There is substantial heterogeneity in clinical presentation of genetic Frontotemporal Dementia (FTD), even within the same family. This suggests that additional heritability may exist and contribute to this variable presentation. We examined whether gene-based aggregate burden of genome-wide rare variants (minor allele frequency [MAF]: ≤1%) contribute to variation in regional cortical and subcortical grey matter volumes, after controlling for effects of causative mutations in GRN , MAPT , and C9orf72 . This study was embedded within the GENetic Frontotemporal dementia Initiative (GENFI), which recruits genetic FTD cases and their asymptomatic at-risk family members, both carriers and non-carriers of FTD mutations. We included 518 participants with genotype (Neurochip; imputed against TOPMed), and T1w-MRI brain volumetric data. Gene-based burden tests that aggregate the number of rare variants by gene were used to examine the association of rare variants (MAF: ≤1%) with regional cortical and subcortical grey matter volumes (70 regions of interest [ROIs]), controlling for age, sex, total intracranial volume, mutation status, scanner site, population stratification, and family membership (kinship matrix) using RVTests. Annotations for loss of function mutations (LOF): start gain, stop loss, start loss, essential splice site, stop gain, normal splice site, and non-synonymous. Multiple testing correction accounted for the number of genes and number of independent grey matter volumes as calculated by matSpD ( p -value threshold: 0.05/(17,053x42) =  6.98 x10 -8 ) . Aggregate burden of LOF mutations ( DNAJB8-AS1, WDR26, RDM1P5, BSND, CNOT2, DDA1, ASAH2B, PPM1A, HOXD13, ALDH1A1, CENATAC, ANKRD45) was associated with significantly lower volumes within the left temporal lobe (ROIs: left temporal and lateral temporal left), and greater volume in the putamen bilaterally ( TSACC) . All genes are protein coding, except the DNAJB8-AS1 (antisense RNA) and RDM1P5 (pseudogene), and are variably expressed in the brain. Molecular functions of significant genes involve regulation of gene expression, transcription, and cell cycle, ion channel function, and chromosomal segregation. WDR26 and CNOT2 genes have been implicated in neurodevelopment and neurological disorders respectively; BSND gene is involved in neurotransmission. Identification of deleterious or protective rare variants contributing to FTD imaging phenotypes may help identify genetic modifiers of familial FTD. Replication in larger cohorts is needed.

Objective Little is known about best practices in service delivery for people experiencing complex brain disorders (CBDs) involving affective, behavioural, and cognitive symptoms. We aimed to assess the experiences and perceived healthcare needs of patients at a Brain Medicine Clinic (BMC), using their insights to drive improvements in care delivery.Methods We contacted all patients seen in the BMC between May and July 2024 and recruited 15 participants. We conducted 30 min semi-structured interviews that were audio-recorded and transcribed verbatim. Line-by-line coding was performed inductively using NVivo V.14 software, followed by a thematic analysis to identify emerging themes and subthemes.Results Three main themes were identified as being related to care quality at the BMC: (1) Access, Navigation and Coordination, (2) Knowledge Translation and (3) Therapeutic Alliance. Based on these themes, three key practice recommendations were developed for care quality improvement, including (1) introducing a care navigator, (2) the provision of structured after-visit summaries and preparatory materials and (3) integrating empathy and communication training into the education of practitioners delivering this care.Conclusions The results support the need for and underscore the benefits of integrated care models in managing CBDs, such as a BMC. Future studies should evaluate the effects of implementing the proposed recommendations.

INTRODUCTION/AIMS:Glucocorticoid (GC)-related adverse reactions and risks are commonly seen during the treatment of immune-mediated and inflammatory neuromuscular disorders. There is wide variation in the management of associated complications. The aim of this study is to develop international consensus guidance on the management of GC-related complications in neuromuscular disorders. METHODS:Through the American Association of Neuromuscular and Electrodiagnostic Medicine (AANEM), an international task force of 15 experts was convened to develop clinical guidance for the management of GC-related complications in neuromuscular patients. The RAND/UCLA appropriateness method (RAM) was used to develop consensus guidance statements. Initial guidance statements were crafted after a thorough literature review and were modified after anonymous panel input, with up to three rounds of voting via email to achieve consensus. RESULTS:Statements were developed and achieved consensus for general care, monitoring of patients while on GC, osteoporosis prevention, vaccinations, infection screening, and Pneumocystis jiroveci pneumonia prophylaxis. A multidisciplinary approach to the management of GC-related complications was emphasized. DISCUSSION:These formal consensus statements provide guidance to clinicians who use GC in the treatment of neuromuscular diseases regarding prevention and management of the more common associated adverse events and risks that arise with long and short-term GC use and serve as a springboard for investigation and updates.

Growing evidence underscores the importance of cardiovascular contributions to Alzheimer's disease and related dementias (AD/ADRD). While sex differences in cardiovascular disease (CVD) risk factors and outcomes are well established, the question of whether vascular contributions to AD/ADRD vary by sex has only recently garnered attention. In this narrative review, we discuss sex differences in conventional CVD risk factors (e.g., hypertension, dyslipidemia, diabetes), as well as underrecognized female-specific (e.g., menopause history, polycystic ovary syndrome, adverse pregnancy outcomes) and female-predominant (e.g., autoimmune conditions, breast cancer) CVD risk factors. Despite their relevance, these sex-specific considerations are rarely incorporated into current approaches to quantify CVD risk in AD/ADRD research. We offer recommendations to address these gaps and promote the use of sex-informed methods for studying cardiovascular contributions to AD/ADRD in women, which is essential for developing precision strategies to improve outcomes for all individuals at risk of dementia. HIGHLIGHTS: There are extensive sex differences in cardiovascular risk, dementia risk, and their interrelationships. Many cardiovascular risk factors confer greater risk for dementia in women than men. Existing approaches to quantifying cardiovascular risk often overlook sex differences and female-specific factors. Sex-informed approaches are essential for an accurate understanding of cardiovascular contributions to dementia.

INTRODUCTION:The prevalence of dementia is rising due to an aging population. Given the known risks of obstructive sleep apnea (OSA) on cerebrovascular health, we hypothesized that markers of OSA would correlate with reduced hippocampal volumes in individuals with cognitive impairment due to neurodegenerative, vascular, or mixed (NVM) etiologies. METHODS:Data from 166 patients were retrospectively analyzed. Participants underwent polysomnography or home sleep apnea tests, alongside structural brain magnetic resonance imaging (MRI). They were categorized into cognitive impairment due to NVM etiology or subjective cognitive complaints. Multiple linear regression models examined correlations between sleep variables and hippocampal volume. RESULTS:The presence of OSA, time under 90% oxygen saturation, and mean SpO2 were significantly associated with reduced hippocampal volumes in the NVM group, but not the subjective cognitive complaints. DISCUSSION:These findings suggest that individuals with cognitive impairment due to NVM etiology experience underlying neurodegenerative processes, which increase susceptibility to the adverse effects of OSA. HIGHLIGHTS:Hypoxic burden, rather than AHI, was associated with hippocampal volume loss. The presence of OSA, T90%, and mean SpO2 were linked with reduced hippocampal volume. Neurodegenerative and vascular processes may raise susceptibility to OSA harms.

Dear Editor, Recognizing the complex nature of functional neurological disorder (FND), there is mounting evidence that an effective patient-centered approach for this population hinges on interprofessional and interdisciplinary collaboration1–3. While the care of persons with FND traditionally involves neurology and psychiatry, physical and rehabilitation medicine (PRM) can also help manage these patients. Presenting with a myriad of functional complaints, patients with FND often present with various rehabilitation needs, and many of the common comorbidities in FND (eg, chronic fatigue, chronic pain4, postconcussion5, and long coronavirus disease 20196) can benefit from a physiatric consultation. There are currently no data available specific to the frequency with which FND presents to PRM, although we can extrapolate that it is quite prevalent from the fact that it ranks as the second most common reason for a new ambulatory general neurology consult7. Defined as altered voluntary motor or sensory function incompatible with recognized neurological or medical conditions8, FND rarely presents as an isolated physical manifestation and is often associated with significant disability impacting one's personal, working, and family life9. Its incidence ranges from 4 to 12 per 100,000 per annum10, making it as common as multiple sclerosis; however, available data may be an underestimate due to under/misdiagnosis and lack of high-quality epidemiologic studies8,9. While neurologists and psychiatrists may be more likely to diagnose FND through a "rule in" rather than a "rule out" diagnosis8,11, physiatrists can also leverage their ability to distinguish FND from other neurological or psychiatric conditions that they have encountered in the past and pragmatically approach its formulation and management. Given the generally limited number of physicians in most health care settings, physiatrists can take a more active role in the interdisciplinary care of persons presenting with FND symptoms by assisting with diagnosis and treatment. The specific skill set unique to PRM can be leveraged to improve the quality of care for individuals experiencing FND. Trained to lead and coordinate holistic, individualized, and patient-centered rehabilitation interventions12, physiatrists can translate these competencies to FND care as well. Throughout the longitudinal care of FND, they can ensure that all aspects of each patient's interdisciplinary treatment are well-integrated and up-to-date tailored to individual progress and changing rehabilitation needs. PRM is a medical specialty highlighting leadership and team dynamics as highly fundamental aspects of training, and these can be leveraged in FND care as the quality of teamwork correlates with improved outcomes13. To illustrate a physiatrist working with rehabilitation therapists attending to a patient with postconcussion syndrome presenting with dizziness, headaches, and brain fog may guide the team in distinguishing which persistent symptom/s may have functional mechanisms14, if any. Depending on the team's collective assessment, the rehabilitation prognosis and plan of care are adjusted accordingly. The physiatrist can also reassure the team that the patient is medically well and safe to proceed and progress with their therapy programs, while medically optimizing symptoms such as musculoskeletal pain that might otherwise hinder rehabilitative progress. Challenges remain to enhancing FND rehabilitation services, which are currently largely "fragmented" because of limited rehabilitation providers and programs that could meet the needs of the "heterogeneous population of people with FND."15 Some physiatrists may not have a high level of confidence or comfort in approaching this population for several reasons. A survey of French junior neurologists, psychiatrists, and physiatrists revealed nearly 90% of respondents did not receive sufficient training on FND during their medical education and residency training16. Existing curricula in health care, including PRM, and relevant continuing medical/professional education programs are lacking in topics related to FND, such as evaluating patients and looking for positive "rule-in" signs on clinical examination, confirming and explaining the diagnosis following evidence-based approaches, triaging patients to appropriate treatments, assessing patients' readiness for rehabilitation therapies, and intervening where appropriate to ensure patients' engagement and success in their therapy programs15. Some patients may need a course of cognitive behavioral therapy or other educational resources to address underlying issues, such as lack of self-agency and suboptimal willingness to participate in therapy, before a course of physical, occupational, and/or speech and language therapy15. Despite the availability of a few consensus recommendations for FND, there are only limited guidelines and research specifying the role of physiatrists in FND rehabilitation17. Consensus recommendations are currently available for physiotherapy for functional motor disorders18, occupational therapy assessment and intervention for FND and commonly associated problems19, and speech and language therapy for functional communication, swallowing, cough, and related disorders20. Furthermore, people with lived experiences of FND, including patients and care partners, may have prior negative experiences with the health care system, making it difficult for them to engage/reengage in rehabilitation. Current and future clinicians without proper education on FND may have a limited understanding of the disorder and a "tendency to disbelieve, blame, or shame patients," potentially resulting in an endless cycle of patients' health-seeking and health-rejecting behaviors and consequently increasing overutilization of already limited health care resources15,17. Lastly, physiatrists may feel under-supported in providing FND-focused therapeutic services, which are significantly lacking because of insufficient funding and few interested, skilled, and committed rehabilitation clinicians among other factors15. De-stigmatization of FND among stakeholders (including health care providers, policymakers, and potential funders), adequate education and training, further research, and research translation are some of the strategies needing urgent attention and more active involvement of physiatrists and other rehabilitation clinicians. An example of a method to improve FND awareness and education among students, trainees, and clinicians is creating "hub-and-spoke" programs, such as through Project ECHO (Extension for Community Healthcare Outcomes), which has been gaining popularity in the context of virtual care and interdisciplinary collaborations21. A Project ECHO model of FND could be conducted through regular videoconference meetings and include didactics from experts, presentations of anonymized cases requiring remote support, and open fora facilitating the exchange of best practices. Another example is adopting an interdisciplinary care model, such as the "Brain Medicine Clinic,"22 that provides cross-training benefits among brain-related specialties (eg, neurology, psychiatry, PRM, geriatric medicine, neurosurgery, and family medicine) by "equipping clinicians with skills that permit an integrated approach to complex brain disorders," such as FND. FND is an untapped area of education, training, clinical practice, and research in the field of PRM. Given its complexity, stigma, incidence, unmet needs, and disease burden, it requires a nuanced and comprehensive approach that calls for stronger interdisciplinary collaborations with a focus on rehabilitation that should include PRM specialists. Ethical approval This paper did not require ethical review or registration. Sources of funding This research was supported by the Azrieli Scholarship & Research Catalyst Grant funded by a donation of the Azrieli Foundation to the Department of Psychiatry, Temerty Faculty of Medicine, University of Toronto. Author contributions All authors contributed to the writing of the paper and have approved the final version. Conflict of interest disclosures The authors declare that they have no financial conflict of interest with regard to the content of this report. Research registration unique identifying number (UIN) Not applicable. Guarantor Not applicable.

INTRODUCTION:Effective longitudinal biomarkers that track disease progression are needed to characterize the presymptomatic phase of genetic frontotemporal dementia (FTD). We investigate the utility of cerebral perfusion as one such biomarker in presymptomatic FTD mutation carriers. METHODS:We investigated longitudinal profiles of cerebral perfusion using arterial spin labeling magnetic resonance imaging in 42 C9orf72, 70 GRN, and 31 MAPT presymptomatic carriers and 158 non-carrier controls. Linear mixed effects models assessed perfusion up to 5 years after baseline assessment. RESULTS:Perfusion decline was evident in all three presymptomatic groups in global gray matter. Each group also featured its own regional pattern of hypoperfusion over time, with the left thalamus common to all groups. Frontal lobe regions featured lower perfusion in those who symptomatically converted versus asymptomatic carriers past their expected age of disease onset. DISCUSSION:Cerebral perfusion is a potential biomarker for assessing genetic FTD and its genetic subgroups prior to symptom onset. HIGHLIGHTS:Gray matter perfusion declines in at-risk genetic frontotemporal dementia (FTD). Regional perfusion decline differs between at-risk genetic FTD subgroups . Hypoperfusion in the left thalamus is common across all presymptomatic groups. Converters exhibit greater right frontal hypoperfusion than non-converters past their expected conversion date. Cerebral hypoperfusion is a potential early biomarker of genetic FTD.

Background and ObjectivesThe COVID-19 pandemic forced a shift to virtual care in several neurologic care settings. Little is known about the validity of the virtual neurologic examination (VNE) for clinical decision making when compared with the in-person neurologic examination (IPNE). The objective of this study was to investigate the utility of the VNE in arriving at an accurate localization and diagnosis in comparison with the traditional IPNE in an ambulatory outpatient setting.MethodsA retrospective chart review of patients examined virtually and in-person within 4 months at outpatient general neurology and neuromuscular clinics from 2 tertiary academic care centers during the COVID-19 pandemic was conducted. The Cohen kappa coefficient was calculated to test agreement between virtual and in-person assessment results, and descriptive statistical methods were used to compare accuracy, localization, and diagnosis.ResultsA total of 81 patients met the inclusion criteria. Overall, there was fair agreement between VNE and IPNE (64% agreement, p = 0.003). Substantial agreement between VNE and IPNE was observed for gait abnormalities; moderate agreement for extraocular movements, facial weakness, dysarthria, fasciculation, and lower limb weakness; and fair agreement for bulk, upper limb weakness, and sensation. No agreement between VNE and IPNE was seen for hypokinetic or hyperkinetic movements and cerebellar signs. Compared with the IPNE, specificity of the VNE was 86% and sensitivity was 56%. Some cases demonstrated a consistent localization (44%) and diagnosis (57%) after virtual and in-person assessments. The localization was changed in 15% and refined in 41% of cases between visits. The diagnosis was changed in 14% and refined in 30% of cases.DiscussionThe high rates of agreement in detecting an abnormality on the VNE and IPNE for some maneuvers and resultant clinical impressions may support the validity of the VNE for initial consultation depending on the clinical scenario. The VNE seems to be a good surrogate evaluation compared with the IPNE for certain chief complaints. The low sensitivity suggests that a normal VNE should warrant further in-person clinical correlation, especially in the context of a highly concerning history. The IPNE is more sensitive in detecting subtle abnormalities on examination, and a low threshold should be used to bring a patient in for an IPNE if the VNE is normal in certain clinical contexts.

Background and objectives: Current virtual care guidance lacks specialty-specific considerations. Neurological care is unique due to its reliance on physical examination and complex patient population. Our aim was to determine which factors impact virtual care suitability in neurology, virtual care adoption patterns, and satisfaction with virtual care among neurologists. Methods: Surveys were sent to Ontario neurologists through a shared email from September to November 2021. The survey consisted of four parts: demographics, virtual care adoption patterns, factors influencing virtual care use, and physician satisfaction with virtual care. Results: Sixty-six of 380 (17.4%) neurologists completed the survey. The pandemic resulted in a substantial increase in virtual care use, from 1.6% of all ambulatory visits in 2019 to 70.6% in 2020. Video teleconferencing was considered more appropriate across a broader range of presentations than phone visits, with both methods more suited to follow-ups. Neurologists were largely satisfied with virtual care except for the virtual neurological examination. The neurological presentations identified as least amenable to virtual consultation were movement disorders, limb weakness, gait/balance changes, and vision changes. Four presentations were felt to be most amenable to virtual care: sleep disorders, seizure, headache, and dizziness/syncope. Factors that were felt to reduce virtual care suitability included discussion of sensitive topics and acute presentations. Conclusion: Neurologists were satisfied with virtual care as a means of providing outpatient care, though the specific reason for referral influenced perceived appropriateness. These results can inform the basis of the development of consensus guidelines for virtual care provision in neurology.

Background and purposeTelestroke has grown significantly since its implementation. Despite growing utilization, there is a paucity of data regarding the diagnostic accuracy of telestroke to distinguish between stroke and its mimics. We aimed to evaluate diagnostic accuracy of telestroke consultations and explore the characteristics of misdiagnosed patients with a focus on stroke mimics. MethodsWe conducted a retrospective study of all the consultations in our Ochsner Health's TeleStroke program seen between April 2015 and April 2016. Consultations were classified into one of three diagnostic categories: stroke/transient ischemic attack, mimic, and uncertain. Initial telestroke diagnosis was compared with the final diagnosis post review of all emergency department and hospital data. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), positive likelihood ratio (LR+) and negative likelihood ratio (LR-) for diagnosis of stroke/TIA versus mimic were calculated. Area under receiver-operating characteristic curve (AUC) analysis to predict true stroke was performed. Bivariate analysis based on the diagnostic categories examined association with sex, age, NIHSS, stroke risk factors, tPA given, bleeding after tPA, symptom onset to last known normal, symptom onset to consult, timing in the day, and consult duration. Logistic regression was performed as indicated by bivariate analysis. ResultsEight hundred and seventy-four telestroke evaluations were included in our analysis. Accurate diagnosis through teleneurological consultation was seen in 85% of which 532 were strokes (true positives) and 170 were mimics (true negatives). Sensitivity, specificity, PPV, NPV were 97.8, 82.5, 93.7 and 93.4%, respectively. LR+ and LR- were 5.6 and 0.03. AUC (95% CI) was 0.9016 (0.8749-0.9283). Stroke mimics were more common with younger age and female gender and in those with less vascular risk factors. LR revealed OR (95% CI) of misdiagnosis for female gender of 1.9 (1.3-2.9). Lower age and lower NIHSS score were other predictors of misdiagnosis. ConclusionWe report high diagnostic accuracy of the Ochsner Telestroke Program in discriminating stroke/TIA and stroke mimics, with slight tendency towards over diagnosis of stroke. Female gender, younger age and lower NIHSS score were associated with misdiagnosis.

Background: Colony stimulating factor 1 receptor (CSF1R) mutations have various clinical, often overlapping, phenotypes. Methods: Case report and literature review. Results: We present a case of a previously independent 49-year-old woman with a 3-year history of early- and insidious-onset, rapidly progressive symptoms resembling CBS (parkinsonism, severe apraxia, global cognitive impairments, personality changes, depression, and functional decline). Brain MRI showed severe atrophy with frontoparietal predilection, asymmetric ex vacuo dilatation, atrophic corpus callosum, and patchy, asymmetric T2/FLAIR hyperintensities in the subcortical white matter. Spine MRI showed no cord signals. Brain MR spectroscopy revealed elevated choline with reduced N-acetyl-aspartate levels. The vasculitis screening, and leukodystrophy and CADASIL workups were all unremarkable. Finally, whole exome sequencing was done and a heterozygous variant of CSF1R (c.1735C>T, p.Arg579Trp) was found. Conclusions: Our patient’s novel CSF1R variant was found to be associated with ALSP. This report supports the utility of a comprehensive genetic testing in adult patients clinically presenting as CBS but with white matter abnormalities on T2-weighted MRI. Given that ALSP has several other clinical and radiologic mimickers, whole exome sequencing proves fundamental and can improve the diagnostic rates and understanding of ALSP. A well-informed diagnosis can lead to appropriate preventive genetic counseling to affected families.

Problem Complex brain disorders involve symptoms in the domains of affect, behavior, and cognition. It is increasingly recognized that there is a need for a novel type of physician who can treat individuals with these conditions in an interdisciplinary fashion to best address their complexity. Few training programs have focused on the education of such practitioners. Approach The authors outline the development and practices of the Brain Medicine Fellowship, an innovative, competency-based fellowship program at the University of Toronto Temerty Faculty of Medicine that accepts trainees from multiple brain medicine–related specialty training programs to develop expertise in integrative assessment and treatment of complex brain disorders. The authors describe how brain medicine competencies were generated, the current assessment process, and the seminal clinical experience associated with the fellowship—the Brain Medicine Clinic—and explain how it exemplifies brain medicine in action. Outcomes The first fellow was registered from July 2019 to December 2020. As of December 2022, 3 fellows have entered the program, with 3 more anticipated to begin in July 2023. More than 26 supervisors are associated with the fellowship, who offer a diversity of experiences for fellows to choose from in developing their individualized learning plans. The Brain Medicine Fellowship not only fosters the development of a novel type of clinician (a brain medicine specialist) but also is innovative in its educational design as one of the first nonsurgical fellowships to implement competency-based medical education and has resulted in original clinical programming in the form of the Brain Medicine Clinic, which benefits patients and their caregivers. Next Steps The development of the Brain Medicine Fellowship continues with competency refinement and translation into entrustable professional activities and constituent milestones. A comprehensive program evaluation will be completed by 2025.

Study objectives: To characterize the impact of CPAP use on cognition in a clinical cohort with obstructive sleep apnea (OSA) and cognitive impairment due to neurodegenerative or vascular etiologies after controlling for baseline sleepiness. Methods: We retrospectively analyzed data from 171 patients with cognitive impairment and an OSA diagnosis confirmed with in-laboratory polysomnography or home sleep apnea testing (mean age 69.8 +/- 10.6; 66% male) who were eligible to use CPAP. Baseline and follow-up Epworth Sleepiness Score (ESS), Montreal Cognitive Assessment (MoCA), and Mini-Mental Status Examination (MMSE) were obtained from clinical and research visits conducted before and after CPAP initiation. Good CPAP adherence was defined as CPAP use >= 4 h/night, for 7 days/week at follow-up. Associations between CPAP adherence and follow-up cognitive scores were analyzed using multivariable linear mixed-effects models. Results: After adjusting for age, sex, body mass index, baseline ESS, duration of CPAP therapy, relevant comorbidities and the random effect of research study cohort, good CPAP adherence (compared to poor CPAP adherence or no use of CPAP) for a duration of 2-12 months was associated with a 2.3-point (1.2 -3.3 95% CI) higher follow-up MoCA score (p < 0.001) and a 1.2-point (0.3-2.3 95% CI) higher follow-up MMSE score (p = 0.01). Conclusions: In patients with OSA and cognitive impairment due to a neurodegenerative or vascular etiology, use of CPAP is associated with improved cognitive outcomes. The findings of this study may aid in motivating patients to use CPAP and support future randomized controlled trials in this area. (c) 2022 Elsevier B.V. All rights reserved.

Objective: To outline features of the neurologic examination that can be performed virtually through telemedicine platforms (the virtual neurological examination [VNE]), and provide guidance for rapidly pivoting in-person clinical assessments to virtual visits during the COVID-19 pandemic and beyond. Methods: The full neurologic examination is described with attention to components that can be performed virtually. Results: A screening VNE is outlined that can be performed on a wide variety of patients, along with detailed descriptions of virtual examination maneuvers for specific scenarios (cognitive testing, neuromuscular and movement disorder examinations). Conclusions: During the COVID-19 pandemic, rapid adoption of virtual medicine will be critical to provide ongoing and timely neurological care. Familiarity and mastery of a VNE will be critical for neurologists, and this article outlines a practical approach to implementation.

KEY POINTS During the coronavirus disease 2019 (COVID-19) pandemic, the Canadian Medical Association and provincial health authorities advised physicians to provide virtual care to patients where possible. Virtual care, or telemedicine, has been defined as “any interaction between patients and/or

POINTS CLÉS Pendant la pandémie de maladie à coronavirus 2019 (COVID-19), l'Association médicale canadienne et les autorités sanitaires provinciales ont conseillé aux médecins d'offrir des soins virtuels à leurs patients lorsque c'est possible. Les soins virtuels, ou la télémédecine

We describe the University of Toronto Adult Neurology Residency Program's early experiences with and response to the coronavirus disease 2019 pandemic, including modifications to the provision of neurologic care while upholding neurology education and safety. All academic and many patient-related activities were virtualized. This maintained physical distancing while creating a city-wide videoconference-based teaching curriculum, expanding the learning opportunities to trainees at all academic sites. Furthermore, we propose a novel split-team model to promote resident safety through physical distancing of teams and to establish a capacity to rapidly adapt to redeployment, service needs, and trainee illness. Finally, we developed a unique protected code stroke framework to safeguard staff and trainees during hyperacute stroke assessments in this pandemic. Our shared experiences highlight considerations for contingency planning, maintenance of education, sustainability of team members, and promotion of safe neurologic care. These interventions serve to promote trainee safety, wellness, and resiliency.