The Brain in Practice

Intracranial disease from epilepsy to cognitive dysfunction and back to vestibular: examination, imaging, fluid and clinical decision making

A two-day advanced course for experienced general practitioners, with practical stations and a CSF wet lab

Concept

This course is written for the experienced general practitioner who sees intracranial cases regularly, refers some of them, and manages the rest alone. It assumes competence and clinical experience, and it assumes no scanner down the corridor. It is built around one question: what do you do on Monday morning, in your own practice, with the resources and the client budget you have?

Three things are done rather than described. Delegates examine live dogs in small groups with a neurologist correcting their technique as they work. They collect cerebrospinal fluid themselves, by both routes, on cadaveric specimens. This is the procedure practitioners are most often told simply to refer, though many could perform it safely if anyone had ever taught them properly. And they read real imaging studies on their own laptops, not slides that already carry the answer.

The remainder of the time is case discussion across the whole intracranial spectrum, from epilepsy through inflammatory disease, vestibular disease and neoplasia to canine cognitive dysfunction. Cognitive dysfunction is included deliberately. It is one of the commonest intracranial presentations in practice and one of the least taught, and the ageing brain is where practitioners most often say they feel unsupported.

How this course differs

The comparison below is the basis on which the course should be marketed. Every claim in the right-hand column carries a corresponding requirement later in this document.

Who the course is for

• Experienced general practitioners who see neurological cases regularly and want to handle more of them confidently.
• Practitioners working towards or holding a general practitioner certificate, or equivalent postgraduate qualification.
• Emergency and out-of-hours clinicians who meet seizures, head trauma and acute vestibular disease first.
• Practice owners and clinical leads deciding what their practice should investigate and what it should refer.

This is an advanced practitioner course, not an introduction to neurology, but if you need to brush up on neurology the course is also for you.

Pre-course

Four weeks in advance, delegates receive a recommended reading list, three practice imaging studies with DICOM viewer installation instructions, and an invitation to submit one anonymised case for the case discussion blocks. Ongoing and unsolved cases are explicitly encouraged: a case that never reached a diagnosis teaches the room more than one that did.

The faculty selects the cases for plenary discussion and tells delegates in advance whether theirs has been chosen, so nobody is put on the spot without warning. Cases not selected receive a short written comment.

Learning outcomes

By the end of the course, delegates will be able to:

• Perform a screening neurological examination within a normal consultation, and a full examination when the screen is abnormal.
• Localise a lesion within the brain reliably and state honestly when localisation is uncertain.
• Decide which patients need advanced imaging, which do not, and what to request when they do.
• Recognise the principal intracranial imaging patterns and read a radiology report critically.
• Collect cerebrospinal fluid safely by the cerebellomedullary and lumbar routes, handle the sample correctly, and decide in advance when a tap should not be performed.
• Diagnose and treat canine and feline epilepsy according to current consensus, including emergency and status management and the recognition of drug resistance.
• Work up and manage inflammatory brain disease, vestibular disease, intracranial neoplasia and canine cognitive dysfunction to the appropriate point in first opinion practice.
• Hold a truthful conversation with an owner about prognosis, cost, referral and the option of not investigating – learn how to put contextual care into practice.

Format

• Two days, 08:30 to approximately 17:40, plus an optional evening session on Day 1.
• Maximum 24 delegates.
• Groups of four at the live dog stations and pairs at the CSF wet lab, with one instructor per station.
• Approximately 55 per cent of contact time is practical, wet lab or structured case discussion.
• Delegates bring their own laptops with a DICOM viewer installed.
• Course notes, the full imaging and video teaching library, and a laminated protocol pack are provided.
• A ninety-minute online case clinic is held approximately three months after the course, included in the fee.

The protocol pack

Every delegate leaves with a set of single-page laminated aids designed for the consulting or preparation room wall, not for a folder nobody opens again:

• The three-minute screening neurological examination.
• Full neurological examination record sheet, suitable for the clinical notes.
• Status epilepticus and cluster seizure protocol, including at-home rescue medication and owner instructions.
• Head trauma and raised intracranial pressure algorithm with the Modified Glasgow Coma Scale.
• Cerebrospinal fluid collection checklist, including the contraindications.
• Referral decision aid: what to refer, when, and what to say about cost and prognosis.

These are the items delegates will still be using in a year, and they are worth the production cost.

Assessment and certification

Delegates sit the same ten-case video paper at the start of Day 1 and the end of Day 2, and receive both scores confidentially. The CSF wet lab carries a written competency list against which each delegate is signed off. The certificate records the practical stations completed, not simply attendance. That is what allows the course to be marketed as advanced.

Holger A. Volk ​(Germany)
DVM, PGCAP, PhD, DipECVN, FHEA, FRCVS
(Neurology)

Holger is currently Professor of Small Animal Diseases and the Head of Department of Small Animal Medicine and Surgery, University of Veterinary Medicine Hanover, Visiting Professor of Veterinary Neurology and Neurosurgery, Royal Veterinary College, London and Affiliate Professor of Veterinary Neurology, University of Copenhagen. He graduated from the University of Veterinary Medicine Hanover in 2001, where he also did his PhD in Neuropharmacology studying basic mechanisms of drug-resistant epilepsy. He then completed his specialist clinical education doing an internship and a residency in Neurology and Neurosurgery at the Royal Veterinary College (RVC). The RVC also provided him with the chance to not only excel academically and clinically, but also in his leadership skills, going through the reigns from lecturer to head of service, clinical director of the Small Animal Referral clinic and last as head of department of clinical science and services. Holger is internationally known for his work in the field of SARS-CoV-2 Medical Scent Detection Dogs, neuropathic pain and epilepsy. He was President of the European College of Veterinary Neurology and active in the Executive Board of Veterinary Specialisation as treasurer. Holger has been chairing the International Veterinary Epilepsy Task Force, which published seven consensus statements for canine and feline epilepsy and was a co-chair of the recent published ACVIM consensus statement about medical treatment of epilepsy and emergency seizures, and ECVN consensus about movement disorders. He has been a recipient of several Jim Bee educator excellent in teaching awards, Professor of the year in Germany (2nd rank biomedical sciences, Unicum), the prestigious Bourgelat Award and also the Woodrow from BSAVA, and the International Canine Health Award from the Kennel Club, and the Royal College of Veterinary Surgeons (RCVS) International Award. In 2022, Holger became fellow of the RCVS for Meritorious Contributions to Clinical Practice. He has published multiple books and book chapters, >300 articles, >180 conference abstracts, and is a frequent flyer on the international conference circuit.