Report from Shabnam Khalilova from Azerbaijan visiting the Department of Neurology at the Haukeland University Hospital, Bergen, Norway under the supervision of Professor Ole Björn Tysnes
It was my big dream to visit a European hospital and to observe the working way of doctors there. This EAN programme has helped me to achieve it and to obtain insights which even I did not expect as a doctor and at the same time as a person.
As a doctor, I have observed very different diagnostic and therapeutic approaches to patients which most of them I had just read in guidelines and medical books before. It was great for me to see and practice it lively. For instance: thrombolysis, sonothrombolysis, botox injection for dystonia, DBS, baclofen pump after spinal injury, neuroradiology, DAT scan, apomorphine pump, EMG and finally some medicines which is not used in Azerbaijan. Furthermore, one of the most important things I have learned is how scientists do research in hospitals. I am very encouraged to do so now during my professional life. Before I had not even any idea about this processes.
Meanwhile, regarding to the fact that it was my first visit to Europe, I should admit that I have observed diverse culture, lifestyle far away from my country. Now I am much more open-minded than I used to be before.
To sum up, thanks to all who have created this programme and especially to the one who admitted my application and gave me a chance to visit Norway. Moreover, all staff of hosting department was very kind to me during this period. They gently replied to all my questions. Undoubtedly, this two month will be very beneficial for my specialty.
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Report from Vuk Milosevic from Serbia visiting the Department of Neurology, UMC Ljubljana, Slovenia under the supervision of Professor Zvezdan Pirtosek
I have visited the Department of Neurology, which is a part of Clinic of Neurology, University Medical Center Ljubljana. The head of department is Professor Zvezdan Pirtosek, MD, PhD. This department is divided in two Wards. Ward A is specialized for multple sclerosis and epilepsy and Ward B for neurodegenerative and cognitive disorders. Center for Cognitive Disorders is a part of Ward B where I spent most of my time in Ljubljana. The head of this center is Associate Professor Milica Kramberger. I had oportunity to be part of a daily routine of this department. After the morning meeting I have usually spent my day at the Cognitive Outpatient clinic with Dr. Kramberger.
I had a chance to get familiar with protocols for the assessment of patients with different types of cognitive impairments: mild cognitive impairment, Alzheimer’s disease, Levy body dementia, Vascular dementia, Parkinson`s disease dementia, Fronto-temporal dementias. Protocol consists of history taking from a patient or a caregiver, neurological examination, cognitive screening (using Mini mental state examination (MMSE) and Montreal cognitive assessment (MOCA) scale. Possible mood disorders were assessed using depression scales (Beck`s depression scale and Geriatric depression scale). After that patients were referred for neuropsychological testing, MRI scan, PET and laboratory analysis. I had chance to be present during the neuropsychological testing performed by psychologist. Battery of tests includes RBANS , Stroop test, Tower of London test, California verbal learning test and a few other relevant tasks. Some of examined patients were admitted to daily hospital where lumbar puncture was performed. Cerebrospinal fluid was sent to the local CSF laboratory where levels of Amyloid Beta 1-42, total Tau and P-Tau were measured. I have spent one day in that laboratory, watching how ELISA test was performed. After that Dr. Uros Rot explained me how to interpret results.
Dr. Maja Trost is an Positron Emission Tomography (PET) expert. She was very kind to show me how the FDG-PET recordings are interpreted in patients with cognitive disorders. I had chance to see typical FDG-PET findings in Alzheimers disease, Levy body dementia and Fronto-temporal dementia. I have also spent some time watching interpretation of DaT scans. Department of Neurology in Ljubljana is a very well known center for neurophysiology. I spent some time in their Cognitive neuroscience laboratory. I had chance to see EEG recording equipment and EEG analysis. Dr. Bon invited me to be present during repetitive transcranial magnetic stimulation treatment. This treatment was performed in patients with mood disorders.
During my stay, Department of Neurology was a host of the Internation Conference on Vascular Dementia. Opinion leaders in this field gave a series of interesting lectures and results of the number of studies were presented.
I had also a chance to duscuss future collaboration between our two departments. Prof. Pirtosek said that hopefully, the end of my visit would be just a beginning of our collaboration and future projects.
I would like to express gratitude to my hosts and to EAN for making my visit possible.
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Report from Marina Padroni from Italy visiting the Stroke Unit, University Hospital Vall d’Hebron, Barcelona, Spain under the supervision of Professors Carlos A Molina Cateriano and Marta Rubiera
The objectives of my visit at the Stroke Unit of the Vall d’Hebron Hospital, Barcelona, Spain were:
- Acquisition of knowledge and management of integral stroke diagnosis in the Emergency department. Patient selection for cerebral reperfusion treatments. Management of treatment complications. The trainee will be a part of the stroke team and will participate in the selection of reperfusion treatment candidates.
- Acquisition of knowledge and abilities in Neurosonology applied to stroke patients. This will include diagnosis of different extra-cranial carotid and vertebral stenosis/occlusion degrees and acute intra-cranial stenosis/occlusion by echo-Doppler. It will also include transcranial Doppler (TCD) monitoring of spontaneous or post-fibrinolytic recanalization of the intracranial arteries, sonothrombolysis, microembolic detection, TCD hemodynamic monitoring during endovascular reperfusion therapies and intra-cerebral hemorrhage detection by B-mode transcranial echo-Doppler. The trainee should perform a minimum of 150 carotid/vertebral and transcranial examinations to acquire the Hospital Vall d’Hebron Neurosonology accreditation.
- Acquisition of knowledge and abilities in echocardiography applied to stroke patients. This will include performance of a minimum of 25 echoscan in stroke patients addressed to find a cardioembolic etiology of stroke.
- Attendance of vascular neuro-interventional procedures, participation in clinical discussion and acquisition of knowledge in image reading
- Clinical research project development. Publication in scientific journals and congresses participation.
All the objectives have been satisfied. For the last point, we wrote two abstracts for the International Stroke conference (AHA) and we performed a study that was submitted as paper to Stroke (revision ongoing).
I am very satisfied with my experience.
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Report from Juliia Solodovnikova from Ukraine visiting the Stroke Unit, University Hospital “La Sapienza”, Rome, Italy under the supervision of Professor Vittorio Di Piero
First of all, I want to thank EAN for unique opportunity to undergo this amazing training. During this visit I improved my practical clinical skills, as well as well as acquired new knowledge in the field of cerebrovascular neurology. It was my great pleasure to spend my training at the Stroke Unit of Department of Neurology an Psychiatry of Sapienza University of Rome in Italy under the supervision of Professor Vittorio Di Piero.
It was an interesting and useful practice for me. During my training, I observed the everyday routines in patient’s rooms together with the residents Alessandro and Giulia, who were very so nice and also taught me some basics of the Italian language. After the daily round with professor Di Piero we discussed the results of neuroimaging studies and further tactics of treatment of stroke patients.
The stroke unit consists of six intensive care beds, where management of critically ill stroke patients was provided. Usually, there are hospitalised patients with stroke who are not candidates for thrombolysis or stroke patients from the intensive care unit transfer there after a certain stabilization. In the neurology department A professor Di Piero also supervises four more non-intensive beds for less severe either convalescent patients. During the training, in addition to the daily activity in Stroke Unite, I also spent some time in the emergency department, led by Professor Tony. This department is carried out thrombolysis and I was also able to meet with clinical trials, in which this clinic involved.
In addition to activity at the ward, I also attended the Multiple sclerosis clinic together with Dr. Marta Altieri. Through these visits I was able to improve my knowledge in the tactics of primary choice and next correction of treatment of patients with multiple sclerosis. I want to particularly thank Dr. Barbara Petolicchio, with whom we spend a wonderful time at the headache outpatient clinic and Dr. Massimiliano Toscano for the cerebrovascular one.
Finally, I would also like to thank my supervisor professor Di Piero who gave me full support, both during grant application process and during the training, as well as all staff of the Stroke unit who were so kind and friendly to me. Hope to see you all again!
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Report from Dimitrios Chatzistefanidis from Greece visiting the Epilepsy Center of University Hospital of Freiburg, Germany under the supervision of Professor Andreas Schulze-Bonhage.
The Epilepsy Center in Freiburg is a certified and highly specialized epilepsy center focused on the treatment of drug resistant epilepsy, mainly by offering pre-surgical evaluation by focus localization and surgery planning as well as other methods (nerve stimulation, drug optimization) in cases where surgery treatment is not an option. Together with other highly specialized colleagues (neurosurgeons, neuroradiologists, neuropsychologists, nurses and a continuously growing group of researchers) Epilepsy Center offers some of the best treatment methods and best clinical practices in Europe nowadays in an environment of full support and understanding with lot of activities toward community.
During my stay I was able to take part in the everyday activities of the department. Every day started with the morning meeting where newly admitted and already hospitalized patients were discussed. During the day I was able to attend and take part in all the various aspects of work demanded in such a challenging setting. I was given the opportunity to study and annotate both intracranial and scalp long-term video EEG recordings of currently or previous hospitalized patients. As I was given full access to patients’ data, I was able to fully understand their history, the specific problems and challenge every patient presented and the solutions proposed by the team. My own findings and questions were every time answered and corrected by the always willing to help and explain colleagues. The study of implanted patients gave me a deep insight of the nature of EEG recordings, focus localization, relationship between the symptomatogenic, the irritative, the seizure onset and the epileptogenic zone as well as the various propagation patterns and their reflections on scull EEG recordings. The study of video-EEG recordings allowed me to better understand not only the importance of seizure semiology for focus localization but also the misleading role it may has.
During my stay in the department I was able to attend to methods which are not available in my home department. Among them, of extremely high interest was the mapping of cortical zones in implanted patients for pre-surgical evaluation. I was able to experience the neurophysiological implications of such tests as well as the variations that may appear in the presence of a pathological process.
During the same period I also attended electrode implantation planning, getting a notion of the extreme challenge this planning presents for the attending neurologists. I was allowed to attend neurosurgical operations for intracranial electrode implantation and understand the various problems and complications that may arise. Attending the outpatient clinic gave me the opportunity to observe the treatment of drug-resistant patients in an outpatient basis and the use of other methods in treating resisting forms of epilepsy, like VNS stimulation. I was able to compare the methods and approaches used here with my home department, discussing and understanding the differences and correcting my practice accordingly. Furthermore, the existence of pediatric patients offered me the chance to deal with epilepsy in those ages, an experience I didn’t have as an adult neurologist until now. Entities such as Sotos syndrome, gelastic seizures and Rasmussen encephalitis were among some of the most interesting cases that came along.
Another important activity was the meetings with experts of Epilepsiezentrum Kork, which were organized twice monthly, where complicated cases were presented and discussed. This was an opportunity to understand the complex thinking behind patients management as well as the important role of networking among experts for achieving a high standard of treatment. I was impressed of the detailed method of analyzing complex seizure patterns, the various approaches of interpreting findings and the solutions offered.
Further, as part of a multidisciplinary team environment I attended neuropsychology evaluations and understood their important role in patient management. Similarly, the contribution of neuroradiologists and the important role of imaging technics in treatment resistant forms of epilepsy were made obvious to me during the weekly meetings with experienced neuroradiologists. I came in contact with the use of advanced technics, some of which are not available to my home department. I should not forget to mention the expanded network of researchers working in different scientific areas in Freiburg and their interesting findings many of which may have an immediate impact in epilepsy management in the future. I was able to attend meetings such as the 3rd BrainLinks-BrainTools Annual Meeting which was a delightful experience regarding the complexity of research efforts.
Finally, I would like to mention the surprisingly pleasant city of Freiburg, with its spectacular city center, the great natural environment surrounding the city and the always polite and open-minded citizens. I especially enjoyed my stay in Freiburg, its cultural events, bicycling in its endless bike roads and the weekend trips in its beautiful surrounding area and the Black Forest as well as the neighbouring countries of France and Switzerland.
In summary, my stay in Freiburg as part of the Department-to-Department Cooperation Program (now Clinical Fellowship) gave me the opportunity to closely attend the work done by some of the most prominent leading experts in the field of epilepsy in a technically advanced setting and in terms of multidisciplinary team work. It helped me better understand the field of epileptology, improve my practice and come in contact with methods and approaches not available in my country. Equally important, I had the chance to spend some time in a beautiful city, improve my german language abilities and meet a lot of new people.
Especially, I want to thank Professor A. Schulze-Bonhage for accepting and supporting me during my stay. I would also like to cordially thank Dr. Dirk-Matthias Altenmüller for being always there for me, patiently explaining everything and kindly supporting me during my stay, making me feeling always at home. I want also to thank everyone in the department for their cooperation as well as my Professor and colleagues in my home department who helped me participate in this program. Finally, I want to thank EAN for this special opportunity and encourage other young neurologists to participate in this program.
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Report from Felix Benninger from Israel visiting the Epilepsie Zentrum Berlin-Brandenburg, Koenigin Elisabeth Herzberge Krankenhaus, Berlin, Germany under the supervision of Professor Martin Holtkamp.
It is my great pleasure to report about my eight-week stay at the Epileptology Center, Berlin-Brandenburg headed by Prof. Martin Holtkamp in the frame of the EAN Department to Department Program. I am currently working as a neurologist at a third-referral center in Israel associated with the Tel Aviv University and we are in the process of establishing an epilepsy center including long-term monitoring and Video-EEG recordings for diagnostic purposes, treatment adjustments and in the future to offer epilepsy surgical work-ups at our hospital. In this frame I was very pleased to find the opportunity by the EAN to support me joining an extremely well established epilepsy center and give me a chance to learn the details of the field. The bureaucracy involved to apply for this program was minimal and pleasant. My contact to the EAN, Magda Dohnalova, was very easily available, helpful and extremely pleasant to contact and I cannot recommend any changes for improvement.
My stay at the epilepsy center was organized and planned very well. I was mainly joining the team in the monitoring unit. This is the part of the department in which Video-EEG in a continuous fashion is being performed. I was very warmly welcomed by the resident doctors and worked closely with the epilepsy and EEG expert Dr. Dehneke. The day started with a short handing over of the patients with the nurses. Then every morning at 9am a short discussion about the new admissions followed with the whole team inclusing the neuro-pediatric epileptologists, the doctors from the unit of disabled patients with epilepsy, the adult ward and the monitoring unit. In this morning session sometimes seizures were reviewed and once a week a teaching talk was presented by one of the staff followed by an open discussion. Next EEG and seizure videos had to be reviewed and I was extremely well integrated by receiving my own patients to take care of. Seizures had to be described and EEG recordings being evaluated and Dr. Dehneke was always available for questions and signed off on the EEG reports with a large amount of teaching. Twice a week a Monitoring-Round was held with a discussion about the patients in the monitoring unit and including the head of the department and the technicians, social workers and psychologists. These meetings are extremely valuable and interesting to see the patient’s problems and impressions from the eyes of the other disciplines many times enriching the medical diagnosis essentially. At 4pm every Monday a Case-Conference was held which included the presentation and discussion of 2-3 patients that have completed the continuous Video Monitoring, MRI, fMRi, PET as well as neuropsychology and psychiatry evaluation. Their history is presented, seizures being viewed and discussed and the EEG evaluated as well as imaging reviewed. Here the decision is made how to proceed: further tests like intracranial electrode placement and further seizure recordings or e.g. advice for resection of the epileptogenic focus. I presented here my own patients and this was very helpful to learn and receive corrections. Furthermore many admissions were elective for medication adjustments. Here the newest anti epileptic drugs and their use was discussed and doses adjusted or medication switched. Side effects and drug interactions could be followed and I received an immense amount of new insides into the practical pharmacologic tools in epilepsy. Additionally to the clinical teaching I was invited to attend the weekly Journal club sessions in basic science and physiology and had great insides in the research being done at the Charite University in this field. I was invited and presented one of my researches I commenced in Israel in one of those dates. Also Prof. Holtkamp invited me to attend with the staff a epilepsy meeting with the epilepsy center in Bielefeld and I used the opportunity to spend a whole day at the hospital to also get to know their hardware for Video-EEG monitoring.
One of the first patients I was able to attend to with the other doctors was a patient suffering from a temporal lobe epilepsy, treatment resistant and he was implanted with a large grid of the left temporal lobe to localize the seizure origin. I was able to attend the following lobectomy where 2/3 of his temporal lobe was resected by the neurosurgeons. After the surgery the patient stayed another week at our ward and was attended to until his release home. These kind of highly sophisticated diagnostic procedures and therapeutic approaches have the potential to cure patients from epilepsy instead of only treating the symptom by medication.
The excellent help I received from Prof. Holtkamp and Dr. Dehneke as well as the other doctors on the team was a very memorable experience and I can only recommend the Epilepsie-Zentrum Berlin Brandenburg to anyone interested in learning cutting edge and patient oriented epilepsy treatment. Thank you very much to the staff at the Epilepsie-Zentrum Berlin Brandenburg and especially to Prof. Holtkamp as well as thank you for the EAN for providing me with this excellent experience.
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Report from Tatiana Poliakova from Russia visiting the Department of Neurolgoy, Hospital de Santa Maria in Lisbon, Portugal under the supervision of Professor José Ferro.
I would like to thank Professor José Manuel Cabral Ferro for inviting me to the Hospital de Santa Maria. In addition, I am very grateful to the doctors for their hospitable attitude. I had a great opportunity to watch the work of Prof. Joaquim Ferreira, Prof. Mamede Corvalho, Dr. Miguel Coelho, Dr. Mario Miguel Rosa, Dr. Ana Patricia Antunes, Dr. Rita Peralta, Dr. Ana Verdelho, Dr. Leonor Correia Guedes as well as doctors of other departments. The doctors shared their secrets of treatment. Working with them was enjoyable and informative. I got valuable skills (botulinum toxin, manage with patients during surgery and after DBS).
I discovered new additional approaches in neurological examination and how to use scales. I visited outpatient clinic of epilepsy, multiple sclerosis, ALS, dementia meeting, movement disorders, sleep medicine and neurogenetic. I observed rare cases like Susac’s syndrom, SCA17, Friedreich-Ataxia in outpatients clinic.
I also had an experience in the emergency department. Today I know more about thrombolysis. There were many severe patients resistant to treatment. I learned the peculiarities of therapy in patients with various sonology. For the first time I was present at the surgery of a Parkinson’s disease patient. This is a very complex operation and the role of the neurologist is significant. I have learned a lot of detail.
I also participated in the daily meeting, conferences, concerning disturbance of consciousness, rational use of pharmaceuticals of antiparkinsonian agents in Europe, frontotemporal dementia and neuromelanin-sensitive MR images (in English).
Finally, I’d like to express my gratitude to the EAN for giving me a chance to take part in this programme
