Team Of Neurologists Research Articles

Abstract 211: Building a Stroke Program in Urban Tanzania: Needs Assessment and a Plan to Move Forward

Introduction Stroke is a leading cause of morbidity and mortality globally with high social and economic burden that disproportionately effects low‐ and middle‐income countries (LMICs). Mechanical thrombectomy (MT) is an effective treatment for stroke but is not available in the majority of LMICs. Tanzania (TZ) lacks MT and has limited access to thrombolytics with very few patients receiving any intervention for acute ischemic stroke (AIS). Key stakeholders in TZ are motivated to build a stroke program and provide treatment of AIS, including MT. Here we present the initial needs assessment and model for developing a system of stroke care in TZ. Methods A needs assessment was performed in TZ through discussion with a multidisciplinary team. Key leaders from the national hospital leadership, Emergency Medicine, Neurology, Neurosurgery, Radiology, Interventional Radiology, and international stroke teams were involved in discussions regarding current stroke management and goals for the future. Key stakeholders provided insight into the current state of stroke management within their health system, including the referral system within TZ, review of data from an existing stroke registry, review of standard operating procedures (SOPs) in place for patients presenting with AIS. Recommendations for improving access to acute stroke treatment were identified and discussed. Results Existing infrastructure and systems within TZ designed to care for patients with AIS include: two newly established, thrombolysis ready stroke units; AIS registry which involves 8 referral hospitals. The barriers to providing AIS treatment include: delayed presentation to healthcare due to lack of public awareness; lack of affordable and rapid access to appropriate imaging; lack of established consulting service between emergency physicians and stroke neurology; lack of epidemiological data as to the true incidence of AIS at the district level, lack of access to endovascular treatment. A model to develop AIS program in TZ was identified consisting of three partially overlapping avenues and targeted at the public, healthcare systems and medical teams. Public: sensitization of the public with media campaigns and education will be focused on identification of stroke symptoms and knowledge about treatments. Healthcare systems: development of a formalized consultation service between district emergency teams and stroke neurology; development and implementation of new SOPs for diagnosis and access to imaging at the district level; expansion of stroke registry to include district level hospitals. Medical teams: continued mentorship through the World Stroke Organization for neurology on identification and acute management of patients with stroke; development of the first endovascular neuro‐intervention training program in collaboration with Mission Thrombectomy 2020. Conclusions There is significant need for a system of stroke care for patients in TZ. Key stakeholders are motivated to establish this system and bring acute interventions, including thrombolysis and MT. to patients suffering from AIS in TZ. This endeavor will require significant effort by many groups, but concurrent efforts in these three domains can help bring this important care to the people of TZ.

Abstract 116: Initial first in man clinical case experience with the novel adaptive tip Hippo ‐ Cheetah Aspiration system: a review of 58 AIS cases

Objective The Q'Apel Medical Hippo aspiration system is a novel, adaptive tip catheter system that is capable of passively adapting its tip shape to conform to the thrombus. It includes a Cheetah delivery insert to aid in tracking to the intracranial circulation. We performed the first‐in‐human cases with the Hippo and present our initial experience. Methods A single center retrospective review of prospectively collected data from consecutive patients who underwent mechanical thrombectomy for anterior circulation LVO is presented from October 1, 2023 (Hippo US approval) to Februraury 28, 2024. All clinical data was prospectively captured by the Stroke Neurology team. Angiography data was adjudicated by two of the authors. All follow up imaging at 24 hrs was reported by Neuroradiology. Results 45 Anterior Circulation4 Posterior circulation6 ICAD cases3 other cases58 total cases 58 total Hippo AIS cases were identified from 10/1/2023 to 2/28/2024. Of these, 3 cases included a cervical ICA occlusion, bilateral MCA occlusion and one case where guide catheter access could not be achieved and the procedure terminated, 6 cases of underlying ICAD where Hippo was used in combination for aspiration and/or as a conduit to deliver adjunctive devices, 4 posterior circulation LVO aspiration cases and 45 AIS Anterior circulation LVO procedures. Of the 45 Anterior circulation LVO cases; 16 (36%) of patients receive TNK. Mean presenting NIHSS was 18.9 and mean discharge NIHSS was 7.5. Mean time of onset to groin puncture was 276 mins, mean time to recanalization was 31 mins. 6 patients had tandem occlusions. First pass TICI □ 2C rate was 22/45 (49%), Final TICI □ 2B: 40/45 (89%), TICI □ 2C: 36/40 (80%), TICI 3 29/45 (64%). 33/45 (73%) were performed with BGC (Walrus). 5 cases required bailout stent‐retriever. In two cases an additional 070 aspiration catheter was used and in total 14 cases required an adjunct aspiration catheter. A 90 day mRS of 0‐2 was achieved in 21/45 (47%), 4 patients were lost to follow up, 1 patient has not reached a 90 day end point. 14 patients had evidence of hemorrhage vs contrast staining on 24 hr imaging, 1 classified as PH2. There was one SAH, from a vessel perforation, likely catheter related 1/45 (2%). Hippo was able to achieve its target location in all but two cases. In one case multiple devices were attempted, finally a velocity microcatheter was used to deliver a stent retriever. In the second case, supraclinoid stenosis prevented Hippo from accessing the M1 and it was used to deliver a RED 43 to the target lesion. Conclusion Our initial experience with the Hippo Aspiration system demonstrates it to be safe and efficacious with high rates of reperfusion, low complications and low use of adjunctive catheters. A synergistic effect with BGCs maybe present. Further studies are warranted.

AntiSox-1 Limbic Encephalitis: When A Movement Disorder Evolves Oddly And Delirium Just Does Not Feel Right

Abstract Background A 74year old male presented to a Movement Disorder service with a 15year history of a parkinsonian syndrome with asymmetric, akinetic rigidity and prominent axial features. Motor features were stable for almost 13years. Neuropsychiatric features rapidly emerged over several months including: multimodality perceptual hallucinosis, upside down and tilt illusion, akinetopsia, intractable insomnia, emotional incontinence and Othello syndrome. A marked motor, mysaesthenic pattern, deterioration occurred in conjunction with hypoactive delirium, dysphagia, pyrexias, raised inflammatory markers and weight loss, necessitating hospitalisation. Computed tomography (CT) of chest, abdomen and pelvis did not demonstrate infective or neoplastic aetiology. CT brain did not demonstrate cerebellar atrophy. Positron emission tomography did not demonstrate a vasculitis. Drg regimen alterations brought about minor improvements, but he remained very severely frail and discharged to hospice care. Unexpectedly, cognition then markedly improved and neuropsychiatric symptoms resolved over months, and he returned home, albeit now severely frail. There was persistence of hemiparkinsonian symptoms, contralateral to which, dystonia had emerged with new bilateral upper limb ataxia and nystagmus. No mysaesthenic features persisted. Methods Cerebrospinal fluid analysis and electroencephalography were not undertaken. MRI brain was not undertaken. Results Anti Sox-1 positive. Anti Zic-4 and Recoverin were equivocal. Neuronal antibodies were negative. Conclusion Limbic encephalitis as a result of AntiSox-1 onconeural antibodies is most commonly associated with small cell cancer of the lung (prevalence of 36.5% of cases). Lambert-Eaton Mysaesthenic Syndrome is a more common presentation than paraneoplastic cerebellar degeneration. Hindsight raises the possibility of non-convulsive status epilepticus as an explanation for abrupt hypoactive delirium presentation on the background of deteriorating neuropsychiatric features. Oncological or immunotherapeutic intervention was not considered appropriate by respiratory or neurology teams respectively; nor did the patient wish for these to be pursued. Case reports indicate that an underlying neoplasm is not always identified. Non-paraneoplastic autoimmune encephalitis can have a better prognosis.

Outcomes and Issues Addressed by Palliative Care in the Neurology Clinic.

Patients with neurological illnesses have many palliative care needs that need to be addressed in the outpatient clinical setting. This review discusses existing models of care delivery, including services delivered by neurology teams, palliative care specialists, telehealth, and home-based programs. We review the existing literature that supports these services and ongoing limitations that continue to create barriers to necessary clinical care for this vulnerable patient population.

P.031 SMILES: Sunnybrook-St. Michael’s Integrated Leadership/QI in Endovascular Stroke care – enhancing hyperacute stroke protocols for optimized door-to-intervention times

Background: Hyperacute stroke care demands rapid, coordinated care. Traditional metrics like Door-to-Needle time are pivotal but insufficient for capturing the complexity of endovascular stroke interventions. The SMILES collaboration aims to standardize and optimize protocols for door-to-intervention times, incorporating Crew Resource Management (CRM). Methods: The multidisciplinary initiative integrates both hospitals, ED, neurology, and QI teams. We employed a comprehensive approach: stakeholder engagement, simulation-based learning, process mapping, and literature review. Emphasis was placed on enhancing situational awareness, triage and prioritization, cognitive load management, role clarity, effective communication, and debriefing. Results: The collaboration led to PDSA cycles and development of refined stroke protocols. Interventions included: 1) A ’zero point survey’ for team pre-arrival briefings, enhancing situational awareness and role clarity; 2) Streamlined patient registration to reduce cognitive load and improve triage efficiency; 3) Direct transfer of patients to imaging. Additionally, digital tools were implemented to facilitate communication. Simulation sessions reinforced CRM principles, leading to improved team cohesion and operational performance. Conclusions: The SMILES initiative is grounded in CRM principles by standardizing protocols and emphasizing non-technical skills crucial for high-stakes environments. This improves outcomes but also fosters a culture of safety and efficiency. Future directions include an evaluation of these protocols’ impact on patient factors.

X-linked adrenoleukodystrophy: Clinical review and case report

Introduction: Adrenoleukodystrophy is a rare, recessive, hereditary genetic disease, linked to the X chromosome, with degenerative and incurable characteristics, which preferentially affects males. It directly affects the non-development of the adrenal/suprarenal glands and the white matter of the brain due to the accumulation of long-chain fatty acids in these sites, causing destabilization of the myelin sheath and affecting the transmission of nerve impulses. Objective: The aim of this study is based on the scarcity of literature on this rare pathology, which affects around 1:15,000 to 25,000 individuals, in an attempt to portray the clinical course of this disease. Case presentation: A 34-year-old male patient, diagnosed with X-linked adrenoleukodystrophy following an investigation into the death of his 13-year-old brother with the disease, has been under multidisciplinary follow-up since diagnosis, with genetics, endocrinology, neurology and psychology teams, undergoing annual consultations and control laboratory tests, as well as a brain MRI. At the age of 19, she informed us that she did not wish to have a bone marrow transplant. She has been followed up clinically ever since. Discussions: The diagnosis can be made in prenatal tests, the gold standard score for grading the pathology is the LOES score, totaling 34 points, according to the patient's score, it is possible to see if they will benefit from treatment.

Rates of delirium referrals to the Neuropsychiatry Service in a tertiary referral centre hospital

IntroductionBeaumont Hospital is the National Neurosurgical Centre in Ireland. Due to the high numbers of referrals from Neurology and Neurosurgery, The Department of Psychiatry established a specialist Neuropsychiatry inpatient Liaison service and a weekly Neuropsychiatry outpatient clinic. Many of the referrals that the service receive involve the management of delirium. Delirium is a common medical complication, particularly in neurosurgical settings. Delirium causes significant symptom burden which can lead to distress to all involved and impacts quality of life.ObjectivesThe aim was to improve the rates of referrals for delirium presentations and referral rates overall from Neurology and Neurosurgery. The neuropsychiatry service have implemented a delirium protocol for all medical and surgical teams in Beaumont Hospital. This protocol can be accessed through the Beaumont hospital phone app, or on site on each ward. For this reason, delirium can be managed by medical teams in the first instance. If this is not successful, neuropsychiatry can be contacted for further advice or review of patients with more complicated presentations.MethodsThe neuropsychiatry service receives referrals through the Patient Information Profile Explorer system which is accessed through the Beaumont Hospital online portal. In the event of an urgent referral, neurology or neurosurgery teams can contact the neuropsychiatry service directly by phone. Referrals are logged on the team referral log book, and details of the referral are recorded along with diagnosis and management. Data was collected retrospectively from the PIPE and log book to measure the rates and reasons for referrals over a one year period. Rates and details of referrals were initially recorded between July-December 2022. An educational intervention was provided where psychoeducation was provided to junior hospital doctors during protected teaching times and further education was provided over the phone when referrals were discussed between team members. Rates and details of referrals were then recorded between January-July 2023.ResultsThere was a reduction in referrals when comparing the two six month periods. There were 115 neuropsychiatry referrals from July to December 2022 and 78 referrals from January to July 2023. Rates of delirium referrals also reduced from 31% to 25% after psychoeducation was provided to junior doctors.ConclusionsThis audit highlights the importance of communication and education for medical and surgical trainees in the management of delirium. There is a high rate of turnover of junior doctors throughout the year in Beaumont Hospital. For this reason, it is imperative that continued education is provided to allow them to follow the delirium protocol independently before seeking tertiary service assistance. Ultimately, early and rapid intervention of delirium can have a positive impact on patient care and prognosisDisclosure of InterestNone Declared

In-hospital stroke protocol outcomes before and after the implementation of neurological assessments by telemedicine: an observational case-control study.

Stroke is the second leading cause of global adult mortality and the primary cause of disability. A rapid assessment by a neurologist for general and reperfusion treatments in ischemic strokes is linked to decreased mortality and disability. Telestroke assessment is a strategy that allows for neurological consultations with experienced professionals, even in remote emergency contexts. No randomized studies have compared face-to-face neurological care outcomes with telestroke care. Whether neurologists in an institution achieve better results remotely than in person is also unknown. This study aimed to compare mortality and other outcomes commonly measured in stroke protocols for stroke patients assessed by a neurologist via face-to-face evaluations and telestroke assessment. Observational single-center retrospective study from August/2009 to February/2022, enrolling 2,689 patients with ischemic stroke, subarachnoid hemorrhage, and intracerebral hemorrhage. Group 1 (G1) comprised 2,437 patients with in-person neurological assessments, and Telemedicine Group 2 (G2) included 252 patients. The in-person group had higher admission NIHSS scores (G1, 3 (0; 36) vs. G2, 2 (0; 26), p < 0.001). The door-to-groin puncture time was lower in the in-person group than in the telestroke group (G1, 103 (42; 310) vs. G2, 151 (109; 340), p < 0.001). The telestroke group showed superior metrics for door-to-imaging time, symptomatic hemorrhagic transformation rate in ischemic stroke patients treated with intravenous thrombolysis, hospital stay duration, higher rates of intravenous thrombolysis and mechanical thrombectomy, and lower mortality. Symptomatic hemorrhagic transformation rate was smaller in the group evaluated via telestroke (G1, 5.1% vs. G2, 1.1%, p = 0.016). Intravenous thrombolysis and mechanical thrombectomy rates were significantly higher in telestroke group: (G1, 8.6% vs. G2, 18.2%, p < 0.001 and G1, 5.1% vs. G2, 10.4%, p = 0.002, respectively). Mortality was lower in the telestroke group than in the in-person group (G1, 11.1% vs. G2, 6.7%, p = 0.001). The percentage of patients with an mRS score of 0-2 at discharge was similar in both groups when adjusting for NIHSS score and age. The same neurological emergency team may assess stroke patients in-person or by telemedicine, with excellent outcome metrics. This study reaffirms telestroke as a safe tool in acute stroke care.

Abstract WP51: Bridging the Gap - Impact of Advanced Practice Nurse in the Community Hospital in Singapore

Background: Stroke is a debilitating condition and patients with acute stroke usually stays about a week in the acute hospital. Those patients with impaired physical function may be transferred to a Community Hospital (CH) for further rehabilitation to optimize their function. In this pilot project, we aimed to incorporate the Stroke Advanced Practice Nurses (APNs) in one of the Community Hospital (OCH) so that stroke care gaps can be identified and to optimize stroke care. Methodology: The Stroke APN obtained their clinical privileges to work in CH. The APN would identify stroke patients admitting to CH for further rehabilitation. APN performed a weekly consultation round to review stroke patients identified in CH. During the consultation round, the APN assessed stroke patients’ neurological function and stroke complications. She also reviewed patient’s vital signs, fluid balances, pending blood results, medications and management. With the information, the APN would recommend change in management accordingly after communicating with the neurology team from the original transferring acute hospital. Results: There were total of 51 issues identified from Aug 2020 to Aug 2021 from 125 patients were reviewed by the Stroke APNs. The Stroke APNs identified 27.5% (n= 14) medical related issues e.g. change in stroke etiology, lack of deep vein thrombosis prophylaxis. There were pharmacological changes in 21.5% (n= 11) of the patients reviewed. Drug changes were usually anti-hypertensives or anti-thrombotics. Post-stroke psychological issue was common and 21.5% (n= 11) of patients developed low mood. To empower patients with their own health, the Stroke APN had to reinforce stroke education in 13.7% (n= 7) of the patients and 7.8% (n= 4) required reinforcement of driving advice. 7 patients (13.7%) requested Information about community resources for them to transit back into the community. Outpatient appointments were streamlined and 7.8% (n= 4) had their appointment has been amended or cancelled. Conclusion: There were high incidence of issues detected during the Stroke APN visiting consultation. The Stroke APN played an important role to manage post-stroke patients appropriately in the CH.

Abstract WP92: Application of a Horizontal Communication Process in Combination With Artificial Intelligence (AI) to Improve Stroke Care in Patients With Large Vessel Occlusion (LVO)

Introduction: Timely acute stroke care in patients with large vessel occlusion (LVO) requires both early detection of LVO and efficient multidisciplinary communication. In this study, we aimed to evaluate the impact of using AI and a horizontal communication system within the RapidAI application platform on acute stroke quality metrics in patients with LVO. Methods: On April 2022, the RapidAI application was launched at our center, which allowed for use of AI as a screening measure for LVO detection with immediate notification to neurology, neuroradiology, and neuro-interventional teams. The various teams used instant messaging within the application to communicate clinical data, imaging findings and shared clinical decision making. In this single center study, we retrospectively evaluated stroke care quality metrics for 167 consecutive patients (mean age: 71.6, 49.1% male) who underwent mechanical thrombectomy (MT) from January 2021 to May 2023. Data were compiled from multiple resources including Get-With-The-Guidelines®, chart abstraction, and internal healthcare databases. The groups were compared using appropriate statistical tests and significance was determined using a two-sided alpha of 0.05. Results: 85 patients underwent MT before implementation of the new system, and 82 patients underwent MT after. Demographic features (age, sex, race), cerebrovascular risk factors (hypertension, diabetes, hyperlipidemia, smoking, BMI) and stroke severity were similar between the two groups (p&gt;0.05). Average door to groin puncture (pre: 97 minutes, post: 82 minutes, p=0.10) and discharge disposition (p=0.02) were significantly different between the two groups. In an adjusted analysis of door to groin puncture time, the difference between pre-RapidAI and post-RapidAI was an average reduction of 19 minutes trending towards significance (p = 0.06). Conclusion: Application of a horizontal communication platform in combination with RapidAI was associated with significant improvements in time to intervention in patients with LVO and a significant improvement in the number of patients discharged home.

A SINGLE-CENTER COMPARATIVE STUDY OF ENDARTERECTOMY AND STENTING FOR SYMPTOMATIC CAROTID ARTERY DISEASE: DECISION-MAKING PROCESSES AND EARLY TO MID-TERM OUTCOMES

Introduction: Ischemic stroke constitutes a significant burden on global health. Carotid artery atherosclerosis is a significant contributor to the occurrence of ischemic strokes. Both carotid endarterectomy and stenting are viable treatment options for symptomatic carotid artery disease, yet the optimal choice between them remains debated, particularly in elderly patients with multiple comorbidities. This study aims to compare decision-making processes and early to mid-term outcomes between carotid endarterectomy and carotid artery stenting in elderly symptomatic carotid artery disease patients. Materials and Method: A total of 88 symptomatic carotid artery disease patients (carotid endarterectomy: n=35, mean age: 71.72±7.87 years; carotid artery stenting: n=53, mean age: 70.64±7.46 years) were retrospectively analyzed. Results: No significant differences were observed in demographic characteristics between carotid endarterectomy and stenting groups. Chronic renal disease was more prevalent in the carotid endarterectomy group. Carotid artery stenting patients had a higher prevalence of 50–69% stenosis and less plaque ulceration. Complication rates were comparable between groups, with longer intensive care and hospitalization durations in the carotid endarterectomy group. Mid-term mortality rates and major complications did not significantly differ between groups. Conclusion: Both carotid endarterectomy and carotid artery stenting are effective treatments for symptomatic carotid artery disease. Despite differences in lesion characteristics, complication rates were similar between carotid endarterectomy and carotid artery stenting. This study emphasized the efficacy of a full cooperation between the cardiovascular surgery and neurology teams through an in-depth evaluation of each of the patients and the creation of individualized treatment strategies that optimized overall outcomes. Keywords: Aged; Endarterectomy; Carotid; Carotid Stenosis; Stents.

Using the Workload Indicators of Staffing Need (WISN) – method to asses HR requirements and optimize processes in health care

Changing market conditions and increasingly scarce human resources require health care providers to analyze, review, and constantly adjust their processes within their healthcare facilities. A personnel requirement assessment based on the WISN method has proven to be a useful instrument for personnel planning, but also for identifying potential for improvement and process optimization. Based on a mixed method approach, using a systematic literature review, focus group-based experts discussions and interviews the WISN – method was applied to calculate human resource needs for a neurology team of therapists in a general hospital in Germany. Furthermore, the study intended to identify concrete measures for optimization. The results show that it is possible to calculate the required personal resources using the WISN-Method. Additionally, three support activities (daily documentation, weekly documentation, and scheduling) which, at 5.5 hours/week per therapist, tie up considerable working time could be identified. After implementing the optimization measures, a maximum of 1.36 full-time equivalents (FTE) therapists out of a team of 9.51 FTEs therapists could be saved or used for value-adding other health activities. It can be concluded that WISN is a good way to calculate Human Resource (HR) requirements and can help to increase transparency and efficiency in health care.

Risk factors for peri-procedural stroke or death in internal carotid artery stenting: A neurology team experience

Background and Objectives: Suitable cases of extracranial internal carotid artery (ICA) stenosis can be treated with carotid artery stenting (CAS) or carotid endarterectomy. However, major complications in the peri-procedural period, like stroke and death, are more common with CAS. We therefore investigated the risk factors for stroke and death during the peri-procedural period following CAS. Methods: In this study, the files of patients who were treated with CAS by a neurology team during 2020–2022 were retrospectively analyzed. Patient age, gender, vascular risk factors, use of antiplatelet therapy, type of carotid artery stenosis (symptomatic or asymptomatic), measured stenosis degrees, contralateral carotid stenosis, types of aortic arch, balloon angioplasty, use of a filter-type embolism protection device, stent cell design (open or closed), and peri-procedural death, stroke, or myocardial infarction (MI) were recorded. All patients were followed up for the first 30 days after CAS. Results: The mean age of 219 patients included in our study was 67.8 ± 8.38 years and 68.5% were male. The most common comorbid diseases in the patients were hypertension (76.7%), hyperlipidemia (53.4%) and diabetes mellitus (DM) (43.4%). Stroke or death occurred in the peri-procedural period in 15 (6.85%) of the patients, but MI did not occur. No statistically significant difference was observed in terms of age or gender when comparing with the cases without stroke or death. Of the patients suffering stroke or death, ischemic stroke developed in 13 (86.67%), cerebral hemorrhage in two (13.33%) and two patients (13.33%) died. Two-thirds of the strokes were either minor (n=7, 46.67%) or moderate (n=4, 26.67%); 13 (86.67%) were ipsilateral, and 14 (93.33%) were in the anterior circulation. The complication risk was found to be significantly higher in patients with prior stroke (OR=3.865; 95% CI 1.282 to 11.652 p=.016), DM (OR=3.634; 95% CI 1.102 to 11.992 p=.034) and pre-dilation angioplasty (OR=13.100; 95% CI 1.762 to 97.422 p=.012). Conclusion: Prior stroke, DM and pre-dilation angioplasty increase peri-procedural stroke and death in CAS. However, even if a stroke complication develops after CAS, it is often not severe.

Blurred boundaries of the brain-1 (Aide-memoire for patient narrative)

Background: This is a case series of clinical cases presenting to our Neuropsychiatry Center, who were either referred by physicians or approached to seek treatment on their own. They were receiving treatment since few years. No improvement in symptom were primary reason for referral and consultation with our team. Re-evaluation in realms of Neurology and Psychiatry depicted the missed link in diagnostic and therapeutic approaches exercised previously. The intent to reflect upon novel findings is not to undermine the effort applied in clinical evaluation by prior physicians, but to reflect few observations which may have been inadvertently missed during routine assessment. This serves as as an aide-memoire to history taking and suggestions to remain well informed and updated in our approach to service seekers. Abstract: Symptom overlap and comorbidities are commonly encountered in clinical practice of Psychiatry or Neurology. Many neurologic disorders have psychiatric symptoms (e.g., depression in patients following a stroke or with multiple sclerosis or Parkinson’s disease), and many psychiatric disorders have been associated with neurologic symptoms (e.g., movement disorders in schizophrenia). This overlap occurs mostly because brain is the source common for both neurological and psychiatric illness and on multiple occasion it becomes difficult to delineate the boundary, leading to diagnostic dilemmas, followed by inappropriate management strategies. Patients and family members suffer for long periods of time in trying to understand the disease phenomenon and prognosis. In this case series, we present 3 cases of clinical interest across different framework of clinical presentation and assessment for e.g, neurological illness being managed as psychiatric illness or scenarios where both neurological and psychiatric illness coexisted but only one aspect was addressed. Re-assessment and work up by a team of neurologists and psychiatrist lead to clarification of the boundaries (at least in these cases who underwent prolonged sufferings owing to lack in clarity of pathology) with precise diagnosis generating improved outcomes in functionality and satisfaction. The diagnosis of neuropsychiatric disorders is performed by psychiatrists through diagnostic interviews, and categorization of patients based on diagnostic and classification manual (ICD-10, DSM-5) which are syndrome/symptom based. Although this has been a standard practice, often error may occur in diagnosing illnesses falling under the wider realm of neurology and psychiatry. Some presenting symptoms may be assumed being part of neurological illness or of functional origin, or mixed states and many may be overlooked during routine clinical assessment.

Atypical optic neuritis in a keratoconus patient and literature review

Myelin oligodendrocyte glycoprotein antibody disease-optic neuritis (MOGAD-ON) is an uncommon form of demyelinating optic neuritis, which may be potentially blinding. Keratoconus (KC) is a noninflammatory, progressive ectatic corneal disorder often affecting young adults, leading to visual dysfunction. A singular account of the coexistence of unilateral KC with bilateral (BL) MOGAD-ON has been reported before. Our report narrates the experience of managing the visual deficit due to BL MOGAD-ON in a patient with BL KC, an association hitherto unreported so far. The emphasis is on highlighting the diagnostic approach and stressing the refined principles of management of optic neuritis in conjunction with the neurology team.

P04 A case of zoledronate-induced ANCA associated vasculitis

Abstract Introduction Bisphosphonates are a well-established treatment for osteoporosis and other metabolic bone disorders. In up to 40% of recipients, infusion is associated with a transient cytokine-mediated acute-phase response. It has been hypothesised that this can rarely cause autoimmune reactions, with case reports linking bisphosphonate infusion to the development of giant cell arteritis (GCA), urticarial vasculitis and dermatomyositis. In this report, we describe a case of ANCA associated vasculitis (AAV) with 3rd nerve palsy, finger joint synovitis, fevers and cough, preceded by zoledronate infusion. To our knowledge, this is the first description of a zoledronate-induced AAV. Case description A 75-year-old lady with a background of ulcerative colitis and gout was referred to rheumatology for the management of osteoporosis after sustaining a left neck of femur fracture. A decision was made to commence zoledronate treatment. Within a few hours of receiving zoledronate, the patient began to feel unwell with fevers, vomiting, headache, and general malaise. Within 24 hours of the infusion she developed pain, stiffness and swelling to the small joints of her hands with fatigue, mild intermittent cough without breathlessness, and ongoing headaches. The initial impression was that she had developed a side effect to zoledronate which would be self limiting and she was treated with over the counter analgesics. Two weeks later she remained symptomatic and bloods showed a newly raised CRP of 29 and ESR of 18. Rheumatoid factor, ANA and CCP were negative. Her joint symptoms settled with a short course of oral prednisolone, which was prescribed for a possible diagnosis of zoledronate-induced inflammatory osteoarthritis. By this point, her chest symptoms had completely resolved. Four weeks after the zoledronate infusion, the patient developed a sudden onset 3rd nerve palsy, headache, eye pain and tingling to her face whilst in Prague. CRP was 1 and PR3 was strongly positive (131.5). MRI brain did not show any inflammation. She was treated with intravenous methylprednisolone for 6 days and her symptoms improved. On return to the UK, she was seen by rheumatology, ophthalmology, and neurology teams. Examination showed a resolving 3rd nerve palsy, without features of retinal vasculitis or any systemic symptoms, likely due to an AAV. She has continued on oral prednisolone and her symptoms have resolved. Her bloods show a down trending PR3 (131.5 to 23.7). Discussion Although zoledronate is generally well-tolerated, up to 40% of patients develop transient flu-like symptoms after infusion. Commonly reported symptoms include fever, chills, muscle and joint pains and headache. These symptoms are thought to be due to a transient acute-phase response mediated by pro-inflammatory cytokines. Symptoms generally reach their peak during the first two days post-infusion, with a rapid decrease in frequency after 3 days. In our case, the patient described many features in keeping with the well-described acute-phase response. Atypically, her symptoms were more persistent than usual with joint pain and swelling lasting for 2 weeks and an associated rise in inflammatory markers. Following an initial improvement in symptoms with oral prednisolone, our patient developed sudden-onset 3rd nerve palsy. Investigations were in keeping with AAV and the patient responded well to corticosteroid therapy. Although the literature is sparse, case reports and series have suggested a rare link between zoledronate and the development of autoimmune disease in patients with pre-existing risk factors . In these patients, it has been hypothesised that the acute phase response can trigger autoimmunity, however further work is needed to understand the underlying pathophysiology. Existing literature suggests that zoledronate can trigger a range of autoimmune pathology. Narkovits et al described six patients who developed a new-onset or an exacerbation of known autoimmune disease within 3 months of zoledronate infusion. These included new-onset rheumatoid arthritis, polymyalgia rheumatica and autoimmune haemophilia with other patients reporting flares of pre-existing Crohn’s disease. Some case reports have described the development of vasculitis secondary to zoledronate. Swarnkar et al, 2021, reported a case of zoledronate induced biopsy-confirmed urticarial vasculitis and there have been two case reports of GCA possibly triggered by zoledronate (Naderi, 2019 and Metyas et at, 2014). To our knowledge, there have been no other reports of zoledronate induced AAV. Key learning points Zoledronate infusion is associated with a proinflammatory acute phase response in up to 40% of recipients. The most common symptoms include fevers, joint pain and swelling, gastrointestinal symptoms including abdominal pain, diarrhoea, nausea and vomiting and general features including fatigue, dizziness, headache and malaise. Very rarely, zoledronate is associated with eye symptoms including pain and scleritis. There have been case reports linking zoledronate infusion to the development of autoimmune and autoinflammatory disease, including vasculitis. Although further work is needed to fully understand this association, clinicians should be aware of these rare reactions in order for rapid diagnosis and prompt management. In this case, zoledronate-associated AAV responded effectively to conventional therapies with corticosteroids.

Identifying and troubleshooting the pitfalls of ictal/interictal brain perfusion SPECT studies.

Epilepsy is a prevalent condition, and surgical intervention can benefit patients with refractory seizures. Single photon emission computed tomography (SPECT) using 99mTc-HMPAO or 99mTc-ECD provides assessment of regional cerebral blood flow and is the primary non-invasive approach for imaging brain perfusion in ictal and interictal states. Ictal/interictal SPECT is valuable in localising epileptogenic foci, particularly when MRI and electroencephalography are negative. However, to obtain accurate images reflecting brain perfusion in both states, meticulous preparation of the patient, timely radiotracer injection and close coordination between neurology and nuclear medicine teams are essential. Tracers also have inherent limitations, and patients may present with coexisting brain pathologies for which coregistration of SPECT images with MRI is recommended to improve diagnostic accuracy. Inconclusive SPECT findings may require repeating the exam or considering additional investigations. A comprehensive approach, considering various factors, is crucial for accurate interpretation of SPECT studies in presurgical epilepsy evaluations. This article provides a summary of the organisation and key challenges involved in conducting ictal/interictal SPECT studies, covering the entire process from a patient's hospital arrival to the integration of results within their presurgical pathway and using our experience of 182 patients over 10 years.

Preimplantation Genetic Testing for Adult-Onset Neurodegenerative Disease: Considerations for Access, Utilization, and Counseling.

Preimplantation genetic testing for monogenic conditions (PGT-M), formerly called preimplantation genetic diagnosis, is a specialized assisted reproduction technique that aims to reduce the risk of a pregnancy inheriting a monogenic condition. Despite calls to increase awareness and prepare neurologists for discussing PGT-M with patients and their families, no guidelines currently exist. When introducing PGT-M to those who may be interested in using it, there are major factors for discussion, including (1) genetic considerations (e.g., requirement for a confirmed genetic diagnosis; timing of genetic test results); (2) practical considerations (e.g., access to PGT-M and genetic services); (3) technical considerations (e.g., factors that can affect the success rate of PGT-M); and (4) psychosocial and ethical considerations (e.g., predictive testing for asymptomatic family members; family dynamics and values). Here, our team of neurologists and specialized genetic counselors discusses the current state of genetic characterization in adult-onset neurodegenerative conditions and highlights the major factors that should be considered when discussing PGT-M with families.

Impact of the NIHSS scale in the Stroke Unit of the Ramón y Cajal University Hospital: A tool to improve the quality of care

IntroductionStroke is a time-dependent pathology which requires a rapid and universal neurological assessment tool. Since October 2021, following training of nursing staff, the NIHSS scale has been implemented in order to increase comparability, concordance and improve communication with the medical team. Objectives1. To examine the concordance among scores of the NIHSS scale implemented by nursing staff and medical team in Neurology Service of the Ramón y Cajal Hospital. 2. To describe the subjective perception of using the NIHSS scale from the nursing staff in the Neurology Service of the Ramón y Cajal Hospital. MethodCross-sectional observational study that included 100 patients distributed in two periods of three months each in the Stroke Unit of the Ramón y Cajal Hospital. The NIHSS scale scores given by nursing and neurology were collected, as well as the discordant items of each assessment. Statistical analyzes included frequencies, percentages, Cronbach's alpha and the Intraclass Correlation Coefficient. A survey was conducted among the 22 professionals to assess the degree of acceptance. ResultsA high concordance (68% and 70% in each period) was achieved between the nursing and neurology. A total of 94% of professionals reported to get used to the NIHSS scale. ConclusionsThe implementation of the NIHSS scale is a clear opportunity for improvement in the stroke unit, facilitating communication between nursing and neurology teams, due to agreement between scores and increasing quality of medical care.

Improving collaboration between palliative care and neurology: Focus on patient, family &amp; healthcare provider experience

AbstractBackgroundThe prevalence of neurodegenerative diseases is increasing as the population ages. As these diseases are often incurable, progressive, and associated with significant loss of ability to communicate over time, it is paramount that advanced care planning (ACP) take place early in the disease trajectory to facilitate goal‐concordant care. There is increasing recognition of the barriers for neurologists to facilitate ACP and end‐of‐life care. Palliative care is a medical speciality that focuses on improving quality of life for patients living with serious illness, including helping with healthcare planning and decision‐making that align with the individual’s values and goals. However, there is a paucity of literature on how to best integrate palliative care or which elements of an integrated neuro‐palliative approach are the most beneficial to patients, caregivers, and clinicians.Our study aims to assess the experience of an embedded pilot clinic between Neurology and Palliative Care at the University Health Network (UHN) Memory Clinic on patients/caregivers and health care practitioners.MethodsWe aim to recruit 60 participants, including patients and family members, seen at the UHN Supportive Care Memory Clinic, and who screen positive for three of seven triggers for palliative care involvement for neurological patients as proposed by the National End of Life Care Programme of National Health Service in England. ACP conversations will follow an evidence‐based semi‐structured conversation guide. The impact of the clinic will be evaluated using patient, caregiver, and both Neurology and Palliative Care team member experience surveys. Secondary measures will include the percentage change in ACP and Power of Attorney documentation pre and post initiation of the clinic.ResultsFrom clinic inception in June 2020, 19 patients were seen (all‐virtual). Due to the COVID‐19 pandemic, the clinic was paused for the majority of 2021. Our study received UHN Quality Improvement approval in March 2021, and we began enrolling patients into our study in November 2021; enrolment is ongoing.ConclusionsThe results of this study will serve as a guide for quality improvement of our existing clinic and can inform future implementation of scalable integrated models of care between palliative care and neurology, and for other subspecialties and centres.