEG, seizure stereotypy and patient management patient were examined. Review of relevant literature was also performed. RESULTS: This patient suffered from a prolonged loss of consciousness after a motorcycle accident. Almost a decade later, he had his first seizure and continued to have 6-7 complex partial seizures per month with or without secondary generalization. Most events were nocturnal and lasted 3-5 minutes. Patient could not achieve seizure freedom on Dilantin and Keppra monotherapy. His neurological examination was non-focal. MRI brain showed mild microvascular disease. Video-EEG captured 2 stereotyped complex partial seizures. Patient reported an aura of nausea and lightheadedness, followed by disorientation, pacing in a confused manner, whistling, and then stiffening and clonic movements of all extremities. Postictal confusion followed. Ictal onset showed bitemporal theta-delta rhythms admixed with right frontotemporal epilpetiform sharps. Patient became seizure free on a combination therapy of Keppra and Tegretol XR. CONCLUSIONS: Ictal vocalizations are more common in temporal lobe epilepsies, though ictal whistling has been reported in both frontal and temporal lobe cases. The very few reported cases show a strong male predominance. The lateralization at ictal onset was not possible in our patient but peri-ictal discharges suggested possible right temporal lobe focus. Our patient continues to be in remission with medical therapy. Disclosure: Dr. Lillemoe has nothing to disclose. Dr. Torres has nothing to disclose. Dr. Singh has nothing to disclose.

Studies suggest that a lack of standardized knowledge may lead to underreporting and undertreatment of sports-related concussion. However, there has been little work done to establish how this knowledge may affect athletes' behaviors toward reporting their concussions and removing themselves from play. We conducted an anonymous online survey to assess athletes' knowledge of signs and symptoms of concussion, and also sought to estimate the potential frequency of underreporting in a collegiate athlete cohort. Among 262 athletes who responded to the survey, 43% of those with a history of concussion reported that they had knowingly hidden symptoms of a concussion to stay in a game, and 22% of athletes overall indicated that they would be unlikely or very unlikely to report concussion symptoms to a coach or athletic trainer in the future. These data suggest that there may be a substantial degree of underreporting of concussion among collegiate athletes, despite most acknowledging that they have been formally educated about the risks of concussion.