David Matthew Greer

Competency in brain death/death by neurologic criteria (BD/DNC) determination is an Accreditation Council for Graduate Medical Education (ACGME) milestone in neurology residency and neurocritical care fellowship; however, trainees have limited clinical exposure and receive inconsistent training across institutions. Simulation offers a standardized, safe environment to teach and assess BD/DNC, but multi-institutional implementation remains unstudied. The aim of this study was to evaluate the feasibility of implementing a consensus-based BD/DNC curriculum and to assess its impact on trainee confidence. By the end of the curriculum, trainees will be confident in assessing BD/DNC prerequisites, performing a complete neurologic examination, safely conducting and interpreting apnea testing, and accurately declaring BD/DNC. Through an iterative consensus process, 3 simulation cases addressing BD/DNC confounders were developed and implemented across high-fidelity and low-fidelity settings. Neurology residents and neurocritical care fellows were recruited by email from 6 academic centers in the United States. Participants each completed one case and received debriefing. Learning objectives were assessed using a 17-item, 5-point Likert pre/postsurvey assessing confidence across 4 BD/DNC domains: “Setup and Family Counseling,” “Prerequisites,” “Neurologic Examination,” and “Apnea Test and Declaration of BD/DNC.” Composite domain medians were compared using the Wilcoxon signed-rank test, and change scores (post–pre) were compared between fidelity groups using the Mann-Whitney U test. Nineteen participants (9 female [47%]; predominantly PGY-4 trainees) were enrolled. Median [IQR] pre-post composite confidence scores improved significantly across all domains: “Setup and Family Counseling,” 4 [3.5–4] to 4.5 [4–5]; “Prerequisites,” 4 [4–5] to 4.5 [4–5]; “Neurologic Examination,” 4 [4–4] to 4.5 [4–5]; and “Apnea Test and Declaration of BD/DNC,” 3 [3–4] to 5 [4–5]. The effect sizes (Wilcoxon r) ranged from 0.79 to 0.88 across domains. There were no significant differences in the magnitude of improvement between high-fidelity and low-fidelity groups. After curriculum implementation, 13 of 19 participants (68%) self-assessed their ACGME BD/DNC milestone competency to be level 4 or 5. This multi-institutional pilot demonstrated that a consensus-based BD/DNC simulation curriculum is feasible and improves trainee confidence despite limited previous clinical exposure. Key lessons include the feasibility of multicenter collaboration, standardizing core practices while accommodating local variability, and designing adaptable curricula that achieve similar outcomes across resource-diverse settings.

The Guest Editors of this issue of Seminars in Neurology are Drs. Christopher Tarolli and Ralph Józefowicz. Dr. Tarolli is Associate Professor of Neurology at the University of Rochester Medical Center in Rochester, New York, United States, where he serves as Associate Chair for Education in the Department of Neurology. Dr. Tarolli's professional work includes clinical expertise in movement disorders with a specific focus on advanced therapies and nonmotor symptom management in individuals with Parkinson's disease. Additionally, he completed fellowship training in clinical trial design and implementation and has an active role in clinical research in Parkinson's disease. Dr. Tarolli's principal professional interest is in neurologic education, and specifically in methods to optimize learning for a diverse group of trainees and mitigate neurophobia. He completed a Master of Science in Health Professions Education and has active roles in curricular design, assessment, and educational scholarship both at the University of Rochester and with national organizations. He is clearly one of the rising leaders in medical education in our field, and we feel quite fortunate to have had him as a Guest Editor for this issue! Dr. Józefowicz, MD, is Professor of Neurology at the University of Rochester and served as the Neurology Residency Program Director between 1996 and 2021. His many teaching accomplishments include two Fullbright Scholar Awards for Lecturing in Neural Sciences and Clinical Neurology from the Jagiellonian University Medical College in Krakow, Poland in 1993 and in 2022; the Gold Medal Award for Excellence in Medical Student Education from the Alumni Association of the University of Rochester School of Medicine and Dentistry in 1998; the Distinguished Teacher Award from the American Neurological Association in 1998; the Robert J. Glaser Alpha Omega Alpha Distinguished Teacher Award from the Association of American Medical Colleges in 2002; the A. B. Baker Lifetime Achievement Award for Neurologic Education from the American Academy of Neurology in 2010; the Edithe J. Levit Distinguished Service Award from the National Board of Medical examiners in 2011; the Merentibus Medal “for great services rendered to the Jagiellonian University” in 2014; the Chair's award from the American Brain Foundation in 2015; the President's Award from the American Academy of Neurology in 2016; the Leading in Excellence through Mentorship award from the American Academy of Neurology in 2018; and the Alumni Service Award from the University of Rochester School of Medicine and Dentistry in 2018. Dr. Józefowicz has held numerous leadership positions in national medical societies and has served on the boards of directors of the National Board of Medical Examiners, the American Academy of Neurology, the American Board of Psychiatry and Neurology, the American Brain Foundation, and the United Council for Neurologic Subspecialties. He is a luminary in the field of Neurology Education! We hope you find this issue of Seminars in Neurology as timely, informative, and practical as we did. Medical education has changed—for both the learners and the teachers, and finding the way to educate the next generation of students, residents, and fellows is both challenging and highly rewarding. These issues help to navigate those changing currents and reaffirm neurology education as central to all medical education. It is incumbent upon us to continue to deliver education in the most practical and meaningful ways, and Drs. Tarolli and Józefowicz expertly provide us with the blueprint to do so. We hope you enjoy this wonderful issue of Seminars in Neurology on Update in Neurologic Education. Article published online: 11 March 2026 © 2026. Thieme. All rights reserved. Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Background: Large middle cerebral artery (MCA) infarctions can result in life-threatening cerebral edema. Quantitative brain atrophy may improve risk stratification for severe edema. We examined whether quantitative brain atrophy is associated with severe midline shift after large ischemic stroke and whether incorporating atrophy improves prediction beyond established clinical and radiographic predictors. Methods: This was a retrospective observational cohort study of patients with ≥½ MCA ischemic infarction, presentation within 24 hours of last known well, and at least one follow-up head CT, admitted to two academic hospitals with comprehensive stroke centers between 2006 and 2024. The study was approved by the institutional review boards of both centers. Brain atrophy was quantified as the inverse of standardized brain volume on admission head CT. The primary outcome was severe radiographic mass effect, defined as midline shift ≥5 mm on follow-up CT. The secondary outcome was in-hospital mortality. Multivariable regression models assessed associations between quantified atrophy and outcomes. Incremental prognostic value was evaluated by comparing models with and without atrophy using measures of goodness of fit, calibration, and discrimination. Results: Among 565 patients (mean age 67.5±15.7 years; 49.9% female), 223 (39.5%) developed severe mass effect. Greater atrophy was associated with lower odds of midline shift ≥5 mm (OR 0.44, 95% CI 0.34-0.58), but not with in-hospital mortality. Incorporation of atrophy significantly improved prediction of severe mass effect compared to the baseline model (likelihood ratio test χ² (1) = 41, p <0.001; AIC 703 vs. 741; BIC 733 vs. 767; AUC 0.68 vs. 0.60). Conclusions: Quantified brain atrophy is independently associated with a reduced risk of severe mass effect after large MCA stroke and improved the performance of established predictive models. Incorporation of this imaging biomarker may enhance early risk stratification, monitoring, and intervention planning for patients at risk of life-threatening cerebral edema.

The guest editors of this issue of Seminars in Neurology are Dr. Mary Angela O'Neal and Dr. Barbara A. Dworetzky. Mary O'Neal, MD, FAAN, is an internationally regarded expert in Women's Neurology and Functional Neurological Disorder. She completed her neurology residency and a vascular neurology fellowship at Boston University, and was on faculty at Brigham and Women's Hospital/Harvard Medical School from 1995 to 2025 where she directed the Women's Neurology Program and Fellowship until accepting a position this past fall as an associate professor of neurology at the University of Pittsburgh Medical Center to lead their Women's Neurology Education and Functional Neurology Division. She is an adept educator and a sought-after speaker who led the Harvard Medical School course in Women's Neurology and Psychiatry for many years, as well as the “Neurology of Pregnancy” courses at the American Academy of Neurology meetings. Dr. O'Neal has published multiple papers in her areas of expertise, edited several books, and is a sought-after national and international speaker on women's health in neurology and functional neurological disorders. Barbara A. Dworetzky, MD, FAAN, FANA, FAES, is a professor of neurology at Harvard Medical School, the A.J. Trustey Endowed Chair in Neurology, and the former chief of the Epilepsy Division at the Brigham and Women's Hospital and Clinical Neurophysiology Fellowship director for many years. She received an ScB with Honors in Psychology from Brown University, her MD from Albert Einstein College of Medicine (interning at Montefiore Medical Center, NY), residency at the former Harvard Longwood Neurology Program (now Mass General Brigham), and a 2-year fellowship in clinical neurophysiology/epilepsy at the Brigham and Women's Hospital, Boston Children's, and Beth Israel Deaconess Medical Center. Dr. Dworetzky has helped train/mentor >65 clinical and research fellows from all over the world and has over 147 peer-reviewed publications, multiple book chapters, and speaking invitations, and has co-edited a book for clinicians on integrating care in functional seizures and is internationally known for this work. She has received awards for leadership, professionalism, mentorship, and her clinical skills. Dr. Dworetzky has served on multiple boards for patient and professional societies, and is currently the President of the Functional Neurological Disorder Society (FNDS). We are so grateful for the efforts of Drs. O'Neal and Dworetzky, as well as all of the contributing authors, for their amazing contributions in this issue of Seminars in Neurology. In recent years, neurologists have not only gained a great appreciation of functional neurological disorder, which touches virtually every aspect of neurology, but we are also now better understanding how to respect and care for these individuals, helping them recover to lead healthier lives. Drs. O'Neal and Dworetzky are heading this effort nationally and internationally, and we are so appreciative of their leadership. I would like to personally thank Drs. O'Neal and Dworetzky for their dedication to this issue, one which I personally very much enjoyed reading and learning about! We hope you also enjoy this issue of Seminars in Neurology on Functional Neurologic Disorder! Article published online: 27 February 2026 © 2026. Thieme. All rights reserved. Thieme Medical Publishers, Inc. 333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

The Guest Editors of this issue of Seminars in Neurology are Drs. Scott Grossman and Rachel Kenney. Dr. Scott Grossman is Assistant Professor of Neurology and Ophthalmology at NYU Grossman School of Medicine. He earned his medical degree from the University of Pennsylvania and trained in Neurology, Clinical Neurophysiology and Neuro-ophthalmology at New York University (NYU). He then joined the NYU faculty and sees a broad array of patients referred for visual issues that arise from the connection between the eyes and brain. His research interests include investigation of neuro-ophthalmic biomarkers in both ocular motility (video-oculography) and optical coherence tomography (OCT) for characterization of neurologic disease. He has been involved in the validation of teleneurology as a tool for care delivery, and has pursued work investigating remote models of care in neuro-ophthalmology, as well as education in teleneurology. Other areas of interest include the use of machine learning models in OCT, eye movement recordings, and other aspects of neuro-ophthalmology. He is a Fellow of the North American Neuro-Ophthalmology Society, and has received numerous awards for his outstanding educational impact. He has served as Chair of the Neuro-ophthalmology and Neurovestibular Disease Special Interest Group for the American Neurological Association. He is a renowned national and international speaker. Dr. Kenney is Assistant Professor of Neurology and Population Health at NYU School of Medicine. She received her PhD in Epidemiology from Vilcek Institute of Graduate Biomedical Sciences at NYU. Her main research focuses on the visual pathway in multiple sclerosis and other neurological conditions, using OCT imaging, artificial intelligence (AI), and electronic health record data to improve diagnosis and better understand disease mechanisms. Since 2014, she has been an integral part of the IMSVISUAL consortium, with a focus on expanding research and education activities in MS research, and currently serves on the Board of Directors. She regularly participates in bi-annual symposiums at academic conferences related to dissemination of scientific research and is leading development of a global registry for visual outcomes in neuroinflammatory disorders. Within the NYU community, she is a biostatistics/epidemiology mentor for residents and medical students in their annual research and weekly didactics courses. She has served as Chair, Panelist, and Speaker at conference events related to AI and OCT worldwide and has been an invited speaker throughout Europe for her groundbreaking work in AI and machine learning in the diagnosis of demyelinating disease of the central nervous system. We greatly appreciate the efforts of Drs. Grossman and Kenney, as well as all of the contributing authors, for their wonderful work in this issue of Seminars. Artificial intelligence is a hot topic in neurology, as well as in medicine in general. It is also one that is difficult to stay on top of, given the rapid change and advances made seemingly on a daily basis. This update is timely, insightful, and impactful, and makes a challenging topic not only understandable but a welcome addition to our field. I would like to personally thank Drs. Grossman and Kenney for their dedication to making this a very fine issue, one which I personally enjoyed reading and learning from very much! We hope you enjoy this marvelous issue of Seminars in Neurology! Article published online: 13 February 2026 © 2026. Thieme. All rights reserved. Thieme Medical Publishers, Inc. 333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

BACKGROUND: The Society of Vascular and Interventional Neurology (SVIN) Guidelines and Practice Standards Committee issues Brief Practice Updates to provide concise, evidence-based recommendations and suggestions on focused topics relevant to vascular and interventional neurology. Currently, there is limited published guidance on the technical performance and interpretative parameters of cerebral digital subtraction angiography for the determination of cerebral circulatory arrest in patients being evaluated for brain death/death by neurological criteria. In this Brief Practice Update, we present consensus-based suggestions for standardizing the performance, interpretation, and application of digital subtraction angiography in this context. METHODS: This Brief Practice Update was developed using the SVIN Standards and Parameters for Guideline Development in the classification of evidence and Class of Recommendation when evidence is available and Expert Opinion recommendation when evidence is lacking. The Guidelines and Practice Standards committee convened a multidisciplinary writing group to establish key clinical questions and develop a survey assessing Expert Opinion on the role of digital subtraction angiography in cerebral circulatory arrest determination. Survey items addressed technical considerations, interpretation criteria, and clinical integration. Iterative refinement was achieved through group consensus, and the final survey was distributed to a panel of experts in neurointervention and neurocritical care. The SVIN Guidelines and Practice Standards Quality Committee reviewed the findings for adherence to SVIN’s internal evidence evaluation guidelines before submission to the SVIN board for societal endorsement. RESULTS: Evidence was evaluated by the writing group when available, and Expert Opinion was assessed using survey results. Suggested recommendations follow the established SVIN guideline framework for Class of Recommendation and Level of Evidence, with an Expert Opinion endorsement category for areas lacking high-quality evidence at the time of publication. CONCLUSIONS: This update standardizes how to perform, interpret, and report digital subtraction angiography when used to assess cerebral circulatory arrest in brain death/death by neurological criteria evaluations, aiming to improve reproducibility across centers. It provides a structured framework to improve consistency and reliability among practitioners performing and interpreting cerebral angiography in this setting.

This position statement provides updated member guidance from the American Academy of Neurology (AAN) regarding (1) communication with surrogate decision makers about brain death/death by neurologic criteria (BD/DNC), (2) management of surrogate decision-maker objections to BD/DNC, (3) the ethical considerations associated with BD/DNC determination in a pregnant person, and (4) enhancing public trust in BD/DNC. This position statement is intended to complement recommendations in the 2023 "Pediatric and Adult Brain Death/Death by Neurologic Criteria Consensus Guideline" published by the AAN, American Academy of Pediatrics, Child Neurology Society, and Society of Critical Care Medicine, as well as the 2021 AAN Code of Professional Conduct. It replaces the 2019 AAN position statement, "Brain death, the determination of brain death, and member guidance for brain death accommodation requests."