bluuebunny/crossref_metadata_2025 huggingface dataset:
LEVETIRACETAM IS INDEPENDENTLY ASSOCIATED WITH FATIGUE IN ADULT GLIOMA OUTPATIENTS
Authors: Zienius Karolis , Rooney Alasdair , Grant Robert
Published: October 2015

Aims

To identify the frequency and severity of fatigue in adults with cerebral glioma, and its association with anti-epileptic drugs (AED).

Methods

Cross-sectional study. Stable glioma patients attending Edinburgh Neuro-Oncology clinic completed a fatigue Visual Analogue Scale (range 0-100mm, “high” >=60 mm). AED type and dose were recorded.

Results

One hundred and sixty six patients were enrolled (61% males; mean age 49 yrs; 70% high-grade glioma). Among all patients, 43% reported high fatigue (95% CI 35–50%). Sixty eight percent were taking AEDs (58% of which were non enzyme inducing). Levetiracetam (LEV) was the most common AED. LEV monotherapy correlated with higher fatigue levels (mean=57 mm, SD 5.2, 95% CI 46–67 mm), compared with other AEDs (mean=43 mm, SD 3.9, 95% CI 35–50 mm, ANCOVA p=0.04). Patients taking LEV had poorer Karnofsky Performance Scores (KPS, Mann–Whitney p=0.03). The effect of LEV on fatigue was independent of KPS (LR p<0.0001, R2= 27.7, OR 2.7 [1.1–6.2]).

Conclusions

Glioma patients on levetiracetam therapy are more fatigued than patients on other or no anti-epileptic therapy. Changes to AED medications may benefit patients with troublesome fatigue.
A CASE OF ENLARGED VIRCHOW ROBIN SPACES CAUSING PROGRESSIVE HEMI SENSORY SYMPTOMS
Authors: Agrawal Amit , Zaidi S , Rathi B , Codony M
Published: October 2015

Introduction

Virchow Robin Spaces (VRS) or perivascular spaces are usually an incidental finding but rarely they can enlarge and causes neurological symptoms. We report a case of symptomatic VRS with striking appearance on MRI Scan.

Case description

A 33 year lady presented with progressive sensory disturbances which initially affected her right arm and later on right side of face. Her MRI Brain scan showed enlarged Virchow Robin Spaces in the left corona radiata corresponding to her symptoms.

Importance

Our case highlights a common MRI finding, typically considered incidental but which can be symptomatic in some cases. The typical scan characteristic and location of Virchow Robin spaces can help to differentiate from close mimics like cystic mass lesion. Its awareness can avoid frequent repeated imaging and interventions.
THE MANY FACES OF MELAS
Authors: AlMasri Omar , Massey Tom , Mukhopadhyay Diptarup , Walters R Jon
Published: October 2015

Mitochondrial encephalomyelitis, lactic acidosis and stroke-like episodes (MELAS) syndrome is the most common of the rare mitochondrial disorders. It frequently is secondary to a point mutation in mitochondrial DNA m.3243 A to G. The main features of the disease include myopathy, encephalopathy, lactic acidosis, stroke-like episodes, seizures and migraine however the clinical presentations can vary widely. Age of onset of the disease has a wide range but patients are typically under 40 years of age, nonetheless cases have been reported in the elderly population. A number of drugs have been used for the management of patients with MELAS including CoEnzyme Q10, Vitamin K-3, Vitamin K-1, Ascorbate and Riboflavin. It is also important to note that seizures in MELAS can be difficult to manage often requiring a combination of antiepileptic drugs. We report the case of a 76-year-old man (the second oldest diagnosed case to the authors' knowledge) whose case exemplifies the complexity of diagnosing and managing these patients including the complications of the disease.
IMPACT & TREATMENT OF NON-MOTOR SYMPTOMS IN EARLY PARKINSON'S DISEASE
Authors: Baig Fahd , Lawton Michael , Rolinski Michal , Ruffmann Claudio , Nithi Kannan , Evetts Samuel , Fernandes Hugo , Ben-Shlomo Yoav , Hu Michele
Published: October 2015

Objective

To delineate treatment and quality of life of non-motor symptoms (NMS) in early Parkinson's disease (PD) and first-degree relatives.

Background

Non-motor symptoms (NMS) are an important prodromal feature of Parkinson's disease (PD). However, their frequency, treatment rates and impact on health-related quality of life (HRQoL) in the early motor phase is unclear.

Methods

769 population-ascertained PD subjects within 3.5 years of diagnosis and 287 control subjects were assessed. Validated severity questionnaires were employed to assess NMS symptoms across the following domains: (1) neuropsychiatric (2) gastrointestinal (3) sleep (4) sensory (5) autonomic (6) sexual. Health related quality of life (HRQoL), functional status and management were also evaluated.

Results

NMS were common in early PD. More than half of the PD cases had hyposmia, pain, fatigue, sleep disturbance or urinary dysfunction. PD cases had worse HRQoL scores than controls (OR 4.1, p<0.001) with depression, anxiety and pain being stronger drivers than MDS-UPDRS motor scores. Quality of life is affected in early PD, although 23% of participants reported no problems. NMS were rarely treated in routine clinical practice.

Conclusions

Despite their major impact on HRQoL, NMS are usually under-recognised and treated. The use of screening tools could improve recognition and treatment of NMS in early PD.
VISUOSPATIAL TESTS TO SCREEN FOR IMPAIRED COGNITION IN PARKINSON'S
Authors: Cosgrove Jeremy , Jamieson Stuart , Smith Stephen , Alty Jane
Published: October 2015

Objective

To determine which test of visuospatial function – copying a wired cube (‘cube’) or interlocking pentagons (‘pentagons’) – is the best screening tool for detecting cognitive impairment in Parkinson's, as defined by abnormal Montreal Cognitive Assessment (MoCA) score.

Methods

107 Parkinson's subjects completed the MoCA and copied pentagons from the Mini-Mental State Examination (MMSE). They were classified into two groups based on MoCA score: <26 (cognitive impairment (CI)) or ≥26 (normal cognition (NC)). Cube and pentagons were scored using MoCA and MMSE criteria.

Results

The CI group (n=57) was older (p 0.032) but disease duration, stage and medication were not different. 28% of CI and 72% of NC correctly copied cube. 69% of CI and 92% of NC correctly copied pentagons. Inability to correctly copy cube (p<0.001) or pentagons (p 0.003) was associated with CI. Age adjusted odds ratio for predicting cognitive impairment was 6.85 (2.97–16.39, p 0.001) for incorrect cube and 4.61 (1.41 – 14.93, p 0.011) for incorrect pentagons.

Conclusions

Incorrect cube was the most predictive visuospatial marker of cognitive impairment in Parkinson's. This is potentially useful when assessing cognitive function in a busy outpatient clinic, for example. Larger numbers are required for validation.
FINGER TAPPING AND COGNITION IN PARKINSON'S
Authors: Cosgrove Jeremy , Lacy Stuart , Jamieson Stuart , Smith Stephen , Alty Jane
Published: October 2015

Objective

To investigate separable components of finger tapping (FT) of the thumb and index finger in Parkinson's (PD) with normal (PD-NC) and impaired cognition (PD-CI) and in healthy controls (HC).

Methods

58 PD and 29 HC performed FT for 30 seconds whilst attached to electromagnetic movement sensors sampling at 60 Hz. All subjects completed the Montreal Cognitive Assessment (MoCA); PD-NC defined as MoCA score ≥26, PD-CI as MoCA score <26.

Results

PD and HC were age-matched. Mean disease duration of PD 6.2 years, Hoehn and Yahr stage 1.9. Mean MoCA score PD 23.1, HC 26.3 (P<0.001). PD had significantly (P<0.01) smaller mean velocity and amplitude of FT, greater decrement of speed and greater variability of rhythm (speed and amplitude coefficient of variation).

Age, disease duration, motor score and levodopa dose were not significantly different between PD-CI (n=36) and PD-NC (n=22). PD-CI had significantly less rhythmic FT movements than PD-NC (P<0.01) but other parameters were similar. MoCA score was negatively correlated with rhythm in PD (P 0.017).

Conclusion

As expected PD have slower, less rhythmic FT movements with greater decrement than HC. Those with PD-CI have significantly less rhythmic movement than those with PD-NC – this finding is currently being investigated.
REWARD SENSITIVITY DEFICITS UNDERLIE APATHY IN PARKINSON'S DISEASE
Authors: Muhammed Kinan , Manohar Sanjay , Tofaris George , Lennox Graham , Bogdanovic Marko , Hu Michele , Husain Masud
Published: October 2015

Apathy is increasingly appreciated to be a major problem in Parkinson's disease (PD), with up to 70% of cases affected. The mechanisms underlying the condition are poorly understood and objective detection methods are lacking. We used eye movement and pupil modulation in response to rewards as metrics of motivation to assess the relation of reward sensitivity to apathy and influence of dopaminergic medication.

30 patients with idiopathic PD, tested ON and OFF medication, and healthy age-matched participants made saccades for different monetary rewards. Saccadic peak velocity and pupil diameter were measured using an infrared eye-tracker, while apathy was indexed by Lille Apathy Rating Scale scores.

PD patients ON demonstrated increased saccadic velocity and pupil diameter as reward magnitude increased, just like controls. This reward sensitivity was blunted in PD patients OFF dopaminergic medication. Crucially, apathetic PD patients exhibited significantly less pupillary reward sensitivity than more motivated PD cases.

Saccadic velocity and pupil diameter are influenced by reward magnitude, with the degree of modulation varying with motivation levels across individuals. These indices provide novel, objective behavioural measures for assessing clinical apathy in PD. Dopaminergic medication may also be an effective treatment for apathy by increasing reward sensitivity, independent of effects on motor control.
NEUROIMAGING OF IDIOPATHIC REM SLEEP BEHAVIOR DISORDER
Authors: Rolinski Michal , Griffanti Ludovica , Szewczyk-Krolikowski Konrad , Menke Ricarda , Quinnell Timothy , Zaiwalla Zenobia , Mackay Clare , Hu Michele
Published: October 2015

Introduction

Resting-state functional magnetic resonance imaging (rs-fMRI) studies have previously shown significantly impaired connectivity in patients within the early motor phase of Parkinson's disease. Is it possible to detect the same imaging signature of Parkinson's in RBD subjects, before a clinical diagnosis of Parkinson's disease is established?

Methods

Twenty-six patients with polysomnography-proven RBD and twenty-two age- and sex-matched healthy controls were recruited into the study. All subjects underwent a comprehensive structural and resting-state MRI protocol.

Results

Voxel-based morphometry analysis did not yield any significant grey matter differences between the two groups. Similarly, no significant differences of fractional anisotropy were found using white matter tract analysis. Rs-fMRI revealed decreased coactivation within the basal ganglia network (involving the caudate, putamen, globus pallidus bilaterally) and the sensorimotor network (precentral gyrus) of patients with RBD. A small area of increased coactivation was found in the default mode network of patients with RBD.

Conclusions

Our findings support the presence of basal ganglia dysfunction in patients with RBD, likely representing the prodromal stages of Parkinson's disease. Clinical and neuroimaging follow up is necessary to assess the clinical utility of resting state fMRI to predict the onset of Parkinson's disease in RBD subjects.
THE EFFECT OF A NEW POLICY FOR INWARD TRANSFER OF PATIENTS DIAGNOSED WITH CEREBRAL VENOUS THROMBOSIS (CVT) ACROSS GREATER MANCHESTER TO THE TERTIARY NEUROSCIENCES CENTRE
Authors: Lavin Timothy , McMinn Jason , Punter Martin , Kellett Mark
Published: October 2015

Background

From June 2014, Greater Manchester, Lancashire and Cumbria neurology network implemented regional guidelines on management of CVT. Central to this was an agreement to transfer where appropriate all radiologically confirmed CVT to the regional neurosciences unit within 24 hr. Given this change in practice we assessed the impact on our service in Greater Manchester Neurosciences Centre.

Results

Between June 2014 and November 2014, 14 patients were admitted; compared to 6 in 2012 and 6 in 2013.

The wait for urgent beds did not vary compared to equivalent period in 2012 and 2013; median wait 1d. The wait for non-urgent beds increased slightly between 2013 and 2014 from 15.9d to 16.7d. Both were worse compared to 2012 (9.8d), likely reflecting overall pressure on acute services.

There was no increase in the average LOS for the acute neurology wards. Average LOS was 15.3d between June and Nov 2014 compared to 22.3d in the equivalent period in 2013.

Conclusion

Despite a large change in practice for management of CVT there was a small increase in number of patients and no significant effect on admission waiting times, average LOS or critical care bed days was noted.
A COMPARISON OF ASSESSMENT, DIAGNOSIS AND TREATMENT OF PATIENTS WITH CEREBRAL VENOUS THROMBOSIS BEFORE AND AFTER INTRODUCTION OF A NEW POLICY AND GUIDELINE ACROSS GREATER MANCHESTER
Authors: Keitley James , Lavin Timothy , Punter Martin , McMinn Jason , Kellett Mark
Published: October 2015

Background

From June 2014, regional guidelines to transfer within 24 hours all radiologically confirmed cases of cerebral venous thrombosis (CVT) were implemented across Greater Manchester. This service review assesses the impact on assessment, diagnosis and treatment.

Methods

We prospectively recorded all CVT cases transferred into our unit between June 1st and November 30th 2014 (14 patients), and retrospectively reviewed the casenotes of patients admitted in 2012, 2013 and early 2014 (13 patients).

Results

Mean number of days from diagnosis to transfer after guideline introduction was 0.4. More patients underwent fundoscopy (86% vs 77%), visual acuity (50% vs 27%), visual field (79% vs 69%) and otoscopy (29% vs 8%). Patients admitted to SRFT previously had shorter symptom to diagnosis, imaging, transfer, and treatment times.

Conclusions

After guideline introduction we found a high level of compliance with time to transfer, with improvements in several aspects of clinical assessments. We expect that patients previously admitted to our centre were more unwell or already admitted for other reasons (e.g. neurosurgical) and therefore time from symptoms to diagnosis appears longer. We aim to extend the current evaluation to all patients in the region who weren't transferred to our centre to allow a more valid comparison.
THE IMPACT OF AN EPILEPSY-CARE BUNDLE ON THE MANAGEMENT OF ACUTE SEIZURES IN A LARGE LONDON-BASED DISTRICT GENERAL HOSPITAL
Authors: Baheerathan Aravindhan , Gananandan Kohilan , Swayne Orlando
Published: October 2015

Introduction

Seizures account for 2–3% of presentations to the Accident & Emergency department. The National Audit of Seizure management in Hospitals (NASH) has demonstrated significant variances with regards to initial assessment and subsequent management. Standardised management protocols are crucial in optimising the care of this commonly encountered medical emergency.

Methods

The care of 30 patients admitted with seizures over a 1–month period was retrospectively reviewed. Following this a trust-wide seizure bundle was implemented and another 30 patients were reviewed. Data collection specifically assessed:
▸ Demographics of patients admitted,
▸ Immediate assessment & initial investigations,
▸ Consequent neuro-imaging & specialist investigations,
▸ Referral pathway.

Results

The results showed poor uptake of the bundle and consequently management was broadly unchanged. The most significant results were:

▸ 24% of cases did not have a senior review

▸ 70% of cases were not discussed with neurology

▸ 36% of cases did not have any follow up arranged

Conclusion

The implementation of a seizure bundle can be challenging in the context of a unit that has a rapid staff turnover and is heavily staffed by locum physicians. Repeated staff education is required. This evidence is being used in a business case to employ an epilepsy nurse at Northwick Park. (Aravindhan Baheerathan and Kohilan Gananandan will both be presenting authors and contributed equally to this abstract).
A NEURAL BIOMARKER FOR CHRONIC PAIN BASED ON DECODED BRAIN NETWORKS
Authors: Kotecha Gopal , Mano Hiroaki , Leibnitz Kenji , Nakae Aya , Voon Valerie , Yoshida Wako , Yanagida Toshio , Kawato Mitsuo , Rosa Maria Joao , Seymour Ben
Published: October 2015

The lack of a biomarker for chronic pain remains an important impediment to clinical and translational pain research. The problem stems from the multiple parallel but subtle abnormalties thought to represent the chronic pain state, yielding the emerging view of chronic pain as a ‘network disorder’. This suggests analysis approaches that aim to identify distributed patterns of data (multivariate, machine learning methods) might offer the best opportunity to discover biomarkers. Here, we performed a multi-center functional brain imaging study to record state functional brain networks resting in 41 patients with chronic back pain and 33 healthy control subjects. We calculated with functional covariance matrix from 160 regions of interest, and used Sparse Multinomial Logistic Regression to classify subjects as patient or control using a leave-one-out cross validation. Diagnostic accuracy was 91.9%, with sensitivity and specificity 90.2% and 93.9% respectively. We then used graph theoretic measures to characterise the pattern of network differences between the groups, and showed that the chronic pain state was associated with disrupted network ‘assortativity’. These data provide evidence to support an accurate functional biomarker of chronic pain, and open the door to the development of translatable biomarkers using similar methodologies in animals.
A SENSE OF DIRECTION: BRAIN STIMULATION IN LATERALISED BRAIN FUNCTION
Authors: Li Lucia , Leech Robert , Seemungal Barry , Malhotra Paresh , Sharp David
Published: October 2015

Many cognitive functions demonstrate varying degrees of hemispheric lateralisation. Lateralised pathology can lead to striking deficits, such as the dyscalculia produced by dominant parietal lesions.

Transcranial direct current stimulation (tDCS) non-invasively delivers weak electrical currents to the brain, resulting in transient changes in neuronal excitability: anodal tDCS is thought to be facilitatory, whilst cathodal is inhibitory.

We investigated the effect of bi-parietal tDCS on numeracy, spatial attention and, sustained attention. We hypothesised that tDCS has distinct effects because of varying lateralisation (numeracy left, spatial attention right and sustained attention uncertain). We performed a single-blinded, cross-over, sham-controlled study. Eighteen healthy right-handed subjects performed cognitive tasks during 3 sessions of bi-parietal tDCS stimulation: sham, right cathodal plus left anodal (RC/LA) and left cathodal plus right anodal (LC/RA).

Inhibition of the left parietal lobe by LC/RA stimulation impaired numeracy performance, compared to sham or RA/LC stimulation (F(2,16)=3.684, p=0.048). LC/RA stimulation also resulted in significantly impaired sustained attention performance, as compared to sham or RA/LC stimulation (F(2,34)=5.3, p=0.01).

We demonstrate that bilateral tDCS modulates numeracy and sustained attention in an electrode polarity-dependent manner. This method can be used to interrogate lateralised cognitive functions in future studies of healthy and diseased populations.
USING FLORBETAPIR PET TO INCREASE DIAGNOSTIC CERTAINTY IN ATYPICAL DEMENTIAS
Authors: Weston PSJ , Paterson RW , Lehmann M , Modat M , Bomanji JB , Kayani I , Dickson J , Barnes A , Cash DM , Ourselin S , Zetterberg H , Toombs J , Warren JD , Rossor MN , Fox NC , Schott JM
Published: October 2015

Amyloid PET or CSF can be used to determine Alzheimer pathology in vivo. Few studies have assessed the additional value of amyloid imaging where CSF results are equivocal. We recruited 20 cognitive patients (65.5+/–7.6 y) with MRI, neuropsychology, and CSF Aβ1–42 and tau measured during their diagnostic assessment. Individuals were selected to have a range of CSF results; ten had amnestic and ten non-amnestic presentations. Following the investigations, the treating neurologist gave a diagnosis (AD or non-AD). Four controls (63+/–7.0y) also had CSF examination. All subjects had Florbetapir PET imaging, reported as positive/negative. The clinicians were given the PET results and asked to review their diagnoses. Eighteen patients had positive Florbetapir scans; two patients and all controls were Florbetapir negative. Following initial investigations, thirteen patients were diagnosed with AD, and seven with non-AD pathology. Providing the Florbetapir result led to a change in diagnosis in seven patients, five of whom had atypical phenotypes. For all seven the CSF results were close to or in a “grey” area, where results overlapped for positive and negative PET scans. Even in individuals with CSF measures of Aβ1–42, and tau, Florbetapir PET imaging may have diagnostic utility, particularly in atypical cases and/or equivocal CSF results.
FIRST CASE SERIES OF VENOUS SINUS STENTING IN IIH PATIENTS IN WALES
Authors: Malik Gauhar Abbas , Joshi Yogish
Published: October 2015

Background

Idiopathic Intracranial Hypertension (IIH), is defined by increased cerebral spinal fluid (CSF) pressure in the absence of other causes of intracranial hypertension. There has been recent interest in the role of intracranial venous sinus stenosis in IIH. The raised pressures in IIH are argued to worsen by the secondary appearance of the venous sinus stenosis.

Objective

5 patients have undergone endovascular pressure measurement in Wales and their clinical details including history, examination, initial management, neuroimaging pre- and post venous stenting, and follow-up (6–24 months) to provide the first case study of patients undergoing Venous sinus stenting in Wales.

Methods

5 patients with IIH refractory to first line treatments underwent venography and manometry and 4 patients underwent stenting of the venous sinuses after this procedure had shown a pressure gradient proximal to stenosis in the lateral sinuses.

Results

Three patients were rendered asymptomatic, two were improved including one patient unmasking a different headache disorder following treatment.

Conclusions

Stenting in venous stenosis provides a further treatment option to patients refractory to first line treatments with IIH. This case series highlights in selected cases treatment is promising with good outcomes.
AUTOLOGOUS HAEMOPOIETIC STEM CELL TRANSPLANT IN MS: SHEFFIELD COHORT
Authors: Kelsey P , Bell SM , Jessop H , Snowden JA , Sharrack B
Published: October 2015

Background

Autologous haemopoietic stem cell transplantation (AHSCT) is an evolving therapy for multiple sclerosis (MS). Here we present the Sheffield experience since 2006.

Methods

Retrospective review of MS cases referred for and treated with AHSCT. Toxicity, clinical and radiological outcome were assessed.

Results

14 patients (8 Rapidly evolving severe [REMS], 3 Relapsing Remitting [RRMS], 3 Secondary Progressive [SPMS]) were selected for AHSCT. One patient underwent AHSCT on a clinical trial (data excluded from analysis). Mean age 34.6 years (SD 8.69), median pretreatment EDSS 6.5 (IQR0.5). All had clinically and radiologically aggressive disease, non-responsive to standard treatment. Follow up range was 3 to 96 months.

All patients were successfully mobilized, 2 patients progressed only to harvest (1 compliance issues, 1 leg ulcer). All patients were treated according to international guidelines. No excess toxicity or treatment related mortality was observed.

Post-transplant MRI's showed no active disease. No patients with RRMS suffered relapse post-transplant, median reduction in EDSS scores was 2 at both 100 days (IQR 2) and at last follow up (IQR 2.5). EDSS scores stabilised in patients with SPMS.

Conclusion

AHSCT is an effective treatment with acceptable toxicity in patients with aggressive, inflammatory MS.
DISEASE MODIFYING TREATMENTS IN MS: INDUCTION OR ESCALATION?
Authors: Williams Owain H , Harding Katharine E , Willis Mark , Pickersgill Trevor , Wardle Mark , Robertson Neil P
Published: October 2015

Background

It is currently unclear whether aggressive induction or stepwise escalation of DMTs provides optimum long term outcomes for patients with MS.

Objective

Compare clinical outcomes in clinical practice amongst unmatched patient groups receiving either initial monoclonal induction, injectable DMT only or escalation from injectable DMT.

Methods

A subset of a population-based cohort identified 268 patients, with a median follow up post treatment of 5.4 years. Time to disability end points (EDSS) were examined using survival analysis.

Results

Monoclonals (25%) pre and post treatment annual relapse rate reduced from 2.28 (±1.92) to 0.28 (±0.42) 88% reduction; injectables (62%) from 1.08 (±0.97) to 0.4 (±1.03), 63% reduction; escalation (13%) had elevated rates of 1.72 (±2.04) to 0.64 (±0.54), only 63% reduction. Time to EDSS4 was shorter for monoclonal against injectable and escalation strategies: 5.7 vs 12 vs 6.8 years, p=0.0002. Time to EDSS6 was similar for the treatment strategies respectively: 14.6 vs 16.4 vs 13.3 years, p=0.13.

Conclusions

Patients requiring escalation had relatively worse outcomes, and could be identified as having higher disease activity on treatment initiation. This data suggest that initial selection of DMT class does not significantly affect long term outcome to EDSS6, or conversely, aggressive induction slows the rate of disability progression to EDSS6.
DESIGNING AN INFORMATION RESOURCE TO EXPLAIN DIAGNOSTIC LUMBAR PUNCTURE AND PROMOTE BEST PRACTICE
Authors: Thomson Alison , Davis Angharad , Paterson Adam , Giovannoni Gavin , Schmierer Klaus
Published: October 2015

Introduction

The lumbar puncture (LP) procedure is an important test in neurological practice. Appropriate information is key to both preparing patients for this invasive procedure and facilitating use of atraumatic LP needles to minimize adverse effects such as local pain and post-LP headache.

Methods

A cross-disciplinary team (designers, clinicians and people with multiple sclerosis (pwMS)) developed a website to explain the LP procedure at The Royal London Hospital (Barts Health NHS Trust, UK). User testing was carried out to review both the visual design and functionality of the resource for people with visual and cognitive limitations.

Results

After successful testing www.clinicspeak.com/LumbarPuncture is being used in the informed consent process for clinical trials involving pwMS at our institution and is being piloted in our day unit and A&E departments. The website includes what to expect, how to deal with adverse effects, why cerebrospinal fluid is examined and information on the atraumatic needle.

Conclusion

The resource provides an appropriate way of communicating sensitive, yet important information to patients. It also demonstrates an innovative way of spreading best practice and encourages the widespread adoption of atraumatic needles for LP in both clinical and research settings. The resource will be demonstrated at the meeting.
DEEP BRAIN STIMULATION IN INTRACTABLE SHORT-LASTING UNILATERAL NEURALGIFORM HEADACHE ATTACKS: A MULTICASE SERIES
Authors: Miller Sarah , Zrinzo Ludvic , Matharu Manjit
Published: October 2015

Introduction

SUNCT and SUNA are primary headache conditions characterized by short lasting attacks of unilateral pain accompanied by autonomic features. Neuroimaging studies have suggested a role of the posterior hypothalamus in its pathogenesis.

Aim

Previous case reports on deep brain stimulation (DBS) of the midbrain tegmentum (just posterior to the hypothalamus) for SUNCT/SUNA are limited to a total of three patients. We present clinical data on eight new patients treated with DBS.

Method

Eight patients underwent midbrain tegmentum DBS with an MRI-guided and verified approach. The target lay between the mammillothalamic tract and the anteromedial quadrant of the red nucleus. Headache diaries were used to monitor response.

Results

The median follow up period was 20 months. Median improvement in attack frequency was 70%. Seven patients obtained a 30% or more reduction in attack frequency at final follow up. At final follow up, one patient had the stimulator off. Seven out of eight patients would opt to have the stimulator again and all would recommend to others.

Conclusion

Midbrain tegmentum DBS may be a useful treatment in intractable SUNCT. It should be reserved only for patients failing all other medical and surgical treatment options.
SEVERE (BUT REVERSIBLE) CERVICAL CORD AND BRAIN IRIS REACTION AFTER DISCONTINUATION OF NATALIZUMAB IN PREGNANCY OF PATIENT WITH MULTIPLE SCLEROSIS
Authors: Massey Tom , Pearson Owen
Published: October 2015

Natalizumab is used to treat highly-active relapsing-remitting multiple sclerosis. It is discontinued in certain clinical situations such as progressive multifocal leucoencephalopathy (PML) and pregnancy. Here we describe a case of cerebral and cervical cord immune reconstitution inflammatory syndrome (IRIS) causing florid CNS inflammation and severe disability in a pregnant patient after discontinuation of natalizumab. The patient was virtually symptom free prior to pregnancy but became bedbound, encephalopathic, hypertonic, and very ataxic after stopping natalizumab. She required 24 hour inpatient nursing care. After minimal response to steroids, clinical rescue was achieved by re-starting natalizumab during pregnancy and accepting a small risk to the foetus. The patient was delivered of a healthy baby girl some months later, and has made a virtually complete recovery. This difficult case highlights many of the dilemmas facing Neurologists as new, effective disease-modifying therapies come to clinic without the longitudinal data to guide decision-making.
TABES DORSALIS IN THE POST ANTIBIOTIC ERA: NEVER SAY NEVER
Authors: Osman Chinar , Clark Tristan , Ghosh Boyd , Halfpenny Christopher
Published: October 2015

Background

Tabes dorsalis is a neurological form of tertiary syphilis and is considered to be rare in the post antibiotic era. It results from damage to nerve cells in the dorsal column and roots of the spinal cord. It is characterised by sensory ataxia, lightening pains and urinary incontinence. If left untreated it can progress to paralysis and dementia.

Case summary

We present the case of an HIV positive 47 year old male with a CD4 count of 400 and an undetectable viral load on HAART. He presented with an 8 month history of progressively severe lightening pains, gait disturbance, tinnitus, hearing loss, and urinary incontinence. He had a positive plasma VDRL with a titre of 1:32, and his CSF was VDRL positive. Whole spine MRI scan demonstrated high signal in the dorsal cord with associated atrophy. He was treated with intravenous benzylpenicillin 2.4 grams 4 hourly for 14 days. Follow up at 4 and 8 months demonstrated marked clinical improvement with a falling serum VRDL titre. Repeat LP at 6 month post treatment demonstrated VDRL negativity.

Discussion

Tabes Dorsalis may still occur in the post antibiotic era. Early recognition and appropriate treatment can lead to good clinical outcomes.
ONE YEAR RETROSPECTIVE AUDIT OF CNS MALIGNANCY 2 WW REFERRALS
Authors: Ashton Elizabeth , Smeeton Benjamin , Weatherby Stuart
Published: October 2015

Background

Since its introduction in 2000, concerns have been raised about the two week wait (2 WW) referral system for suspected malignancy. Studies have demonstrated poor compliance to guidelines, low detection rates and questioned the time effectiveness of the referral process.

Method

All patients referred under the 2 WW system for suspected CNS malignancy to Derriford Hospital, Plymouth Hospitals NHS trust, over a one-year period were retrospectively audited. Data was gained from clinic letters and radiological imaging. The aims were to determine the number of referrals, their appropriateness and subsequent time taken to outpatient appointment, imaging and final diagnosis.

Results

103 referrals were made between September 2013 and September 2014 with just 48.5% fulfilling NICE referral guidelines for suspected CNS malignancy. Just three tumours were diagnosed with guidelines identifying all of these. Only 28% of 2 WW referrals received diagnostic imaging and an outpatient appointment within two weeks.

Conclusions

Unnecessary referrals are placing strain on the 2 WW system. We suggest that a potential solution is for general practitioners to refer patients for imaging at the same time as they make their neurological 2 WW referral in order to cut down waiting times.
ARE FEMALE ACADEMIC NEUROLOGISTS GETTING THEIR VOICES HEARD?
Authors: Lynch Emma
Published: October 2015

Objectives

Neurology as a specialty is becoming increasingly feminised. Generally, women are under-represented in academic medicine, particularly at more senior levels. The aim of this study was to assess the gender balance of presenters at the 2014 ABN meeting.

Methods

Data on gender mix of the specialty was obtained from the 2012 Federation of the Royal College of Physicians Census. Oral presenters and first authors from posters were identified using the Meeting Programme and Abstract Book and the GMC register was used to ascertain individuals' gender.

Results

29.5% of neurology trainees and consultants are female. There were 38 platform presentations, and 188 poster presentations. It was possible to identify the gender of 99.6% of presenters and first authors. 48.9% of first authors on posters were female; women conducted 18.4% of platform presentations. Oral presenters were significantly more likely to be male (p<0.01).

Conclusion

Compared to the specialty as a whole, women were well represented at the meeting. However, females were significantly less likely to undertake more prestigious oral presentations. Further work is planned to identify whether the reason behind this imbalance is explicit or implicit bias, and to help identify barriers to increasing female participation in academic neurology.
DEMENTIA AND THE ‘COCKTAIL PARTY’ PROBLEM
Authors: Kamourieh Salwa , Wise Richard
Published: October 2015

Background

Listening to one speaker in the presence of others (the ‘cocktail party’ problem) increases demands on attention and cognitive control. This study investigated the function of fronto-parietal systems and auditory regions in patients with progressive memory impairment.

Methods

Twenty-five healthy volunteers (controls) and 32 patients were studied with functional MRI. The task involved attending to a female speaker, either in the absence or the presence of a masking male speaker.

Results

A behavioural measure designed to assess success at attending to the female speaker demonstrated a significant impairment in the patient group compared to the controls. This was associated with reduced activity in the dorsal anterior cingulate cortex (dACC), involved in attention and cognitive control, and in the left planum temporale (lPT), an auditory region central to solving the ‘cocktail party’ problem. However, treatment with galantamine in 18 patients resulted in no behavioural improvement and no increase in dACC or lPT activity.

Conclusions

An inability to register verbal information when listening in the presence of distracting background speech will contribute to complaints of ‘impaired memory’ and social isolation. We did not find evidence that central cholinesterase inhibition can improve this function in patients complaining of progressive memory decline.
A SYSTEMATIC REVIEW & META-ANALYSIS OF F-18-LABELLED AMYLOID IMAGING IN ALZHEIMER'S DISEASE
Authors: Yeo Jing Ming , Waddell Briony , Khan Zubair , Pal Suvankar
Published: October 2015

Introduction

There has been recent interest in the use of fluorine-18-labelled (18F) tracers in amyloid imaging as they have longer half-lives compared to 11C-labelled Pittsburgh compound-B (11C-PIB). This systematic review and meta-analysis aims to assess the sensitivity and specificity of 18F tracers florbetapir, florbetaben and flutemetamol in diagnosing Alzheimer's disease (AD).

Methods

We systematically searched MEDLINE and EMBASE for relevant studies published from January 1980 to March 2014. We pooled the studies comparing imaging findings in AD and normal controls (NC) in a meta-analysis, calculating the pooled weighted sensitivity, specificity and diagnostic odds ratio (OR) using DerSimonian-Laird random effects model.

Results

A total of nineteen studies investigating 682 patients with AD, met the inclusion criteria; florbetapir (n=10), florbetaben (n=6), flutemetamol (n=3). Our meta-analysis for florbetapir revealed a pooled weighted sensitivity of 89.6%, specificity of 87.2% and diagnostic OR of 91.7 in differentiating AD from NC; and for florbetaben a pooled weighted sensitivity of 89.3%, specificity of 87.6% and diagnostic OR of 69.9.

Conclusion

This meta-analysis demonstrated favourable sensitivity and specificity for 18F tracers in diagnosing AD. Further and larger prospective studies are required to establish an optimal imaging analysis methodology for these tracers for consistency and comparability
DISCUSSING SUDDEN UNEXPECTED DEATH IN EPILEPSY: ARE WE EMPOWERING OUR PATIENTS?
Authors: Keddie Stephen , Angus-Leppan Heather , Parker Thomas , Toescu Sebastian , Nash Adina , Adewunmi Lola , Liu Rebecca
Published: October 2015

Disparity exists between clinical practice and guidelines on discussion of Sudden death in epilepsy (SUDEP) with patients. This study examined how patients were informed about SUDEP; the impact of such discussion, and their views on the discussion.

Methods

A quantitative/qualitative questionnaire was given to 50 consenting patients attending epilepsy clinics. Exclusions were patients with intellectual disability, and/or those deemed at risk of negative consequences on completing the study.

Results

98% of patients were aware of the importance of medication adherence, 78% of driving regulations in epilepsy, and 84% of factors influencing seizure frequency. Only 50% of patients were aware of SUDEP and 38% of status epilepticus.

42% of patients preferred SUDEP information at diagnosis and 36% only after three clinic appointments.

Negative emotional responses (in 38%), and not behavioural changes, resulted from SUDEP discussions.

Conclusions

In this small in-depth study, only half the patients recalled information about SUDEP. More than one-third of patients reported adverse consequences. There was no improvement in self-management.

We suggest a paradigm shift: embedding SUDEP discussion with all potential complications of epilepsy; and emphasising optimal healthcare and self-management. This model has been successfully applied in other areas to empower patients and improve outcome.
FYDATA STUDY: PERAMPANEL STUDY IN A REAL-LIFE SETTING
Authors: Villanueva V , Garces M , Gonzalez FJ López , Rodriguez-Osorio X , Uranga JJ Rodriguez , López-Gomáriz E , Montoya J , Aldea JJ Poza , Molins A , Saiz-Diaz R , Aleja J González de la , Mauri J Angel , Castillo A , Picho FJ Lopez-Trigo , Toledo M , Puig J Salas , Blance D Campos , Flores J
Published: October 2015

FYDATA is a multi-centre, retrospective, 1-year, observational study (inclusion criteria: written informed consent to review clinical charts; patients ≥12 years old; partial-onset seizure [POS] diagnosis; perampanel treatment according to clinical practice as add-on therapy; patients with ≥1 POS in year prior to starting perampanel). The source of data was patient clinical records collected by physicians. An interim analysis was performed at 3 months in 111 patients (mean age: 37.8 years; mean epilepsy duration: 24 years). Mean seizure number/month at onset was 19.3. At baseline, patients had tried a mean of 8.3 antiepileptic drugs (AEDs) and half were taking ≥3 concomitant AEDs. 31% of patients had a comorbid psychiatric condition. At 3 months, with a mean perampanel dose of 5.4 mg, 9% of patients were seizure-free and 44% were responders (≥50% reduction in seizure number). Adverse events were reported by 41.4% of patients; most frequent were irritability (13.5%), somnolence (10.8%) and dizziness (9.9%). Irritability and aggressiveness were more frequent if patients had a comorbid psychiatric condition – personality disorder/hyperactivity. Preliminary results at 3 months in refractory POS patients receiving adjunctive perampanel in a real-life setting showed a promising response. Study sponsors: Eisai Inc. Writing support: Choice Healthcare Solutions; funding, Eisai Ltd.
BARRIERS IN CLINIC TO DISCUSSING SEXUAL DYSFUNCTION DUE TO MULTIPLE SCLEROSIS
Authors: Tudor Katarina Ivana , Eames Stefani , Haslam Collette , Panicker Jalesh
Published: October 2015

Background

Sexual dysfunction is underdiagnosed in patients with multiple sclerosis (pwMS). Little is known about barriers faced by patients and health care professionals (HCPs) in discussing sexual problems.

Patients and methods

74 PwMS (20 male, 54 female (mean age 45,877±8,823 years)) and 99 HCPs (8 male, 91 female; 82 (83%) nurses) completed questionnaires evaluating barriers to discussing sexual problems in clinic and sexual dysfunction (MSISQ-15 and ASEX), specifically developed for this study.

Results

Symptoms that interfere most with sexual activity are: Takes too long to orgasm (69.11%), bladder symptoms (66.17%), less intense orgasm (66.17%), lack of sexual interest (60.29%), genital numbness (50%). Most common barriers cited by patients include the prominence of other MS symptoms (43.5%), presence of family/friends in consultation room (41.8%), not being asked (37.3%). HCPs identified presence of family/friends in consultation room (57.6% agree), faced lack of knowledge (48.4% agree), patient not ready (44.3% agree), lack of time (42.2%).

Conclusions

Sexual dysfunction is common in both men and women following multiple sclerosis. However both patients and HCPs face barriers to addressing the problem. Providing time and privacy during the consultation to discuss sexual dysfunction, and training to HCPs will help to address these barriers.
WHAT IS THE NIN, AND WHAT CAN IT DO FOR YOU?
Authors: Morrish Paul
Published: October 2015

The Neurology Information Network (NIN) is jointly sponsored by Public Health England and NHS England, and identifies, collates and interprets nationally available indicators on all adult neurological conditions. Its priorities are to:
▸ address health inequalities in England
▸ collect and make publicly available national neurology data, in one place
▸ identify gaps in the data and promote research to address these deficits
▸ improve the quality of commissioning by providing relevant data and evidence
▸ promote research to improve the quality of neurological care throughout England

Resources Available Now: 1. Neurology profiles: http://fingertips.phe.org.uk/profile-group/mental-health/profile/neurology/data. Download and compare figures for: 18 different measures of epilepsy care in 4 Clinical Commissioning Regions and 211 Clinical Commissioning Areas in England. 21 different measures concerning emergency admission to hospital with a neurological condition in 4 Clinical Commissioning Regions and 211 Clinical Commissioning Regions. 2. Compendium of neurology data England 2012–13: The Compendium of Neurological Data, England 2012–3 http://www.hscic.gov.uk/catalogue/PUB13776. Download and compare hundreds more tables concerning neurological care in hospitals and in the community.

And in the future? The NIN hopes to offer information on every neurological condition where reliable data can be collected. It will involve clinicians, commissioners, clinical networks, providers, charity groups and other stakeholders in discussions about its future work.
FEVER, ACUTE HEMIPARESIS, APHASIA, STATUS EPILEPTICUS, PSYCHOSIS… MIGRAINE?
Authors: Massey Tom , Hill Marguerite , Sadiq Shaheena , Smith Rachel
Published: October 2015

A young female patient, who was otherwise well, presented with acute hemiparesis, dysphasia and confusion after a night out in town. She was febrile and developed focal motor seizures that were difficult to control, culminating in secondary generalisation and status epilepticus. She required intubation and ventilation on ITU. Blood and CSF testing revealed no evidence of infection, drugs, or toxins. MRI brain scans and angiography showed subtle left hemisphere swelling associated with cerebral vasoconstriction, and a degree of cerebellar atrophy. EEG found delta waves over the left hemisphere. After extubation the patient developed delusional and paranoid thoughts about the medical team. All symptoms resolved rapidly after treatment with steroids and three anticonvulsants, and the patient recovered to baseline. The underlying diagnosis proved to be a rare variant of Familial Hemiplegic Migraine type I (CACNA1A I1709T) of which there are two previous reports in the literature, and which seems to have a characteristically severe phenotype.
HEADACHE IN MILLER-FISHER SYNDROME
Authors: Amin Reem , Hughes Tom
Published: October 2015

A 22-year-old female presented with a three day history of headache, unsteadiness and double vision. The headache was described as being occipital, constant, radiated to the front of the head, and was exacerbated by lying down. On direct questioning, it appeared that she had an acute diarrheal illness two weeks previously. Neurological examination was remarkable for a complete external ophthalmoplegia, areflexia and ataxia. A plain CT scan of the head was normal. A lumbar puncture revealed clear cerebrospinal fluid with an opening pressure of 29 cm H2O, a protein content of 0.42g/l, WCC of 0 and RBC of 82. Nerve conduction studies were normal. She was treated with a 5-day course of intravenous immunoglobulins and over the course of four weeks made a complete recovery but for the first week was greatly troubled by headache. The headache was not abolished by the lumbar puncture and became a considerable source of concern for the patient and family. The subsequent Anti GQ1b Antibodies were highly positive.
 Headache can be one of the presenting features of MFS but the aetiology is not clear. However it is important that clinicians are aware of headache as a possible feature of the condition, and that it appears to be self limiting.
FLUNARIZINE IN PRIMARY HEADACHE DISORDERS
Authors: Karsan Nazia , Palethorpe David , Bhola Ria , Goadsby Juana Marin, Peter
Published: October 2015

Background

Flunarizine is a widely used migraine preventive not licensed in the UK. In September 2014, the National Institute for Clinical Excellence (NICE) published supportive guidelines for flunarizine use in migraine based on available randomised controlled evidence.

Aim

To collect data for an audit of flunarizine use from our tertiary headache practice in the UK over twenty years, to try to establish indications for its use, typical doses, short and long term side effects, and treatment outcomes, including changes in acute treatment use and change in frequency and intensity of headache on treatment.

Results

For the first 30 patients audited the most common indication for flunarizine was chronic migraine, followed by migraine with aura, sporadic hemiplegic migraine and familial hemiplegic migraine and then new persistent daily headache of a migrainous type. Doses up to 15mg were generally well tolerated, with only five patients stopping treatment due to adverse effects. Flunarizine is generally effective; with only three patients reporting no clinical effect: two had hemiplegic migraine and one chronic migraine. The commonest dose used was 10mg and a significant proportion of patients continued treatment for more than one year.

Conclusion

Flunarizine is an effective, well tolerated migraine preventive that can be used for extended periods in a range of migraine sub-types.