bluuebunny/crossref_metadata_2025 huggingface dataset:
WP1-18 Risk factors and patterns of recurrence of low grade glioma: a systematic review
Authors: Narbad V , Lavrador JP , Elhag A , Acharya S , Hanrahan J , Vergani F , Bhangoo R , Ashkan K
Published: February 2019

Objectives

To review the risk factors and patterns of progression/recurrence of low grade glioma (LGG).

Design

Systematic review of the published literature.

Subjects

Inclusion criteria were peer reviewed publications of cohort studies of recurrent/progressive LGG. Studies of wider populations were included if relevant LGG data could be analysed separately.

Methods

Medline and Cochrane databases were searched using MeSH and non-MeSH terms, including ‘glioma’, ‘astrocytoma’, ‘oligoastrocytoma’, ‘diffuse glioma’, ‘oligodendroglioma’, ‘low grade’ and ‘disease recurrence’ by two independent reviewers.

Results

Overall, 917 studies were screened, of which 57 studies met the inclusion criteria. The most frequently described risk factor for recurrent LGG was suboptimal extent of resection (EOR) of the initial tumour (in 20 studies); recurrence was also associated with the patient’s age (2), tumour location (4), neurological status (3), tumour volume (6), bihemispherical tumour (3) and astrocytic histology (6). IDH mutation was associated with recurrence in 1 out of 3 studies, but TP53 mutation (2 of 4) and MGMT methylation status (4) were not. Malignant transformation was associated with TP53 mutations (3), IDH mutation (1) and EOR (1). Favourable progression free survival (PFS) and/or overall survival (OS) were associated with greater EOR (16), oligodendroglioma histology (2 of 4), initial KPS (3) and the use of adjuvant therapies (9 of 14). IDH mutation was associated with improved PFS and OS (3 of 4). TP53 mutation improved PFS in 1 of 3 studies. MGMT methylation and 1 p/19q codeletion may predict treatment response but their effects on survival are unclear.

Conclusions

Astrocytoma histology, IDH and TP53 mutation statuses and surgical treatment (EOR) are essential in determining the time to recurrence or progression in LGG.
WP1-20 Investigating immunotherapy as an adjunct to surgery for brain metastases
Authors: Zakaria Rasheed , Jenkinson Michael D
Published: February 2019

Objectives

Brain metastases (BM) are more common due to improved survival from solid organ cancers. Immunotherapy is a promising treatment but little is known about the intracranial effects and there are no predictive biomarkers of response.

Design

We examined a prospective database of BM patients to compare those treated with surgery and immunotherapy versus surgery and standard adjuvant therapy.

Subjects

We identified 51 adult patients over 12 months operated for BM.

Methods

Outcomes of 7 patients treated with surgery and immunotherapy were compared with matched controls, as well as examining the timing of surgery, radiation therapy and immunotherapy.

Results

Patients received ipilimumab or pembrolizumab alone or in combination. Median overall survival was greater in the group receiving immunotherapy (44 months vs. 14 months) despite no significant difference in primary, age or RPA score but there was no difference in intracranial progression. One patient with melanoma receiving ipilimumab prior to surgery underwent supra-marginal resection and peritumoral tissue showed growth pattern, macrophage and T-cell infiltration were all significantly different compared to matched melanoma cases not pre-treated with immunotherapy.

Conclusions

Immunotherapy and surgery have been proposed to act synergistically on BM. Immunotherapy certainly influences the BM microenvironment and prolongs overall survival. A prospective biomarker study is planned to investigate the use of brain imaging as a predictor of systemic response to immunotherapy.
WP1-21 Maximum safe resection of large medial temporal intrinsic tumours: does the outcome justify the risk?
Authors: Kumaria A , Paterson A , Sitaraman M , Basu S
Published: February 2019

Objectives

To analyse on the long-term outcomes in patients undergoing maximum safe resection (MSR) for large intrinsic temporal tumours.

Design

Case series

Subjects

All patients undergoing MSR of large medial temporal intrinsic tumours between May 2006 and February 2012 at a tertiary neurosurgical centre with a minimum follow up of 6 years.

Methods

Retrospective review of hospital records.

Results

Fifty-one patients underwent MSR (28 male, 23 female); age range 20–80 years (mean age 55.3). There was no difference in laterality, although dysphasia was a feature in 32% of left-sided lesions. Presenting features in general included seizures (46%), headaches (27%), hemiparesis (12%) and visual field defects (6%). Surgery was generally well tolerated (median post-operative Karnofsky score 92.5). No patients developed new dysphasia or weakness, but there was transient worsening of existing hemiparesis (n=4) and dysphasia (n=2). Other complications included CSF leak/pseudomeningocoele (n=2), oculomotor palsy (n=1) and wound infection (n=1). Histopathological casemix was GBM (50%), WHO 3 gliomas (14%), WHO 2 gliomas (10%) and metastases (4%). In total, 57% of patients received radiotherapy and 35% received chemotherapy. Survival correlated with pathology; in glioblastoma patients it ranged from 2–19 months (mean 10.4 months). Survival in grade 3 tumours ranged from 10–38 months (mean 24.4 months). 60% of patients with Grade 2 tumours are surviving symptom free with no histological upscale at 8–10 years follow-up. No patient required a second debulking procedure.

Conclusions

MSR did not result in survival benefit in glioblastoma. MSR is justified in lesions with pre-operative radiological features of Grade 2 glioma.
TM1-2 Diffuse low grade glioma after the 2016 WHO update, seizure characteristics, imaging correlates and outcomes
Authors: Roberts M , Hayhurst C , Shires J , Northmore T
Published: February 2019

Objectives

Seizures are a common presenting symptom in patients with low grade glioma (LGG). Exact mechanisms of epileptogenesis are unknown and the influence of radiological and histological characteristics are not well studied, particularly after the 2016 WHO reclassification of gliomas. We aimed to define predictors of seizure development and outcome in patients with LGG.

Design

Retrospective single institution case series.

Subjects

63 patients who underwent resection of supratentorial LGG in a single institution, 45 presented with seizures.

Methods

Retrospective analysis of patient records to assess seizure outcome and other demographics including radiological variables, tumour characteristics, type of surgery and histology based on the 2016 WHO update.

Results

After surgery, 33 patients (73%) who presented with seizures were Engel class I at median follow up of 43 months. Complete and near total resection were associated with improved Engel class compared to subtotal resection. Awake craniotomy gave improved seizure outcomes compared to under general anaesthesia (84% vs 65%). Molecular genetics did not predict seizure outcome. Updated histology did not predict seizures at diagnosis, only tumour heterogeneousity on initial MRI (p=0.043). Tumour volume at presentation impacted EOR but not seizure outcome.

Conclusions

Seizure outcome is directly related to EOR. Tumour histology based on molecular genetics did not predict seizure development or outcome. Use of awake craniotomy results in greater EOR and improved Engel class.
TM1-3 Improved prediction of surgical resectability in patients with glioblastoma multiforme using an artificial neural network
Authors: Marcus A , Marcus HJ , Camp SJ , Nandi D , Kitchen N , Thorne L
Published: February 2019

Objectives

In managing a patient with glioblastoma multiforme (GBM), a surgeon must weigh up whether sufficient tumour can be removed so that the patient can enjoy the benefits of decompression and cytoreduction, without impacting on the patient’s neurological status. In a previous study we identified the five most important anatomical features on a pre-operative MRI that are predictive of surgical resectability and used them to develop a grading system. The aim of this study was to apply an artificial neural network (ANN) to improve the prediction of surgical resectability.

Methods

A prospectively maintained database was searched between February and August 2017 to identify all adult patients with supratentorial GBM that underwent resection. Pre-operative MRI scans were scored using the aforementioned grading system and post-operative scans assessed to determine the extent of resection. Performance of the standard grading system and ANN were then evaluated by analysing their Receiver Operator Characteristic curves; Area Under Curve (AUC) and accuracy were calculated and compared using the t-­test with a value of p<0.05 considered significant.

Results

In all, 47 patients were included, of which 18 (38.3%) were found to have complete excision. The AUC and accuracy were significantly greater using the ANN compared to the standard grading system (0.87 vs. 0.79 and 0.81 vs. 0.77 respectively; p<0.01 in both cases).

Conclusions

An ANN allows for improved prediction of surgical resectability in patients with GBM.
TM1-5 Optimising observation strategies for incidentally discovered intracranial meningiomas
Authors: Islim AI , Mohan M , Moon RDC , Mills SJ , Brodbelt AR , Haylock BJ , Rathi N , Kolamunnage-Dona R , Jenkinson MD
Published: February 2019

Objectives

Develop a model to identify incidental meningiomas at risk of observation failure.

Design

Retrospective study (2007–2015).

Subjects

385 patients. Mean age 62.6 years.

Methods

Observation failure was defined as: new symptoms, MRI progression (absolute growth rate 2 cm3/year or absolute growth rate 1 cm3/year +relative growth rate 30%/year) or loss of treatment options. A prognostic model was developed using MRI and patient comorbidity.

Results

Over a median of 36 months, 44 (10.9%) meningiomas failed observation. Median time to failure was 33 months. Model parameters were based on statistical and clinical considerations and included: increasing tumour size (HR=2.17 [95% CI=1.53–3.09], p<0.001), peritumoural signal change (HR=1.58 [95% CI=0.65–3.85], p=0.313), FLAIR/T2 hyperintense meningiomas (HR=10.6 [95% CI=5. 39–21.0], p<0.001) and proximity to neurovascular structures (HR=1.38 [95% CI=0.74–2.56], p=0.314). Patients were stratified based on the model into low, medium and high-risk groups and rates of failed observation at 5 years were 3%, 28% and 75% respectively. Low-risk patients had small meningiomas, free of all risk factors. After 5 years of follow-up the probability of failure plateaued in all risk groups. Older patients with comorbidities were 15-times more likely to die than to receive intervention at 5 years following diagnosis, regardless of risk group.

Conclusions

Most meningiomas remain clinically and radiologically stable. Stratifying follow-up according to risk-group has the potential to reduce the cost to healthcare.
TP1-1 Endovascular versus surgical management of pericallosal artery aneurysms, single centre experience
Authors: Draz MS , Toma AK , Bezouich S , Grover P
Published: February 2019

Objectives

Comparing surgical versus endovascular management of pericallosal artery aneurysm.

Design

Retrospective case series.

Subjects

Patients managed in our unit for pericallosal artery aneurysms.

Methods

Patients medical and radiological records were reviewed collecting data about presentation, management, complications. Clinical outcome was assessed by mRS at 3,6 and 12 months. Imaging were reviewed to report aneurysm size and treatment outcome.

Results

Average follow up period 3.3 years SD ±3.5. 38 patients had SAH and 19 were incidentally discovered. Initial CT showed SAH in 21 patients, IVH in 3,ICH in 3 IVH and ICH in 9. 33 patients treated using endovascularly, 13 patients conservatively and 2 by surgical clipping. 33% of endovascular group had stroke caused by approach related complications. 41.3% of the patients had mRS (0–2) at 3 months period. Increased to 46.5% at 12 months. Average imaging follow up was 1.5 years (SD ±1.6). 36.3% of endovascular group showed aneurysm remnant filling or recurrence.

Conclusions

Pericallosal artery aneurysms are complex in nature and both management modalities are challenging. Complications were high in endovascular group. Surgical intervention should be considered in selected patients where complex intervention is required.
TP1-4 In vitro induced cytokine response of astrocytes modelling conditions in human traumatic brain injury
Authors: Thelin EP , Hall CE , Frostell A , Tajsic T , Carpenter KLH , Hutchinson PJA , Patani R , Helmy A
Published: February 2019

Objectives

The objective of this study was to investigate how in vitro astrocyte cultures respond to cytokine pro- and anti-inflammatory cytokine concentrations, corresponding to those seen in the aftermath of human TBI, by analysing downstream cytokine generation.

Design

In vitrostudy.

Subjects

Human induced pluripotent stem cells (iPSC)-derived astrocytes.

Methods

The astrocytes were exposed to levels of TNF (1–10,000 pg/ml), IL-6 (100–1,000,000 pg/ml), Interleukin-1β (IL-1β, 1–10,000 pg/ml), Interleukin-4 (IL-4, 1–10,000 pg/ml) and Interleukin-10 (IL-10, 1–10,000 pg/ml). Following 24, 48 and 72 hours, culture supernatant was extracted and analysed using a human cytokine/chemokine 39-plex luminex assay (ThermoFisher).

Results

The astrocyte secretome revealed concentration-, time- or concentration*time-dependent production of downstream cytokines (12, 8 and 2 cytokines, respectively p<0.05). IL-1β and TNF exposure generated the most downstream cytokine production, while IL-6, IL-4 and IL-10 did not generally induce a robust response.

Conclusions

iPSC-derived astrocytes exposed to cytokine concentrations reflecting those in TBI generate an increased downstream cytokine production, especially when exposed to IL-1β and TNF. This is in contrast to our previous work on neuronal cultures where IL-1β only produced a few down-stream cytokines.1More work is needed to better understand how different cells in the CNS respond to the neuroinflammatory milieu after TBI alone and in combination.
TP1-6 Pathological patterns of spinal cord blood flow after injury visualised with laser speckle contrast imaging
Authors: Gallagher MJ , Hogg FRA , Saadoun S , Papadopoulos MC
Published: February 2019

Objectives

In humans the effect of spinal cord injury (SCI) on spinal cord blood flow (SCBF) is poorly understood. We imaged SCBF intraoperatively using laser speckle contrast imaging (LSCI).

Methods

We recruited 4 patients without SCI and 22 patients with SCI. Inclusion criteria for SCI patients are: AIS A–C, 18–70 years old, surgery within 72 hour of injury. In the SCI patients, we monitored spinal cord perfusion pressure and microdialysis from the injury site for 24 hour postoperatively. Mean patient follow-up after SCI was 7 m.

Results

LSCI signal is dampened by cerebrospinal fluid, but not dura. In patients without SCI we observed intact autoregulation, as well as SCBF variation with cardiac cycle, respiratory cycle and arterial pCO2. In SCI patients three pathological SCBF patterns were seen: necrosis-penumbra, patchy-perfusion and hyper-perfusion. Increase in MAP (>20 mmHg) increased overall injury site SCBF, but in 5/22 SCI patients there was a local steal effect where SCBF increased in some regions but decreased in others. In 7 SCI patients there was diastolic ischaemia, with regions only perfused in systole, but not diastole. Low injury site SCBF correlated with low spinal cord perfusion pressure, low tissue glucose, high tissue lactate and less improvement in combined sensory AIS score at follow-up.

Conclusions

LSCI can be used to visualise SCBF non-invasively with high spatial-temporal resolution. We observed pathological SCBF patterns after SCI and some unanticipated SCBF responses to blood pressure changes.
TP1-7 Extended glasgow outcome scale – when would you rather die?
Authors: Hasan S , Uff C
Published: February 2019

Objectives

Extended Glasgow Outcome Scale is the primary outcome measure in trials involving neurotrauma patients. Conventional dichotomization characterises unfavourable outcomes as upper severe disability or worse, however RESCUE-ICP changed this to consider upper severe disability as a favourable outcome. As the recent consensus meeting in Cambridge proved, opinion of what constitutes acceptable recovery can vary widely between individuals.

Design

To survey patients with brain injury and compare them to the opinions of staff routinely involved in the care of such patients.

Subjects

Patients with brain injuries, neurosurgery staff and ITU staff.

Method

GOS-E sheets were given to neurotrauma patients and asked to circle the outcome they considered unfavourable and therefore would rather not survive. This was compared to the same question posed to neurosurgery staff members, and ITU staff members.

Results

67 responses collected (20 patients, 27 neurosurgery staff, 20 ITU staff). Mean GOS-E score deemed unfavourable and therefore not worth survival was 3.6, mode 3 (Patient mean 3.15, mode 3. Neurosurgery mean 3.63, mode 4. ITU mean 4.0, mode 5. p>0.05).

Conclusion

What constitutes unfavourable outcome varies between each group of people questioned. Patients who have experienced brain injuries were more likely to feel that upper severe disability was an acceptable outcome when compared to the staff that care for them. It is imperative we take this in to consideration when recommending treatment strategies in an acute setting.
TP1-9 Vestibular dysfunction in acute traumatic brain injury
Authors: Tsang K , Marcus HJ , Paine H , Sargeant M , Jones B , Smith R , Wilson MH , Seemungal BM
Published: February 2019

Objectives

Vestibular dysfunction following traumatic brain injury (TBI) is a major cause of morbidity and unemployment and has impact on the patient’s ability to rehabilitate. Chronically, up to a quarter of TBI cases have cryptogenic dizziness and imbalance, possibly due to chronic brain adaptation that masks the diagnosis. Establishing the spectrum of vestibular diagnoses in acute TBI – when they may be more obvious – may aid diagnosis in chronic TBI cases.

Design

Prospective audit of referrals to specialist neuro-otology team.

Subjects

Consecutive Major Trauma Ward TBI in-patients admitted between June 2014 and May 2015.

Methods

All cases were screened by the therapists for vestibular symptoms and/or signs and referred for specialist neuro-otology review.

Results

Of 111 patients screened, 96 had features of vestibular dysfunction. Of 96 cases, SYMPTOMS (i.e. subjective report) included: – imbalance (58.3%) – headache (50%) -dizziness (40%) Of 96 cases, SIGNS (i.e. examination) included: – gait ataxia (75.5%) – broken smooth pursuit (61.2%) – positive Hallpike (51%) – positive head impulse test (18%). The data indicate that BPPV affects 49% and headache with migraine-like features affect 40.8%. Acute peripheral unilateral vestibular loss affects 18% TBI cases.

Conclusions

Vestibular dysfunction in TBI is common, typically involving peripheral and central structures, often in the same case, and requires specialist neuro-otological management.
TP1-10 Non tumour brain biopsies in alder hey paediatric neurosurgery
Authors: Tonder LV , Foster M , Hennigan D , Kneen R , Iyer A , Parks C , Burn S , Mallucci C
Published: February 2019

Objectives

To review the utility of non-tumour brain biopsies in Alder Hey Children’s NHS Foundation Trust Paediatric Neurosurgery Department.

Methods

Operative records were searched for ‘biopsy’. Case notes were reviewed for referral source, histology, surgical complication and outcome. Tumour, epilepsy and non-brain biopsy cases were excluded.

Results

83 ‘biopsy’ cases were identified between 2008 and 2017. 31 tumour, 5 epilepsy, 2 infections and 28 non brain/other biopsies were excluded. 17 brain biopsies for non-tumour causes were seen. 15 patients were referred by neurology, 2 by rheumatology. 14 underwent a craniotomy/mini-craniotomy, 3 had burrholes.4 biopsies were non diagnostic, 2 were abnormal but inconclusive for diagnosis. Diagnoses included: 3 demyelinating lesions, 2 normal brain tissue, 1 neurosarcoidosis, 1 autoimmune encephalitis, 1 definite Rasmussen’s Encephalitis, 1 possible Rasmussen’s Encephalitis, 1 systemic lupus erythematosus associated CNS vasculitis, 1 inflammatory infiltrate (secondary to hydrocephalus/ventriculitis), 1 patient developed a late wound infection. No other surgical morbidities/mortalities were recorded. 11 of these cases had a change in management or the treating team were reassured due to the result of the biopsy (i.e. were able to start immunomodulatory drugs in the absence of infection).

Conclusions

65% of brain biopsies were diagnostic. 71% of biopsies either changed management or reassured the treating team about a line of management. The procedure is low risk with 0.06% morbidity and 0% mortality.
TP1-11 MS-STAT2: a phase 3 trial of high dose simvastatin in secondary progressive multiple sclerosis
Authors: Williams E , John NA , Blackstone J , Brownlee W , Frost C , Greenwood J , Chataway J ,   T.p.h.l.s.t.8.a.A.f.l.o.a.c.c.b.p.o. request
Published: February 2019

Objectives

Disease modifying treatment for secondary progressive multiple sclerosis (SPMS) represents a major unmet need. We outline here the rationale for the MS-STAT2 trial – a phase 3 study of simvastatin in decreasing clinical progression in SPMS. MS-STAT2 will be a landmark study not only for patients with SPMS, but also for the area of drug repurposing and academically led clinical trials as a whole.

Design

Multicentre, double blind, parallel group randomised placebo-controlled trial. It follows the positive outcome from the phase 2 MS-STAT1 trial, which demonstrated a 43% reduction in the annualised rate of brain atrophy compared to placebo.1

Subjects

1180 patients with SPMS with an expanded disability status scale (EDSS) score of 4.0–6.5. Patients need to show evidence of disease progression over the preceding 2 years.

Methods

Subject will be recruited at 28 sites across the UK, and randomised to simvastatin 80 mg or matched placebo and assessed every 6 months over the 3 year trial.

Results

The primary outcome measure is time to 6 month confirmed disability progression, based on change in Expanded Disability Status Scale (EDSS) scores compared to baseline. Secondary outcomes include assessments of cognition, walking, upper limb function and vision. Sub-studies will include advanced imaging outcomes, ocular coherence tomography and fluid biomarkers.

Conclusions

MS-STAT2 is set to be a pivotal trial for SPMS. Recruitment has now commenced and further sites are welcome.

Reference

Chataway J, et al. MS-STAT. Lancet2014;383:2213–21.
TP2-4 The impact of social deprivation upon global traumatic brain injury outcome
Authors: Humphries TJ , Singh R , Ingram S , Sinha S
Published: February 2019

Objectives

The aim of this study was to assess the impact of social deprivation upon global TBI outcome.

Design

The study was a prospective observational study.

Subjects

1332 consecutive adult TBI patients were recruited into the study. 131 study participants were lost within the study.

Methods

All patients were assessed by the acute TBI team at the point of their injuries. Both injury and demographic data was collated at this point including: age, gender, medical comorbidities and GCS. The measure of social deprivation used, was the Indices of Multiple Deprivation (IMD) Score. The outcome measure, conducted at 12 months post-injury, was the GOSE. Univariate analyses were conducted prior to the final Multinomial Regression, between the GOSE score and injury factors.

Results

With regard to the representation of IMD deciles, the study population and the general population are two independent groups, but the standard deviation is sufficiently similar for them to be considered pooled (equal variance)(t-test p=0.139). Within the univariate analyses statistically significant relationships were noted between IMD and GOSE (p≤0.00). There was no relationship noted between IMD and GCS at the time of injury (p=0.409), or medical co-morbidity (p=0.682). The multinominal regression revealed a significant relationship between between worsening GOSE and IMD, Age, Medical Comorbidity and GCS (p≤0.00).

Conclusions

There is a statically significant relationship between increasing social deprivation and worsening global TBI outcomes.
TM3-1 Idiopathic intracranial hypertension: consensus guidelines on investigation and management
Authors: Mollan SP , Davis B , Silver NC , Shaw S , Malucci C , Wakerley BR , Krishnan A , Chavda SV , Ramalingam S , Edwards J , Hemmings K , Williamson M , Burdon MA , Hassan-Smith G , Digre K , Liu GT , Jensen RH , Sinclair AJ
Published: February 2019

Objectives

The aim was to capture interdisciplinary expertise from a large group of clinicians, reflecting practice from across the UK and further, to inform subsequent development of a national consensus guidance for optimal management of Idiopathic Intracranial Hypertension.

Design

Consensus guideline critically reviewed by the Association of British Neurologists, British Association for the Study of Headache, the Society of British Neurological Surgeons and the Royal College of Ophthalmologists.

Subjects

An initial UK survey of attitudes and practice in IIH was sent to a wide group of physicians and surgeons.

Methods

Between September 2015 and October 2017 a specialist interest group including neurology, neurosurgery, neuro-radiology, ophthalmology, nursing, primary care doctors, and patient representatives met. A comprehensive systematic literature review was performed to assemble the foundations of the statements.

Results

Over twenty questions were constructed: One based on the diagnostic principles for optimal investigation of papilloedema and twenty-one for the management of IIH. 3 main principles were identified:

to treat the underlying disease;

to protect the vision and

to minimise the headache morbidity.

Statements presented provide insight to uncertainties in IIH where research opportunities exist.

Conclusions

In collaboration with many different specialists, professions and patient representatives we have developed guidance statements for the investigation and management of adult IIH.
TM3-2 The expanding burden of idiopathic intracranial hypertension
Authors: Mollan SP , Aguiar M , Evision F , Frew E , Sinclair A
Published: February 2019

Objectives

To quantify the hospital burden and health economic impact of Idiopathic Intracranial Hypertension.

Design

Observational cohort study.

Subjects

All those within England with a diagnosis of Idiopathic Intracranial Hypertension were included.

Methods

Hospital Episode Statistics (HES) national data was extracted between 1 st January 2002 and 31 st December 2016. Those with secondary causes of raised intracranial pressure such as tumours, hydrocephalus and cerebral venous sinus thrombosis were excluded.

Results

23 182 new IIH cases were diagnosed. 52% resided in the most socially deprived areas. Incidence rose between 2002 to 2016 from 2.3 to 4.7 per 1 00 000 in the general population. Peak incidence occurred in females aged 25 (15.2 per 100,000). 91.6% were treated medically, 7.6% had a cerebrospinal fluid diversion procedure. Elective caesarean sections rates were significantly higher in IIH (16%) compared to the general population (9%), p<0.005. Admission rates rose by 442% between 2002 and 2014, with 38% having repeated admissions in the year following diagnosis. Costs rose from £9.2 to £50 million per annum over the study period with costs forecasts of £462 million per annum by 2030.

Conclusions

IIH incidence is rising (by greater than 100% over the study), highest in areas of social deprivation and mirroring obesity trends. Re-admissions rates are high and growing yearly. The escalating population and financial burden of IIH has wide reaching implications for the health care system.
TP3-3 Why do some patients fail to respond to VNS? – a retrospective analysis of cardiac based seizure detection (CBSD) therapy
Authors: Wysota B , Samarasekera S , Hamilton P , Soryal I
Published: February 2019

Objectives

To identify predictors of poor response to cardiac based seizure detection (CBSD) VNS therapy.

Design

Data was collected retrospectively for patients with epilepsy who had VNS Aspire SR implanted between June 2014 and June 2017. 51 patients who reached a therapeutic level of stimulation were included. We compared those who achieved significant seizure reduction (at least 50%) with the remainder to identify potential factors predicting response.

Subjects

51 patients achieving therapeutic stimulation (1.5mA) with the VNS Aspire SR.

Methods

We reviewed patients’ electronic records over the period between June 2014 and June 2018.

Results

32 (63%) patients achieved significant seizure reduction. The following factors applied equally to both responders and non-responders: patient age, duration of epilepsy prior to VNS insertion, seizure type, the presence of a causative structural abnormality and the presence of a carer. Co-existing learning disability and/or non-epileptic attacks were commoner among poor responders. Polytherapy (3 or more AEDs) and non-compliance with medical treatment were also commoner among the poor responders; none of these factors was statistically significant.

Conclusions

Factors potentially predicting response to resective surgery (including patients’ age and duration of epilepsy) do not necessarily predict response to VNS therapy. The presence of a learning disability and the extent of seizure refractoriness may influence response to VNS therapy; a larger study is needed to assess their significance.
TP3-4 Changes in whole brain connectomes with simulated laser interstitial thermal therapy (LITT) using seizure free and non-seizure free ablation cavities in mesial temporal sclerosis: a graph theory approach
Authors: Vakharia N , Manchini M , Vos B , Li K , McEvoy A , Sparks R , Ourselin S , Duncan S
Published: February 2019

Objectives

LITT is a novel means of focal lesioning. Improved seizure free outcome has been associated with the extent to which the mesial hippocampal head is ablated, but not overall ablation volume. We question whether specific changes in structural network connectivity exist in patients that achieve seizure freedom.

Design

Retrospective

Subjects

25 MTS patients after LITT with 2 year outcome.

Methods

Ablation cavities from 11 seizure free and 14 non-seizure free patients were combined to generate group masks. In 12 separate pre-operative patients with MTS (6 right), weighted normalized connectomes were generated with 1 × 10^7 streamlines. To simulate ablations the group cavity masks were excluded from the connectomes prior to normalization. Differences in connectomes were assessed by graph theory metrics.

Results

Greater node strength (str) in non-seizure free patients were present in the ipsilateral basal temporo-occipital cortices in both right and left MTS. Str and local efficiency were relatively maintained in the ipsilateral thalamus of seizure free cavities. Betweenness centrality in non-seizure free cavities were greater in ipsilateral temporal poles in right and left MTS.

Conclusions

Differences in network connectivity are present following simulated LITT for MTS between seizure free and non-seizure free ablation cavities. LiTT ablation cavities may be pre-operatively modelled to ensure the ablation cavity includes important structures and non-essential or inhibitory connectivity is spared. Prospective validation is required.
TP3-6 Preliminary evaluation of diagnostic home video telemetry (HVT)
Authors: Stern W , Leschziner G , Howard R , Koutroumanidis M
Published: February 2019

Objectives

To assess the clinical usefulness of HVT over the first 2 years.

Design

Cohort observational.

Subjects

60 patients (49 F) with epilepsies or non-epileptic paroxysmal clinical events.

Methods

48–72 hour continuous video EEG at patients’ own environment.

Results

HVT answered the primary clinical question in 45/60 patients (75%), and provided additional clinical information in 5 patients [2 with unsuspected coexistent psychogenic non-epileptic seizures (PNES) and 3 with unsuspected sleep disorders (SD)]. Of the 12 patients with Idiopathic Generalized Epilepsy, absences had been overestimated in 6 and underestimated in 4, while absence status was recorded in 1 of the 2 patients in whom it had been suspected. Valproate was possible to drastically reduce or stop in 3/6 women. Focal seizures were recorded in 19 of 28 patients with focal epilepsies, PNES were the habitual seizures in further 2 patients, while syndrome classification changed in one. In all 4 patients referred for differentiation between SD and epilepsy, HVT confirmed parasomnias in 2, daytime naps in 1 and idiopathic hypersomnia in 1. The diagnosis of PNES was confirmed in 8 of 13 suspected patients. HVT was unhelpful in the 3 patients referred for not witnessed, poorly understood episodes of loss of consciousness. Three patients switched off the video and 2 failed to change battery on day 2.

Conclusions

HVT is a useful diagnostic test provided that diagnostic hypothesis and clinical question are appropriate.
FM1-2 A prospective study on surgical management of foot deformities in charcot marie tooth disease
Authors: Laura M , Ramdharry G , Singh D , Kozyra D , Skorupinska M , Reilly M
Published: February 2019

Objectives

Charcot-Marie-Tooth (CMT) Disease is the most common inherited peripheral neuropathy. Foot deformities are frequently observed in CMT patients and orthopaedic surgery is often required. Currently the evidence base on surgical management is limited. We prospectively studied surgical management of CMT patients attending our centre.

Subjects

Patients were assessed at baseline and yearly after surgery.

Methods

Assessment and data included: history of ankle instability, pain, skin condition, lower limb strength assessment, Charcot-Marie-Tooth Examination Score, Foot Posture Index, ankle dorsiflexion range of movement, questionnaires, details of surgical procedures.

Results

29 feet in 24 CMT patients (17 males, 7 females, mean age: 38.6±13) were evaluated prior to surgery. All patients but one had genetically confirmed CMT (18 CMT1A; 4 CMTX; 1 CMT4A). 17 feet in 12 pts were evaluated after 1 year; 10 feet in 9 pts were evaluated after 2 years; 8 feet in 7 pts were evaluated after 3 years. A wide range of surgical procedures were performed by one dedicated orthopaedic surgeon. There was significant improvement of foot alignment (p<0.001), callosities (p=0.002) and pain (p=0.022) after surgery. Surgery had no significant effect on strength, ankle range of movement, falls and fatigue.

Conclusions

The findings showed significant improvement of foot alignment, callosities and pain after surgery. Data acquired from this study will help developing orthopaedic intervention guidelines and identify areas for further research.
FM1-4 Intraneural perineuriomas: radiologically classic, clinically varied
Authors: Kapoor Mahima , Pierce Kirsten , Quaegebeur Annelies , Lunn Michael P , Carr Aisling S , Shah Sachit , Reilly Mary M
Published: February 2019

Objectives

Intraneural perineurioma is a rare, benign neoplasm of peripheral nerve. The histopathological features are well defined.

Design

We describe 5 cases of histologically confirmed perineuriomas and 14 cases diagnosed on clinical and radiological characteristics to highlight the features of this rare entity.

Methods

We identified cases from the imaging and histopathology database and conducted a retrospective case note review.

Results

The subjects include 7 men and 12 women, with mean (standard deviation) age of 17.64 (13) years at onset of symptoms. 14 of the 15 lower limb cases were located in the sciatic nerve or its divisions. 1 each was identified in ulnar, median and radial nerves and 1 case was in a facial nerve. The MRI features were homogenous between the groups. The nerves biopsied included 1 tibial, 1 ulnar, 1 radial, 1 facial and 1 sciatic all showing classic pathology findings. 2 patients, interestingly, had coincidental intracranial meningioma, given the recent discovery of a potential shared pathogenesis (mutations in TRAF7) with intracranial meningiomas. 2 patients had ‘skip lesions’ within the same nerve and 3 patients had foraminal and extraforaminal involvement of lumbosacral nerve roots.

Conclusions

Our unit now favours the clinicoradiological features for diagnosing perineuriomas rather than performing a biopsy on all patients. Also, the potential shared pathogenesis with meningiomas raises the clinical issue of screening in patients with perineuriomas but more clinical evidence is required.
FM1-5 The impact of neurosurgical technique on outcome of adult patients with chiari I malformation
Authors: McAllister SM , Gallo P
Published: February 2019

Objectives

This study aimed to compare and evaluate any differences in clinical and radiological outcomes between three surgical techniques of cranio-cervical decompression (CCD) in adults with symptomatic Chiari malformation type I (CM1).

Design

Retrospective review using the theatre management system (ORSOS) and records of the patients who underwent CCD for CM1 from January 2011 to January 2018.

Subjects

Patients over 16 years of age who underwent CCD secondary to CM1 diagnosed by clinical and radiological criteria.

Methods

Patients were divided in three cohorts according the operative technique used: an extradural osteo-ligamentous decompression (BD), BD plus dural opening either without duroplasty (DOWD) or with watertight augmentative duroplasty (DOPD). The primary clinical outcome was measured by utilizing the Chicago Chiari Outcome Scale (CCOS). Syrinx outcome was measured on post-op MRI. Statistical analysis was performed using IBM SPSS 24 with α=0.05.

Results

Fifty-two adults underwent fifty-three CCD: 7 BD, 29 DOWD, 17 DOPD. Median follow-up was 12 months (IQR 6–23). Patients who underwent BD or DOPD had a shorter median hospital stay (6 days) than DOWD (11 days). Median CCOS was lower following DOWD (13) compared to BD (14) and DOPD (15). Post-operative complications were higher in DOWD (51.7%) compared to DOPD (17.5%).

Conclusions

Better clinical outcomes, lower complication risk and shorter duration of hospital stay were associated with DOPD. Prospective randomized studies could confirm these findings.
FM1-7 Cranio-cervical instability in ehlers-danlos syndrome employing upright, dynamic MR imaging; a comparative study
Authors: Prezerakos GK , Khan F , Davagnanam I , Smith F , Casey AT
Published: February 2019

Objectives

Ehlers-Danlos syndrome (EDS) is a hereditary connective tissue disorder leading to hypemobile joints including the craniocervical junction. Neck pain is a prominent feature. Structural abnormalities may have a dynamic element and thus may not be captured in a recumbent MRI. There is currently a lack of evidence1assessing the use and diagnostic impact of positional MRI in Ehlers-Danlos syndrome. We aim to evaluate structural features and dynamic instability in an EDS cohort employing dynamic MR imaging against a non EDS symptomatic cohort.

Design

Comparative Study.

Subjects

Patients diagnosed with Ehlers-Danlos syndrome and control subjects (non EDS with cervical spondylosis) were included in this study.

Methods

Cranio – cervical spine global and segmental movement parameters in the neutral, extension and flexion positions were measured from T2-weighted images in the midline sagittal plane. These parameters included the clivo axial angle, grabb oakes line, C2 sagittal vertical axis, C0-C1 angle, C1-2 angle, cervical lordosis and T1 slope.

Results

The clivo- axial angle measured in neutral was 139.7±10.4 degrees in the EDS group vs 148.9±8.4 in the control group (p<0.01) The cervical range of movement between flexion and extension was 74.6±24.4 in the EDS group vs 39.4±11.3 in the controls (p<0.0001).

Conclusions

EDS patients with neck symptoms exhibit different static as well as dynamic craniocervical structural features compared to a general population control.

Reference

Ont Health Technol Assess Ser[Internet]2015July;15(13):1–24.
FP1-2 Implementation of duty of candor regulation within neurosurgery: a national cross-sectional survey
Authors: Marcus HJ , Sayal P , Kitchen N , Surajit B , Thorne L
Published: February 2019

Objectives

Statutory Duty of Candor was introduced in 2014 for NHS bodies in England. Contained within the regulation were definitions regarding the threshold for what constitutes a notifiable patient safety incident. The aim of this survey was to evaluate the interpretation of these definitions by British neurosurgeons.

Methods

Full members of the SBNS were electronically invited to participate in an online survey. Surgeons were presented with 15 cases and asked to decide in each one whether they would trigger the process of Duty of Candor. Cases were stratified according to their likelihood and severity.

Results

In all, 106/357 (29.7%) members participated in the survey. Responses varied widely with almost no members triggering the process of Duty of Candor in cases where adverse events were likely (>10% likelihood) and required only outpatient follow up (7/106; 6.6%), and almost all members doing so in cases where adverse events were rare (<0.1% likelihood) and resulted in death (102/106; 96.2%). However, there was clear equipoise in triggering the process of Duty of Candor in cases where adverse events were unlikely (0.1%–10% likelihood) and resulted in moderate harm (38/106; 35.8%), severe harm (57/106; 53.8%), or death (49/106; 46.2%).

Conclusions

There is considerable nationwide variation in the interpretation of definitions regarding the threshold for Duty of Candor; this has important implications with some providers at risk of penalties, and others unduly burdened by the associated administrative processes.
FP1-4 Factors affecting patient flow in a neurosurgery department
Authors: Irvine S , Chharawala F , Lawrance N , Peterson D , Banerjee S , Camp S
Published: February 2019

Objectives

The objectives of this study were to audit the NHS Improvement SAFER patient flow bundle, evaluate the impact of the Red2Green initiative, and assess the impact of frailty on patient flow.

Design

A prospective review over a 3 month period.

Subjects

All patients admitted to a Neurosurgery Unit from 01/09/2017 to 30/11/2017 were included.

Methods

Data were prospectively collected from daily ward lists and patient notes, including demographics, admission/discharge details, length of stay (LOS), expected discharge date, red days with reasons, and frailty (Rockwood Clinical Frailty Scale). NHS Improvement Reference Costs were used for cost analyses.

Results

420 patients (55% elective) were included, total 3909 bed days. All patients received a daily senior review before midday, and EDDs were set at daily MDT meetings. 10% patients were discharged before midday. There were 21% (837) red days, significantly more (76%) for emergency patients (639 vs 198 elective; p<0.001). 63% red days were attributed to awaiting a bed in a local hospital. 25% (106) patients were classed as frail (50 elective), which was associated with a significantly longer LOS (17.3 vs 6; p<0.01), and more red days (615 vs 222; p<0.01). Considering bed costs and lost revenue (with penalties), red days cost is estimated at over £1M per year.

Conclusions

SAFER has identified areas for improvement in patient flow, with obvious cost implications. It has created a platform for discussion within the referral network, and identified a role for a geriatric liaison service.
FP1-6 Factors influencing clinician’s participation in neurosurgical research – a multicentre cross-sectional study
Authors: Ansaripour A , Burford C , Hanrahan J , Korkor A , Ashkan K , Zebian B
Published: February 2019

Objectives

Research remains a foundation in advancing the field of neurosurgery. We explore attitudes and perceived barriers to conducting research in neurosurgery globally.

Design

A 29-item questionnaire, consisting of multiple-choice questions, Likert scales and short answers.

Subjects

Clinicians at various stages of the Neurosurgical career.

Methods

The questionnaire was distributed through the Society of British Neurological Surgeons (SBNS) and European Association of Neurosurgical Societies (EANS).

Results

A total of 324 responses from 29 countries consisted of Clinical Fellows (n=26), Junior Trainees (n=48), Senior Trainees (n=46), Sub-specialty Fellows (n=18), Consultants (n=128) and Professors of Neurosurgery (n=58). Whilst 83% of participants believe research is a crucial aspect of a neurosurgeons’ career, only a third (33%) believed that neurosurgery as a speciality fosters a culture that promotes research. The top three perceived barriers to conducting research were lack of time (78%), insufficient access to funding (58%) and lack of mentorship (49%). Despite these, more than 87% of participants are interested in formal academic roles with 58% willing to interrupt clinical training to pursue research opportunities. The region of clinical practice had no correlation with respondents’ research output or their perceptions towards research barriers.

Conclusions

This study identified important barriers to research, elucidating which, allows the neurosurgical community to improve integration of research into clinical practice.
FM2-1 A smartphone camera can detect functional tremor
Authors: Williams S , Fang H , Shepherd S , Alty J , Graham CD
Published: February 2019

Objectives

Functional neurological disorders are common, but there is a lack of objective tests for these conditions. Although accelerometry can distinguish functional from other tremor types, it is not routinely used at the bedside. Computer vision describes the processing of camera images by computer. It requires only ubiquitous hardware (e.g. smartphone, laptop) and standard clinical assessment, i.e. simple observation. We investigated computer vision to detect tremor distraction/entrainment in functional tremor.

Design

Early results comparing computer analysis of video from a functional tremor and an essential tremor.

Methods

30 s (60 fps) video of extended forearm was recorded using a smartphone, for a functional tremor and an essential tremor patient. From 15 s, each participant tapped in time with a 3 Hz metronome using the contralateral hand (outside the video frame). Computing algorithms amplified the magnitude of video pixel movement and then measured the direction and size of pixel movement over time.

Results

After the metronome onset, there was a marked change in video pixel movement for the functional tremor patient, with the frequency concentrating at 3 Hz, and this was statistically significant by linear discriminant analysis. There was no significant change in pixel movement after the metronome for the essential tremor patient (frequency remained 8–12 Hz).

Conclusions

Smartphone video pixel movement can detect functional tremor entrainment, suggesting a possible new objective, bedside test.