Greater Manchester Neuroscience Centre Research Articles

P63 Botulinum toxin a for post craniotomy head pain: a single centre case series of 11 patients

ObjectivesBotulinum Toxin for post craniotomy head pain is not an established therapy. One small case series commented that it was effective in 3 patients.1 We report our single centre experience.DesignWe performed a retrospective review of case notes of all patients treated with Botox for persistent post craniotomy or craniotomy head pain at Greater Manchester Neurosciences Centre, UK. All patients treated with Botulinum Toxin from 2014 at Greater Manchester Neurosciences Centre are listed on a central database, irrespective of indication. From the database 11 patients were identified who had received Botulinum Toxin A for post craniotomy scalp pain.SubjectsEleven (n=11) patients were identified. The mean age was 43 year. Of the 11 patients; 6 were women and 5 were men. The majority of patients underwent surgery for medically intractable epilepsy (n=7).MethodsInformation obtained: -Demographics -Date, indication and type of initial cranial neurosurgery Headache Characteristics (site, descriptors, duration, frequency) -Previous medical therapy -The presence of Epileptic Seizures -Frequency, dose and site of Botulinum Toxin injection -Response.ResultsA majority of patients (10/11) reported improvement in headache burden with 6 patients reported being pain free with no further daily headache. The duration of this effect varied from 4 to 12 weeks. No specific headache characteristic (site, descriptor) predicted a favourable response. Of the remaining 5 who continue to report daily head pain, 4 felt the burden was more manageable. One patient felt there was no response. Of the 5 patients with persistent headaches, 3 were chronic epileptics with ongoing seizures, compared to only 1 patient in the responder group.ConclusionsThis case series is limited by small numbers and no objective headaches made prior or post therapy. Botulinum Toxin A appears to have a beneficial effect in the management of chronic post craniotomy head pain within this small sample with complete abolition of pain in 55%. The presence of ongoing epileptic seizures may indicate a poor response. Further controlled studies are warranted.

THUR 153 Antibodies against the voltage-gated potassium channel complex

Voltage-gated potassium channel (VGKC) complex antibodies have been associated with a spectrum of presentations including peripheral nerve hyperexcitability (PNH), Morvan’s syndrome, autoimmune encephalopathy, epilepsy and recently psychosis.We retrospectively reviewed the medical records of 70 patients from the Greater Manchester Neuroscience Centre, who had tested positive for VGKC-complex antibodies between 2012 and 2015 to identify the clinical relevance of positive results.The majority were diagnosed with autoimmune encephalopathy(19) followed by epilepsy(14), psychosis(10) and PNH(6). The remaining fifteen had other neurological presentations and six had no primary neurological disorder. 39/70 patients who had antibody titres>400 pM, were diagnosed with autoimmune encephalopathy(19), epilepsy(9), psychosis(4), PNH(3) and other disorders(4). 24/39 patients, who received treatment with one or a combination of corticosteroids, intravenous immunoglobulins, cyclophosphamide, plasma exchange, azathioprine or rituximab, had a diagnosis of autoimmune encephalopathy(18), epilepsy(2), psychosis(2) and malignancy(2). 16/24 were treatment responsive. 3/31 patients with lower titres were also treated, but only one with the classic phenotype (PNH) responded to treatment.The classic phenotype often had a titre >400 pM. PNH may have a titre ≤400 pM. The patients without classic presentations typically had titres≤400 pM. Consistent with previous studies, clinical phenotyping and antibody titre helped to determine the relevance of VGKC-complex antibodies.

PO011 Therapeutic plasma exchange for neurological disorders: experience at a tertiary neuroscience centre

Therapeutic plasma exchange (TPE) is often used to treat confirmed or suspected immune-mediated neurological disorders. Our experience with TPE at a tertiary neurosciences centre is reported. In this retrospective study, we reviewed the medical records of all 63 patients receiving TPE at the Greater Manchester Neuroscience Centre between 2012–2015. During one procedure, 1–1.5 plasma volumes were removed and replaced with isotonic 4.5% human albumin solution. A typical therapeutic cycle was consisted with 5 procedures within 14 days. A total of 349 procedures were performed during 70 therapeutic cycles. Anti-VGKC antibodies-mediated disorders (n=11), chronic inflammatory demyelinating polyneuropathy (10) and multiple sclerosis (9) were the three commonest indications for TPE. It was used as the first-line treatment in 6% of patients, whilst in 75% it was the second-line therapy. Majority of patients (89%) following TPE required further immunosuppression. 75% of patients had a favourable clinical outcome with TPE. The adverse event rate was 8.6 per hundred treatment cycles (bleeding=1, central line infection=2, venous thromboembolism=3). TPE is being used commonly for the treatment of immune-mediated neurological disorders and is associated with a low adverse event rate. Overall, we observed favourable clinical outcomes following TPE.

Ictal bradyarrhythmias and asystole requiring pacemaker implantation: Combined EEG-ECG analysis of 5 cases.

Seizures can lead to cardiac arrhythmias by a number of mechanisms including activation/inhibition of cortical autonomic centers, increase in vagal tone through activation of brainstem reflex centers, and respiratory failure. Ictal asystole (IA) is a potential mechanism underlying sudden unexpected death in epilepsy (SUDEP). We analyzed the clinical features of 5 patients who developed IA requiring pacemaker implantation. Patients with ictal arrhythmias were identified from the video-telemetry and ambulatory EEG database at Greater Manchester Neurosciences Centre, as well as an independent epilepsy residential care facility. Only those who had IA requiring pacemaker implantation were included in the analysis. A total of 5 patients were identified. Of the 5 patients with IA, 4 were female. All 5 patients had focal epilepsy, and four had temporal lobe epilepsy. Ictal asystole occurred with focal seizures with impairment of awareness. Seizure onset was left-sided in 2 patients, right-sided in one, left-sided onset with switch of lateralization in one, and nonlateralized in one patient. Three patients had hippocampal sclerosis, one of whom had undergone epilepsy surgery, one had traumatic encephalomalacia of the temporal lobe, and one patient had no lesions detected on MRI. Interictal epileptiform activity was more pronounced during sleep in all patients. Asystole occurred in association with sleep-related seizures in 4 of 5 patients. Ictal asystole (IA) occurred in association with sleep-related seizures in 4 out of 5 cases, predominantly in patients with temporal lobe epilepsy. These findings may be of relevance to SUDEP.

Patient expectations and experiences of multiple sclerosis interferon ß-1a treatment: a longitudinal, observational study in routine UK clinical practice

BackgroundPremature discontinuation and poor treatment adherence are problems in chronic conditions, such as multiple sclerosis in which patients must take long-term treatment in order to receive maximum benefit from their medication. The Assessing needs In Multiple Sclerosis (AIMS) study explored factors related to premature treatment discontinuation and patients’ experiences of subcutaneous (sc) interferon (IFN) β-1a treatment in the UK.MethodsA questionnaire-based survey was integrated into the Bupa Home Healthcare patient-support program, which delivers sc IFN β-1a to patients in their home. Data were collected via patient questionnaires incorporated into routine clinical care and administered upon registration of a new patient by the coordinator, following initial delivery of treatment, prior to each delivery during therapy and at the end of treatment. Univariate and multivariate analyses were performed to identify factors associated with premature discontinuation.ResultsData were collected from 2,390 patients (1,267 new; 1,123 existing) from 59 UK prescribing centers (November 2006–April 2011). Following the first delivery of sc IFN β-1a, 94% (1,149/1,225) of patients had received training, and 73% (818/1,120) reported that they had no concerns. In total, 24% of new patients discontinued therapy by the end of the study. In the univariate model, none of the candidate variables tested were significant predictors of treatment discontinuation. The strongest predictors of discontinuation in multivariate analyses were lack of information prior to starting treatment and patients feeling unwell on treatment and geographic region (P<0.05 for each variable).ConclusionThis study suggests that patients feeling well on treatment and provision of high-quality information are the main determinants of persistence with sc IFN β-1a therapy. A package of care that targets these issues should therefore be considered when initiating sc IFN β-1a therapy.

Investigating the bundle compliance of IVIG delivery in the Greater Manchester Neuroscience centre.

Salford Royal Hospital is one of the largest users of IVIG for chronic neurological illnesses within the UK. The majority of patients are being treated for chronic inflammatory polyneuropathy and multifocal motor neuropathy. We hypothesised that the components of care being delivered to these patients differed to our stated standard of care (IVIG care bundle). We performed a service review exercise to identify shortcomings and improve quality of patient care. The aim was to measure overall bundle compliance being delivered to 75 patients with a view to improving the overall quality of care being delivered in the future. A retrospective case note study was carried out to measure compliance with the 17 areas of care, which constituted the IVIG bundle. Nine areas of care were being delivered to all 75 patients. This meant that all patients were receiving three monthly bloods, a documented cannula pathway, a filed prescription, a medical assessment, and the correct follow-up. Not all patients had a filed consent form, ECG or HAT assessment and an even smaller number of patients had a documented calculation for the amount of IVIG that needed to be given and few had a serum save. No patient in the group was receiving the intended complete bundle of care.The results led to the development of an electronic treatment dashboard for the delivery of chronic IVIG therapy to this group. A re-audit has shown that rates of individual areas of care being delivered has increased markedly but overall compliance has only increased a slightly due to a lack of serum saves for patients.

Imaging in young adults with intracerebral hemorrhage

ObjectiveVascular malformations are a common yet treatable cause of intracerebral hemorrhage (ICH) in the young. The goal of this study was to review the implementation of appropriate secondary angiographic/venographic imaging to identify vascular malformations in young adults with ICH at our specialist neuroscience center. MethodsA retrospective analysis was undertaken of five years of prospectively recorded referral data to the on-call neurosurgery service at the Greater Manchester Neuroscience Centre. ResultsThe authors identified 111 ICH patients aged 18–40 over the five-year period, with a wide etiologic spectrum. When assessing the implementation of secondary imaging, they focused on 90 individuals, incorporating those without an identifiable precipitant for their ICH and those with recent recreational drug use and hypertension. Of these 90, 52 (58%) were admitted to the neuroscience center for further management; when excluding three with bilateral fixed and dilated pupils, the remaining 49 all underwent appropriate secondary imaging. Of the 38 subjects not accepted to the neuroscience center, 13 (34%) had bilateral fixed and dilated pupils, 10 (26%) underwent appropriate secondary imaging, and 15 did not – all but two of these 15 were referred outside of normal working hours. The positive yield from secondary imaging was 63%. ConclusionYoung adults with ICH are more likely to get appropriate imaging to identify vascular malformations in a specialist neuroscience center compared to a non-specialist center. Out of hours care appears to be a significant contributor to this shortfall. This study suggests a need for service redevelopment and specialist neuroscience center input for all cases of young ICH.

The importance of angiographic and venographic cranial imaging in intracerebral hemorrhage occurring during pregnancy and the puerperium

European Journal of NeurologyVolume 18, Issue 9 p. e112-e113 LETTER TO THE EDITOR The importance of angiographic and venographic cranial imaging in intracerebral hemorrhage occurring during pregnancy and the puerperium M. A. Kirkman, M. A. Kirkman Brain Injury Research Group, The University of Manchester, Greater Manchester Neurosciences Centre (GMNC), Salford Royal NHS Foundation Trust, SalfordSearch for more papers by this authorP. J. Tyrrell, P. J. Tyrrell Brain Injury Research Group, The University of Manchester, Greater Manchester Neurosciences Centre (GMNC), Salford Royal NHS Foundation Trust, Salford Department of Stroke Medicine, The University of Manchester, Clinical Sciences Building, Salford Royal NHS Foundation Trust, SalfordSearch for more papers by this authorA. T. King, A. T. King Brain Injury Research Group, The University of Manchester, Greater Manchester Neurosciences Centre (GMNC), Salford Royal NHS Foundation Trust, Salford Department of Neurosurgery, Greater Manchester Neurosciences Centre (GMNC), Salford Royal NHS Foundation Trust, Salford, UKSearch for more papers by this authorH. C. Patel, H. C. Patel Brain Injury Research Group, The University of Manchester, Greater Manchester Neurosciences Centre (GMNC), Salford Royal NHS Foundation Trust, Salford Department of Neurosurgery, Greater Manchester Neurosciences Centre (GMNC), Salford Royal NHS Foundation Trust, Salford, UKSearch for more papers by this author M. A. Kirkman, M. A. Kirkman Brain Injury Research Group, The University of Manchester, Greater Manchester Neurosciences Centre (GMNC), Salford Royal NHS Foundation Trust, SalfordSearch for more papers by this authorP. J. Tyrrell, P. J. Tyrrell Brain Injury Research Group, The University of Manchester, Greater Manchester Neurosciences Centre (GMNC), Salford Royal NHS Foundation Trust, Salford Department of Stroke Medicine, The University of Manchester, Clinical Sciences Building, Salford Royal NHS Foundation Trust, SalfordSearch for more papers by this authorA. T. King, A. T. King Brain Injury Research Group, The University of Manchester, Greater Manchester Neurosciences Centre (GMNC), Salford Royal NHS Foundation Trust, Salford Department of Neurosurgery, Greater Manchester Neurosciences Centre (GMNC), Salford Royal NHS Foundation Trust, Salford, UKSearch for more papers by this authorH. C. Patel, H. C. Patel Brain Injury Research Group, The University of Manchester, Greater Manchester Neurosciences Centre (GMNC), Salford Royal NHS Foundation Trust, Salford Department of Neurosurgery, Greater Manchester Neurosciences Centre (GMNC), Salford Royal NHS Foundation Trust, Salford, UKSearch for more papers by this author First published: 11 August 2011 https://doi.org/10.1111/j.1468-1331.2011.03463.xCitations: 1 Matthew A. Kirkman, Brain Injury Research Group, Clinical Sciences Building, Salford Royal NHS Foundation Trust, Salford M6 8HD, UK (tel.: +44 (0) 7886608978; fax: +44 (0) 161 7076534; e-mail: [email protected]). Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article.Citing Literature Volume18, Issue9September 2011Pages e112-e113 RelatedInformation

Reversible increases in cortical diffusion-weighted MR signal in a patient with Sturge–Weber syndrome and subacute hemiplegia

A 30-year-old man with Sturge–Weber syndrome (SWS) diagnosed 10 years previously was admitted with a 3 day history of headache, photophobia, drowsiness and progressive left hemiplegia. There was a history of a similar episode in 2004, complicated by a period of generalised tonic–clonic status epilepticus. He had remained seizurefree for some years on levetiracetam 500 mg bd. Examination revealed a port-wine stain in a right trigeminal V1 distribution. He was drowsy and partially oriented, with left lower facial weakness. There was complete left hemiplegia with brisk left-sided deep tendon reflexes, left extensor plantar response and left-sided sensory extinction. There was no acute haemorrhage or infarct on CT brain. CSF white cell count and protein were normal. A T1weighted MRI brain showed dilatation of the deep venous system (Fig. 1a) and pial enhancement following gadolinium, with normal opacification of the superficial venous sinuses (Fig. 1b). There was high diffusion-weighted imaging (DWI) signal limited to the right cerebral cortex (Fig. 1c). EEG showed right-sided slowing but no epileptiform activity. He was treated with aspirin 300 mg/day and tinzaparin 17,000 u/day. Levetiracetam was increased to 1,000 mg bd. The left hemiplegia completely resolved over the next 10 days, and no seizures were observed. He complained of intermittent non-threatening formed visual hallucinations which gradually resolved. Repeat MR showed a resolution in the cortical DWI signal (Fig. 1d). Recurrent stroke-like episodes due to ischaemia or seizures occur frequently in children with SWS [3, 4, 9], but are less well-described in adults. Headaches, mostly with migrainous features, are common and have been associated with stroke-like episodes in one study [6]. Post-ictal Todd’s paresis was also considered as a potential cause of the patient’s symptoms, but the absence of definite seizures and the progressive nature of the deficit were against this, although levetiracetam was increased as a precaution against further deterioration [2]. The deep venous anomalies and pial enhancement we describe are consistent with longstanding vascular changes in SWS [2, 9]. The increased DWI signal over the right cerebral cortex likely represents cortical ischaemia due to microcirculatory stasis within the aberrant leptomeningeal vasculature, a mechanism which has been proposed for neurological complications of SWS [3, 9]. Acute hemiparesis due to chronic venous sinus occlusion is reported in SWS, albeit without DWI changes suggestive of ischaemia [5]. A recent report described increased cortical DWI signal in a patient with SWS with a subacute history of headache and hemiparesis [7], although the DWI changes only occurred after a series of prolonged seizures. Increases in cortical DWI signal have been reported in patients with SWS and chronic neurological deficit, and may reflect gliotic changes in this context [1]. Aspirin is thought to reduce the risk of stroke-like episodes due to microcirculatory stasis [8], and its use in adults with SWS is described anecdotally [7] although there are no large clinical trials to support its use. Given the imaging changes suggestive of C. Kobylecki (&) M. Jones A. Gerhard Department of Neurology, Greater Manchester Neurosciences Centre, Stott Lane, Salford M6 8HD, UK e-mail: christopher.kobylecki@manchester.ac.uk

Difficulties with recruiting into neurosurgical clinical trials: The Surgical Trial in IntraCerebral Haemorrhage II as an example

Background: Spontaneous supratentorial intracerebral haemorrhage (ICH) is a devastating condition with a high morbidity and mortality, and uncertainty remains regarding the role of surgery in many cases. The Surgical Trial in IntraCerebral Haemorrhage II (STICH II) was initiated to look at subjects with superficial lobar ICH, as the initial STICH trial showed the greatest benefit from early surgery in this subgroup. Our aim was to estimate how many patients with ICH referred to the Greater Manchester Neurosciences Centre (GMNC) met the inclusion and exclusion criteria of the STICH II trial.Methods: The number of patients eligible for STICH II was determined from the GMNC referral database and admissions to the stroke unit over 1 year (2008). Eligibility was determined by predefined criteria, and equipoise was agreed by two consultant neurosurgeons.Results: One hundred and sixty-eight (38.7%) of 434 ICH referrals were lobar ICH; 53 (31.5% of lobar ICH) of these met the radiological and Glasgow Coma Scale (GCS) criteria for STICH II, but only 16 (9.5% of lobar ICH; 3.7% of all ICH) had equipoise agreed on by two neurosurgeons. Thirty-five ICH patients were admitted to the stroke unit, and 12 (34.3%) of these had lobar ICH; none were eligible for STICH II.Conclusions: The number of patients eligible for recruitment into STICH II is small, necessitating an aggressive recruitment approach. Recruitment should focus on neuroscience centres with neurosurgical units as opposed to stroke units.

Clinical neuroscience attachments: a student’s view of ‘neurophobia’

neurophobia has been described as a fear of clinical neuroscience, and is known to affect both medical students and junior doctors alike. There is some evidence that it may affect the practice of GPs, who may not feel confident enough to give advice to neurological patients. I am a fourth year undergraduate at The University of Manchester, and have undertaken two four-week placements in neurology at the Greater Manchester Neuroscience Centre in Salford. The first was a student-selected component in movement disorders, and the second was part of the standard undergraduate curriculum at the University. in this piece I relate my experience of clinical neuroscience training to the theory surrounding neurophobia. I aim to demonstrate how students and teachers can reduce the effect of the phenomenon through the use of good educational strategies. My experience is divided into individual and group learning opportunities. Five points for teachers of clinical neuroscience are presented as possible ideas to help students venturing into clinical neurology for the first time. the experience I had during my eight weeks in neurology suggests that neurophobia can be reduced. It is important that clinical teachers have an awareness of the implications of neurophobia in their students so they can both anticipate and counteract its effects.

Progress on CSF drainage and IVIg benchmarks

The Royal Victoria Hospital, Belfast (now part of Belfast Health and Social Care Trust) hosted the North West Benchmarking Group's regional meeting on 28 January 2009, sponsored by Beagle Orthopaedics. Beaumont Hospital Dublin, the Walton Centre Liverpool, Greater Manchester Neuroscience Centre, and the Royal Victoria Belfast were represented. Apologies were received from The Royal Preston.