MAIN SESSION 1 - Wednesday 19th September

WM1 – Neurovascular and Stroke

WM1-1

Is it time to change our practice in investigating thunderclap headache and suspected

subarachnoid haemorrhage?

S. Al-Araji, B. Davies

Royal Stoke University Hospital, Stoke-on-Trent, UK

Objectives. To evaluate our current practice of investigating suspected subarachnoid haemorrhage

(SAH) and whether the current pathway needs revision.

Design. A 5 year retrospective audit and CT and CSF analysis with clinical correlates.

Subjects. Adults admitted to an acute headache service at a University Hospital and investigated for

SAH.

Methods. Adult patients presenting with headache and investigated for suspected SAH were

identified through CSF xanthochromia requests sent to our biochemistry laboratory between January

2012 and January 2017. Patients with positive xanthochromia results were evaluated in more detail

including clinical presentations, CT head results, timing of scan, further investigations, final diagnosis

and follow up outcome.

Results. 1135 patients investigated for suspected SAH over five years were identified. Only 6 (0.5%)

patients had positive CSF xanthochromia when initial CT head was negative. All 6 patients had non-

aneurysmal SAH. No patient represented with further episodes and all had a benign course following

a minimum follow up of 2 years.

Conclusions. SAH is a life threatening emergency but when CT head is negative the yield of CSF

analysis for SAH is exceptionally low based on our 5 year data. In our series those who do not show

evidence of a bleed on early CT head seem to have a more benign clinical course. We highlight

potential alternatives to current practice.

WM1-2

SFX-01 after subarachnoid haemorrhage: protocol of a multi-centre, phase II, double-

blinded, randomised controlled trial

A. Zolnourian¹, P. Holton¹, I. Galea²

¹University Hospital Southampton, Southampton, UK, ²University of Southampton, Southampton, UK

Objectives. To assess the safety and efficacy of SFX-01 after subarachnoid haemorrhage.

Design. SFX-01 is a synthetic agent that contains sulforaphane that has been shown to be

neuroprotective in animal models of subarachnoid haemorrhage. This is a phase II double-bilinded,

placebo-controlled randomised clinical trial.

Subjects. Target of 90 patients with fisher 3 or 4 subarachnoid haemorrhage

Methods. Patients admitted to the three recruiting centres within 48 hours of ictus will be randomly

allocated to placebo or SFX-01. The randomisation is stratified into WFNS 1-3 or 4-5. Participants will

receive the trial medication in a capsule format twice-daily for 28 days. Patients will have transcranial

dopplers (TCD) on alternate daily basis for at least 7 days. The maximum mean MCA flow velocity as

well as safety are the two primary end-points. All patients will have paired blood and CSF taken at

day 7 either through an LP or via EVD sampling. Follow-ups are performed at day 28, 3 months and 6

months which include safety bloods, functional questionnaires, mRS, GOSE and MRI.

Results. 64(71% of the target) patients have been enrolled. 35 patients have completed the study.

Statistical analysis of the TCD data will be performed at the end of the trial. The mortality is at 9.5%

(6). DSMB have met twice since the start of the trial and there have been no safety concerns.

Conclusions. The trial is recruiting on the planned trajectory and at this rate we are projected to

complete the trial by the end of the year.

WM1-3

Management of cerebellar stroke: a five-year single centre experience.

D.C. Rowland¹,², A. Boukas², G. Hadley³, A.L. Green²

¹Royal Free Hospital, London, UK, ²John Radcliffe Hospital, Oxford, UK, ³Radcliffe Department of

Medicine, University of Oxford, Oxford, UK

Objectives. There is heterogeneity in management of cerebellar stroke, with no agreed criteria, and

limited evidence in the literature. The aim was to assess if surgical decompression or conservative

management is associated with good clinical outcome.

Design. Retrospective cohort study.

Subjects. Adult patients admitted to a tertiary referral centre over a 5-year period between 2012-

2017 with cerebellar stroke - infarction or haemorrhage.

Methods. There were two groups according to intervention – a decompression group that underwent

suboccipital decompressive craniectomy +/- EVD and a conservative group that underwent medical

management +/- EVD. The primary outcome was mRS at discharge. Secondary outcomes included in

hospital mortality, number of days on ICU and number of days in hospital. Baseline clinical and

radiographic characteristics were collected.

Results. 43 patients were included in the study, 58% were treated with decompression and 42% with

conservative management. There was no significant difference in mRS at discharge, in-hospital

mortality or length of hospital stay between the two groups. The decompression group spent a

significantly greater time on ICU (p = 0.01*). Younger age was associated with surgical

decompression (p = 0.01*). GCS on admission or radiographic features were not associated with

surgical decompression.

Conclusions. Our findings agree with the current literature that the effectiveness of decompressive

craniectomy in cerebellar stroke is unclear and requires further investigation with a multi-centre RCT.

WM1-4

Decompressive craniectomy versus strokectomy for malignant middle cerebral artery

(MCA) infarction

S. Moughal¹, D. Boeris², A. Hainsworth¹, E. Pereira¹, A. Shtaya¹, P. Minhas²

¹Molecular and Clinical Sciences Research Institute, St George’s, University of London. London, UK, ²

St George’s University Hospital NHS Trust, London, UK

Objectives. To compare the outcomes of decompressive craniectomy (DC) with craniotomy and

debulikng of stroke tissue (Strokectomy (SC)) for malignant MCA infarction at our centre.

Design. Retrospective records review

Subjects. All Patients with malignant MCA infraction that underwent DC and SC between Jan 2012

and Sep 2017

Methods. 20 patients had DC (11F/9M, mean age 44.7 ± 1.8 y) and four patients had SC (1F/3M) 51.5

± 5.9 7 y). Outcomes were assessed by Modified Rankin Scale (mRS) scores before surgery and at

latest follow up (3-6 months). mRS was dichotomised as good (0-3) and poor (4-6). Craniotomy size

was measured by antero-posterior (AP) diameter and compared between the groups

Results. 18 patients (90%) of the DC group had mRS 4-6 before surgery versus 100% in the SC group.

Post-surgery 15 patients (75%) of the DC group had poor outcome with 7 mortalities (35%) in

comparison to one patient (25%) with poor outcome in the SC group and no mortalities. The average

craniotomy size in DC was 120.1 ± 4.1 mm versus 85.5 ± 13.1 mm in the SC, p=0.003 students t test).

Six patients of the DC group underwent cranioplasty where two developed post-operative seizures.

There was no significant difference in age, sex and side of craniotomy (7 Left/13 Right in DC vs 2

Left/2 Right in SC).

Conclusions. Strokectomy is comparable to decompressive craniectomy in outcomes without taking

the extra risks and costs of cranioplasty. Further studies are required to promote this approach

WM1-5

Predictors of retreatment of anterior communicating artery aneurysms after endovascular

embolisation

A. Borg, P. Grover, A. Schmitt

The National Hospital for Neurology and Neurosurgery, London, UK

Objectives. To establish recurrence and retreatment rates of anterior communicating artery

aneurysms (ACom) after endovascular embolization and the complication rate of retreatment. To

establish predicting morphological characteristics that would favour surgery or endovascular coiling.

Design. Retrospective review of all ACom aneurysms treated at a single neurological centre over a

thirteen-year period.

Subjects. Patients undergoing endovascular treatment of ACom aneurysms

Methods. Aneurysm and patient characteristics were recorded for retreated patients. Analysis of

retreatment predictors on imaging was made.

Results. Between 2005 and 2018, 510 Acom aneurysms were treated, of which 456 presented with

SAH and 54 were elective. Out of these, 36 underwent re-treatment. Out of the re-treated

aneurysms 33 were identified from radiological follow up and three presented with a re-bleed. The

complication rate from the second endovascular procedure was 5.6%. Four patients underwent

surgical clipping after failed coiling. Retreatment was more likely in ruptured aneurysms. The dome

shape, size (mm) and orientation, were recorded for both aneurysms requiring retreatment and

aneurysms successfully excluded after the first procedure. Other parameters reported included time

interval, coiling technique (balloon-assisted/stent-assisted)

Conclusions. Recurrence of Acom aneurysms after coiling carries significant morbidity. Recognising

predictors of recurrence would help identify those aneurysms that are better treated with surgery.

WM1-6

Arteriovenous malformations (AVMs): changing practice over 10 years and proposal for a

national registry

P. Grover, A.K. Golahmadi, H.L. Horsfall, J. Grieve, L. Watkins, A. Toma, M. Murphy

National Hospital for Neurology and Neurosurgery, London, UK

Objectives. The treatment of arteriovenous malformations (AVMs) is variable and controversial (1).

We describe trends in the management of cerebral AVMs over the last 10 years at a single centre,

and propose a national AVM registry.

Design. Review of a single centre prospective AVM database

Subjects. All cerebral and spinal AVMs and AV fistulas

Methods. All AVMs admitted to at single UK centre were entered into a prospective database from

2008 to 2017. Data was collected on demographics, presentation, management, length of stay,

outcome and follow up. Outcome was recorded as Glasgow Outcome Scale and Modified Rankin

Score on discharge, 3 months and 6 months.

Results. 805 cases were identified of which 314 had bled previously. This included 584 AVMs, 141

dural AV fistulas, 54 carotid-cavernous fistulas and 26 spinal AVMs. Of treatments performed, there

were 321 (45%) embolisations, 254 (36%) gamma knife radiosurgery, and 129 (16%) surgical

excisions. There has been a trend towards decreased rates of embolisation and increased surgery

and gamma knife radiosurgery over time. Prospective outcome data was collected in 35% of cases.

Conclusions. This single centre prospective database has documented change in practice over the last

10 years. In the post-ARUBA era a national registry will help inform guidelines for care.

WM1-7

Brain parenchymal oxygen monitoring in delayed cerebral ischaemia

C.L. Craven, U. Reddy, H. Asif, L.D. Watkins, A.K. Toma

National Hospital for Neurology and Neurosurgery, London, UK

Objectives. At this single centre, tri-modal monitoring of ICP, temperature and direct brain tissue

oxygen tension (PbtO2) is used to guide management of delayed cerebral ischaemia (DCI). We

describe our experience of PbtO2 monitoring and its relationship with symptoms of DCI, regional

cerebral blood flow (rCBF, perfusion imaging), intra-arterial chemical angioplasty and CSF diversion.

Design. Prospective cohort.

Subjects. Patients with aSAH who underwent over 24-hours of multi-modal PbtO2, temperature and

intracranial pressure (ICP) monitoring via a Raumedic NEUROVENT-PTO probe.

Methods. Longitudinal analysis of PbtO2 values, presented as mmHg (mean +/- SD).

Results. Analysis of 1392 hours of tri-modal monitoring in 13 SAH patients. PbtO2 decreases >50%

consistently reproduced focal neurological deficit. Symptomatic PbtO2 values ranged from 12-

20mmHg. Of the six patients who had reduced rCBF, all had a mean PbtO2 <15mmHg. Five

patients underwent intra-arterial chemical angioplasty (10mg Verapamil in 100ml NaCl over 30-40

mins). PbtO2 increased by at least 30% for 3.4 +/- 0.47 hours. CSF diversion resulted in a sustained

mean increase in PbtO2 of 7.6 +/- 2.94 mmHg over the first 5 minutes (p=0.034).

Conclusions. PbtO2 <15mmHg may predict development of a clinical deficit. Chemical angioplasty

resulted in a pronounced but short-lived increase in PbtO2. CSF diversion resulted in a persistent

increase in PbtO2. PbtO2 targeted management may be a valuable addition to the clinicians’ arsenal

against DCI.

PARALLEL SESSION 1 - Wednesday 19th September

WP1 – Short orals

WP1-1

Sphenopalatine ganglion stimulation for chronic cluster headache

S. Miller, S. Lagrata, M. Matharu, L. Zrinzo

The National Hospital for Neurology and Neurosurgery, London, UK

Objectives. To assess outcome of sphenopalatine ganglion stimulation (SPGS) in chronic cluster

headache (CCH) in a UK centre

Design. Uncontrolled open-label single centre prospective study

Subjects. Nine patients with medically refractory CCH

Methods. Participants underwent sphenopalatine ganglion stimulator implantation, ipsilateral to CCH

symptoms via a gingival incision, with fluoroscopy guidance and dyna-CT confirmation of contact

location adjacent to the Vidian canal in the pterygopalatine fossa. One month after surgery, the

device was programmed. Patients were instructed to provide stimulation as early as possible after

attack onset and at least twice daily. The primary outcome was change in headache frequency as well

as adverse events

Results. Mean follow up was 14 months (SD 11.1, range: 3-31) with median reduction in headache

frequency at last follow up of 73% (IQR: 67-88%). At 3 months post op, 4/9 (45%) had at least 50%

reduction in frequency of attacks; this increased to 8/9 patients (89%) at last follow up. Two patients

became pain free (after 3 and 9 months). Preventative effects were seen in 7/9 and an acute effect in

2/9. One patient suffered numbness over the V2 distribution and did not respond to SPGS. The

stimulator was removed 1 year later at the patient’s request. One wound infection settled with oral

antibiotics

Conclusions. Initial data from the UK confirms the results from previous studies and compares well

with the results of occipital nerve stimulation for CCH

WP1-2

Labial gland biopsy for the investigation of Neurological Sjogrens

A. Jebril¹, T. Lavin²

¹University of Manchester, Manchester, UK, ²Salford Royal Hospital, Salford, UK

Objectives. : Nervous System involvement in Sjogren’s Syndrome (SS) commonly affects the

peripheral nerves, though central nervous manifestations such as myelitis can occur. Peripheral

Neuropathy has of 2- 10% of SS cohorts (1). Involvement of different segments of the peripheral

nervous system leads to a widespread spectrum of neuropathic manifestations including dorsal root

gangliopathy (DRG), small fibre neuropathy (SFN), sensorimotor neuropathy (SMN), trigeminal

neuropathy (TN) and vasculitic mononeuropathy (VMN). Less commonly, the central nervous system

can also be affected, causing various focal or multifocal CNS disorders. In the absence of antibodies,

LGB remains central to validated diagnostic criteria (2) We aimed to ascertain the yield of labial gland

biopsy (LGB) for suspected Neurological Sjogrens and identify predictive factors for positive and

negative biopsies.

Methods. 10-year retrospective case note review of patients referred for LGB for suspected

Neurological Sjogrens, from during a period of October 2007 to 2017. Demographics, Clinical

syndrome, Investigations and Biopsy Results were obtained.

Results. 107 patients (73.8% female, mean age 55yr) had LGB for suspected Neurological Sjogrens.

Phenotypes were DRG 60/107 (56.0%), SFN 37/107 (34.6%), TM 3/107(2.8%), TN 1/107(0.9%), VMN

1/107 (0.9%). Overall positive biopsy yield was 32/107 (29.9%). Yield in different phenotypes; DRG

11/60 (18.3%) and SFN 20/37 (54.1%). The presence or absences of SSA/SSB or Sicca were not

significant in predicting a positive biopsy.

Conclusions. LGB remains a vital investigation in suspected neurological Sjogrens including small fibre

neuropathy. Prior investigations and different phenotype did not predict positive biopsy. Our

practice and biopsy yield is similar to other published series (3).

WP1-3

AChR-antibody mediated arthrogryposis: inhibition of placental transfer in a mouse model

protects the fetus

E. Coutinho, L. Jacobson, B. Lang, A. Vincent

Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK

Objectives. Rare cases of arthrogryposis multiplex congenita (AMC) are caused by maternal

antibodies (abs) to the fetal acetylcholine receptor (fAChR) transferred to the fetus during gestation.

AMC has been modelled by injecting human fAChR-abs into pregnant mice; we used this mouse

model to test whether an inhibitor of placental IgG transfer could prevent neonatal disease.

Design. Sera from AMC mothers were injected into pregnant mice on gestational days 12 to 17,

together with an inhibitor of placental IgG transfer (n=5 dams), a control drug (n=5) or no additional

treatment (n=3).

Subjects. MF1 mice were used.

Methods. Pregnancies were terminated at day18 and fetal deformities registered; fAChR-abs were

measured in dam/fetuses blood.

Results. AMC-injected dams fAChR-abs serum levels were not affected by the inhibitor, but fetal

levels were reduced by 70% compared to control-treated mice. With a more pathogenic AMC serum,

and higher doses of inhibitor and control, the majority of fetuses of control-treated dams were

deformed, clearly different from inhibitor-treated fetuses. Both maternal and fetal levels of fAChR-

abs were substantially reduced.

Conclusions. It is possible to inhibit placental transfer to protect babies from pathogenic abs.

Recently, neurodevelopmental disorders were linked to CASPR2-abs in gestational sera. Thus,

inhibition of fetal transfer of abs during gestation could have wide implications for preventing

transient (eg. neonatal myasthenia) and permanent antibody-mediated diseases (eg. arthrogryposis

or autism).

WP1-4

Bilateral laminotomy through a unilateral approach (minimally invasive) vs open

laminectomy for lumbar spinal stenosis

J. Horan¹, M.B Husein², C. Bolger²

¹UCD Medical School, Dublin, Ireland, ²Department of Neurosurgery, Beaumont Hospital, Dublin,

Ireland

Objectives. The purpose of our prospective randomised study is to compare safety and functional

outcomes in traditional laminectomy versus minimally invasive (MI) bilateral laminectomy via

unilateral approach for lumbar spinal stenosis (LSS)

Design. This is a prospective randomised trial comparing two procedures for LSS

Subjects. 62 patients were treated for LSS and randomised to one of two groups over a 6-month

period

Methods. Group A comprised 37 patients that underwent MI intersegmental unilateral

decompression. Group B comprised 25 patients that underwent traditional laminectomy. Follow-up

duration was 3 years. The primary outcomes were walking distance, the visual analogue scale (VAS)

pain outcome score and the Oswestry Disability Index (ODI)

Results. VAS pain outcome was reduced from 9 to 2 and 8 to 5 in MI and open, ODI improved from

56.5 to 13 and 58 to 24 in MI and open respectively. Complication rates were lower in MI compared

to open (8% vs 56%) and consisted of CSF leak, temporary leg pain, TIA, urinary retention and wound

infections. Length of stay was 1-3 days compared to 7-30 days in MI against open respectively

Conclusions. Bilateral laminectomy through a unilateral approach (MI) and traditional laminectomy

are both effective in improving pain, ODI and walking distance in LSS. MI procedures have an

advantage in shorter hospital stays, sparing of more bony structures and lower complication rates.

We conclude that MI unilateral decompression is at least as good as laminectomy in the treatment of

pain and disability in LSS

WP1-5

Surgical management of spinal meningiomas and appraisal of possible association with

oestrogen receptor positive breast carcinoma

D. Wang, A.R. Sadek, A. Nader-Sepahi

Wessex Neurological Centre, University Hospital Southampton, UK

Objectives. Evaluation of the presentation, demographics, pathology and outcomes associated with

surgical management of spinal meningiomas and review of an association with a history of preceding

breast carcinoma.

Design. A retrospective single-centre case series of surgically managed meningiomas over a 4-year

period.

Subjects. 184 cases of surgically managed intradural lesions from 2014 to 2018.

Results. 48 patients were identified as having a spinal meningioma [26% of all spinal tumours]. 42

[88%] were female with a cumulative mean age of 69 years [SD+/-10]. Most lesions were located in

the thoracic spine [n=41]. The cohort had a Charlson comorbidity index of 3. Weakness [median MRC

grade 3], neuropathic pain [mean NPS of 26/100] and problems with gait [median mJOA score of 2]

were the commonest presenting symptoms. Post-operatively improvements in MRC, NPS, mJOA and

SF36 scores were observed. 16% [n=7] of cases had a preceding history of oestrogen-receptor

positive breast carcinoma, with a mean interval time between diagnoses of 8.1 years [SD+/-5.1]. Risk

analysis using baseline data from national cancer registries demonstrates that the likelihood of both

diagnoses to be 2.4%, this is considerably lower than the observed 16% (p =0.01).

Conclusions. Analysis of our cohort has demonstrated an association between a preceding diagnosis

of oestrogen-receptor positive breast carcinoma and spinal meningiomas that cannot be explained

by chance alone.

WP1-6

Syndrome of the Trephined

A.M. Shah¹, L. Hayes², P. Weston³, C. Liu⁴, L. Watkins³, R. Greenwood⁵

¹Royal London Hospital, London, UK, ²Regional Neurological Rehabilitation Unit, Homerton University

Hospital, London, UK, ³National Hospital for Neurology and Neurosurgery, London, UK, ⁴Regional

Neurological Rehabilitation Unit, Homerton University Hospital, London, UK and Royal London

Hospital, London, UK, ⁵Regional Neurological Rehabilitation Unit, Homerton University Hospital,

London, UK and National Hospital for Neurology and Neurosurgery, London, UK

Objectives. Syndrome of the Trephined (SoT) or sinking skin flap syndrome is characterised by

neurological deterioration occurring after a delay post-craniectomy, with or without a significant

postural component, that may improve with cranioplasty. The symptoms and signs seen are

heterogeneous and can be readily missed. With increasing numbers of patients surviving after

decompressive craniectomies, and often a long delay before cranioplasty, we think it important that

awareness of this potentially lethal but reversible condition is raised.

Design. Case Series

Subjects. Cases with suspected SoT were identified retrospectively from all admissions to a Level 1

Neurorehabilitation Unit over 2 years.

Methods. Cases were identified by their treating clinicians. Their clinical features are described, and

outcomes after cranioplasty are discussed.

Results. From 36 patients admitted after craniectomy over 2 years, 4 patients with suspected SoT

were identified, with a latency of 4-12 months post-injury. Late neurological deterioriation included

reduced alertness and mobility, cognitive decline and headache. Two patients had a clear postural

component to their symptoms. Coexisting hydrocephalus was sometimes seen, and complicated

neurosurgical management. All cases improved after cranioplasty.

Conclusions. SoT is an under-reported and under-recognised complication of craniectomy. It is a

potentially reversible cause of significant late deterioration following craniectomy. Further research

into the optimal timing for cranioplasty is needed.

WP1-7

Towards iNPH multimorbidity score system: do we need to exclude patients from surgical

treatment?

L. D'Antona, S.C. Blamey, D. Thompson, L. Craven, L. Thorne, D. Watkins, V. Luoma, K. Toma

The National Hospital for Neurology and Neurosurgery, London, UK

Objectives. It is common practice to exclude high-risk patients from surgical intervention due to the

association with complications and worse outcomes. Normal Pressure Hydrocephalus (NPH) patients

are often affected by multiple comorbidities and the safety of surgical treatment in this group has

been debated. This study investigates the safety of surgery in NPH through the use of the Post-

Operative Morbidity Survey (POMS).

Design. Single centre prospective study.

Subjects. 73 consecutive NPH patients (53F, mean age of 74±7 years, range 54-90) referred for

surgical treatment.

Methods. NPH patients referred for lumbar drainage (LD) protocol or ventriculo-peritoneal shunt

(VPS) from May 2017 were included. Patients were reviewed in a multidisciplinary pre-operative

assessment clinic prior to admission. The POMS was conducted on post-operative day 4, 7 and 10.

Results. All patients had surgery and none was excluded.33 patients underwent VPS and 40 LD

protocol. Of the 33 patients who underwent VPS: 79% returned to baseline within 3 days, 18% had a

moderate worsening in mobility and 3% a UTI. Of the 40 patients who underwent LD protocol: 90%

returned to baseline within 3 days, 7.5% had a moderate worsening in mobility and 2.5% had a UTI.

All patients who reported a worsening mobility returned to their baseline with physiotherapy before

discharge. There was no mortality.

Conclusions. Multidisciplinary preadmission assessment and optimisation of NPH patients ensure

safety of surgery and avoid denying NPH patients the benefits of surgical treatment.

WP1-8

Radiographic markers of disturbances in CSF dynamics: correlating imaging with 24-hour

ICP monitoring

H. Asif, C. Craven, L. Thorne, L. Watkins, A. Toma

National Hospital for Neurology and Neurosurgery, London, UK

Objectives. Disorders with chronically elevated ICP have salient imaging findings associated with the

sella turcica and optic nerves. We aim to quantify the degree of correlation between imaging

features and ICP.

Design. Prospective case-cohort study.

Subjects. One-hundred and twenty-six patients (35M:91F) underwent ICPM with recent MR imaging.

Methods. T1-saggital views for sella volume, optic nerve vertical tortuosity, then T2-axial views for

optic nerve sheath distension were blindly reviewed against respective median ICP and pulse

amplitudes (PA). Imaging was triple reviewed for discordant values.

Results. The mean ICP of four sella morphologies (full/flat/concave/empty) were 1.2, 4.8, 8.4 and

16.7mmHg respectively (p<0.01). AUROC for sella morphology predicting ICP was 0.81. This

measurement was able to detect minimum ICP of 5.3mmHg with 73.0% sensitivity and specificity,

73.0% PPV and 69.8% NPV. The mean PA values were 4.0, 5.2, 6.1 and 9.6mmHg respectively

(p<0.01). AUROC for sella morphology predicting PA was 0.78. This measurement was able to detect

minimum PA of 5.47mmHg with 76.3% sensitivity, 79.5% specificity, 63.5% PPV and 81.0% NPV.

Mean PA values for vertical tortuosity (nil/uni/bi) were 5.2, 7.1 and 7.0mmHg respectively (p<0.05).

Mean ICP values for rail tracking (nil/uni/bi) were 4.5, 7.5 and 15.7mmHg respectively (p<0.01).

Mean PA values were 5.2, 5.8 and 8.0mmHg respectively (p<0.0001).

Conclusions. Combined radiological features of ICP are promising non-invasive markers for raised ICP.

WP1-9

Treatment implications of Parkinson’s disease in normal pressure hydrocephalus

J.P. Funnell¹,2, C.L. Craven², L. D'Antona², L. Thorne², L.D. Watkins², A.K. Toma²

¹UCL Medical School, London, UK, ²The National Hospital for Neurology and Neurosurgery, London,

UK

Objectives. Patients with Parkinson’s disease (PD) presenting with worsening gait and

ventriculomegaly could have underlying normal pressure hydrocephalus (NPH). We aim to identify

features of concurrent PD and NPH, assess investigations and benefits of intervention.

Design. Single-centre retrospective cohort study of patients diagnosed with PD and NPH, presenting

to neurosurgery between April 2004 – April 2018.

Subjects. 24 patients (20M: 4F) with concurrent PD and NPH, mean age 74.5 +/- 6.49 years (mean +/-

SD). 22 patients were diagnosed with PD prior to NPH diagnosis.

Methods. Medical records were studied for demographics, symptoms, and response to

ventriculoperitoneal (VP) shunting. Chi-square test was used to compare frequency of post-operative

symptoms against a local database of NPH patients.

Results. All patients presented to neurosurgery with gait disturbances, 21/24 with cognitive

impairment, and 18/24 with urinary incontinence. 19 patients underwent VP shunt insertion; 5

patients were not suitable having failed a lumbar drain trial. Patients with PD and NPH improved in

walking test outcomes and in urinary continence similarly to other NPH patients. Cognitive

impairment did not respond well to VP shunting in patients with concurrent PD, significantly less

than NPH patients without PD (p < 0.01).

Conclusions. Diagnosis of NPH in patients with PD is a complex clinical problem due to frequent

overlap of symptoms. Benefits may be gained if this subset of patients do reach neurosurgical

services and receive intervention.

WP1-10

Prevalence of normal pressure hydrocephalus in falls clinic patients

S. Sennik, C. Craven, L. D'Antona, H. Asif, W. Dawes, L. Thorne, A. Toma, L. Watkins

National Hospital for Neurology and Neurosurgery, London, UK

Objectives. Patients with idiopathic Normal Pressure Hydrocephalus (iNPH) present with Hakim

Adams triad and radiological findings suggestive of iNPH. We compare the presence of clinical and

radiological signs of iNPH present in patients presenting to falls clinic at a District General Hospital

with the general population.

Design. Retrospective analysis of patients referred to falls clinic (January 2017 to December 2017)

and interpretation of CT or MRI head imaging with Evans index.

Subjects. Falls clinic patients presenting to a District General Hospital outpatient clinic.

Methods. Retrospective cohort of patients admitted to a single District General Hospital with falls

and recent CT or MRI head. An Evans Index above 0.35 was used as an indicator of hydrocephalic

ventricular enlargement.

Results. 371 patients were seen in one year. 216 had previous CT or MRI head. 6.75% of all patients

seen in falls clinic (11.6% who have had brain imaging) have hydrocephalic ventricular enlargement.

This is compared to 4.5 % in a study of patients aged 70 and over in a normal population (1).

Conclusions. Patients seen in Falls clinic have an increased probability of having radiological signs

consistent with idiopathic normal pressure hydrocephalus.

References. 1. Jaraj D, Marlow T, Jensen C, Skoog I, Wikkelso C (2014). "Prevalence of idiopathic

normal-pressure hydrocephalus". Neurology. Apr 22;82(16):1449-1454

WP1-11

What is an optimal intracranial pressure? An analysis of 115 tele-sensor reservoir ICP

recordings.

S. Pandit, C.L. Craven, S. Thompson, L.D. Watkins, A.K. Toma

The National Hospital for Neurology and Neurosurgery, London, UK

Objectives. Pathological intracranial pressures (ICP) in neurosurgical patients have been widely

characterised, yet normal physiological values remain unknown. At our centre, we routinely insert

sensor reservoirs to enable telemetric recording of ICP following CSF diversion. We aim to study this

cohort to determine at what thresholds pressure-related symptoms resolve.

Design. Single-centre retrospective analysis.

Subjects. 115 patients with a Miethke tele-sensor reservoir inserted following a shunt procedure or

endoscopic third ventriculostomy (ETV).

Methods. Supine and sitting ICP measurements were recorded and compared to simultaneous

clinical symptoms.

Results. 21 patients were identified as asymptomatic with respect to pressure-related symptoms

(headache, visual impairment, nausea or confusion). 16 had a VP shunt, 2 had a VA, 2 had an ETV and

1 had a ventriculo-pleural shunt.

Conclusions. Of these, 13 had ICP data recorded with mean lying pressures of 8.3mmHg (SD +/- 5.0)

and sitting pressures of -5.1mmHg (SD +/- 4.8).

WP1-12

Reducing infection rates in an intrathecal baclofen service; closing the audit cycle.

A. Donnelly, M. Balaratnam, M. Murphy, H. Lee, H. Padilla, E. Keenan, R. Farrell, V. Stevenson

The National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS

Foundation Trust, London, UK.

Objectives. Intrathecal baclofen (ITB) is a recognised treatment strategy for the management of

spasticity. We have 30 years of experience, and 152 patients currently receiving treatment.

Design. An audit (Jan 13 - Jul 15) demonstrated complication rates of 4.4% (infection) and 11.9%

(catheter). After this we recommended 1 vancomycin wash of the pump pocket, 2 occlusive dressing

of pressure sores, 3 timely MRSA pre-screening, and this was introduced June-August 2016. We

present a re-audit of the service.

Subjects. All patients admitted for ITB pump surgery between June 2016 and June 2018.

Methods. The database of patients was used, from which the patient notes were reviewed with

information relating to each surgical procedure recorded.

Results. There were 90 surgical procedures and 77 patients (M 29, F 48). 12 had complications,

requiring 16 surgical procedures. Outside the audit window 3 more patients presented with

complications and will be in our discussion. Out of 16 surgical procedures, (10 catheter related and 4

‘flipped’ pump related). Our infection rate was lower at 3.3 % of all surgeries (compared with 4.4 %),

or 1.0 % of all ITB pump patients per year (compared with 3.4%), and our catheter complication rate

was 3.3 % of all patients per year. Our annual incidence rate of all complications was 5.62 in 2015

and was 5.3% 2017.

Conclusions. The infection risk is lower and complication rate remains stable. We will discuss factors

which may influence the risk of complication, and consider recommendations for the future.

WP1-13

Lack of association of cranial lacunae with intracranial hypertension in children with

Crouzon syndrome and Apert syndrome: a 3D morphometric quantitative analysis

A. Mondal¹, N. Rodriguez-Florez², J.L O'Hara¹, J. Ong¹, N.u.O. Jeelani¹, D.J. Dunaway¹, G.

James¹

¹Great Ormond Street Hospital, London, UK, ²Mondrian University, Arrasate, Spain

Objectives. Cranial lacunae on CT is equivalent to the plain X-ray “copper beating" seen in

craniosynostosis. Copper beating has not been shown to correlate to intracranial hypertension (IH).

However it is a purely quantitative assessment - can qualitative measurement of CT cranial lacunae

more accurately predict IH in children with craniosynostosis?

Design. Retrospective cohort study.

Subjects. 18 consecutive children with Crouzon and 17 with Apert syndrome were identified.

Methods. Patients were divided into IH and non-IH groups defined on an intention to treat basis. 3D

software was used to analyse % of calvarial lacunae.

Results. Mean age at CT scan was 380 days (range 6-1778). Of the 35 children, 21 required surgery

for raised ICP (17 posterior vault expansion 2 ventriculo-peritoneal shunts (VPS), 1 spring-assisted

cranioplasty and 1 fronto-orbital advancement) at mean age of 512 days (range 38-1710). Of the 21

children with raised ICP, 15 had lacunae with mean lacuna/calvarium percentage of 3% (0-28%). Of

the 14 non-raised ICP children, 8 had lacunae with mean lacuna/calvarium percentage of 2% (0-8%).

T-test demonstrated no significant difference between the 2 groups. For both groups, parietal bones

were most likely to show lacunae (IH 14/21, non-IH 9/14), followed by occipital (IH 8/21, non-IH

3/14), followed by frontal (IH 6/21, non-IH 2/14).

Conclusions. Results suggest that cranial lacunae, measured using quantitative 3D methods, do not

predict IH, in agreement with evidence from qualitative plain skull radiograph studies.

WP1-14

A systematic review to evaluate different management strategies for incidental

intracranial meningiomas

M. Mohan¹, A. Islim¹, R.D.C. Moon¹, N. Srikandarajah¹, A.R. Brodbelt², S.J. Mills², M.D.

Jenkinson¹

¹The Walton Centre, Liverpool, UK and University of Liverpool, Liverpool, UK, ²The Walton Centre,

Liverpool, UK

Objectives. Evaluate the outcomes of differing management strategies for incidental intracranial

meningiomas.

Design. Systematic review.

Subjects. Studies with ≥10 patients ≥16 years of age diagnosed radiologically with an incidental

intracranial meningioma.

Methods. PRISMA compliant methods were used to scan 6 databases up to September 2017.

PROSPERO ID: CRD42017077928.

Results. Twenty retrospective studies (n=2130 patients) were included. Initial management strategies

at diagnosis were: 27% (n=560) surgery, 22% (n=450) SRS and 51% (n=1040) active monitroing with a

mean follow-up of 49.5 months (SD=29.3). 21% (n=220) of patients in the active monitoring cohort

eventually had or were recommended an intervention due to: radiological progression (n=153),

development of symptoms (n=66) and patient preference (n=1). Mean time-to-intervention was 24.8

months (SD=18.2). 94% (n=207) of interventions were within 5 years. The definition of "growth" and

the radiological surveillance regimens varied widely. Morbidity rates following surgery and SRS,

accounting for cross over, were 15% and 22% respectively. Surgery revealed benign histology in 94%

of the cases. Quality of life is improperly examined.

Conclusions. The management of patients with incidental intracranial meningiomas varies widely.

Most patients who develop clinical or radiological progression will do so within 5 years of diagnosis.

Intervention at diagnosis may result in unnecessary overtreatment. Prospective data is needed to

develop a risk calculator for managing incidental meningioma.

WP1-15

Computer-assisted versus manual planning for stereotactic brain biopsy: retrospective

comparative pilot study

H.J. Marcus¹, V.N. Vakharia¹, R. Sparks¹, R. Rodionov¹, N. Kitchen¹, A. McEvoy¹, A. Miserocchi¹,

L. Thorne¹, S. Ourselin², J.S. Duncan¹

¹The National Hospital for Neurology and Neurosurgery, London, UK, ²Kings College Hospital, London,

UK

Objectives. Stereotactic brain biopsy is among the most common neurosurgical procedures. Planning

a safe surgical trajectory requires careful attention to a number of features including: (1) traversing

the skull perpendicularly; (2) avoiding critical neurovascular structures; and (3) minimising trajectory

length. The aim of this study was to develop a platform, SurgiNav, for automated trajectory planning

in stereotactic brain biopsy.

Methods. A prospectively maintained database was searched between February and August 2017 to

identify all adult patients that underwent stereotactic brain biopsy in whom post-operative imaging

was available. In each case, the standard pre-operative T1-weighted gadolinium-enhanced MRI was

used to generate models of the cortex and vasculature. A surgical trajectory was then generated

using automated computer-assisted planning (CAP) and metrics compared to the trajectory of the

implemented manual plan (MP) using the paired T-test.

Results. 15 consecutive patients were identified; who had a diagnostic biopsy and there were no

immediate complications. Feasible trajectories were generated using CAP in 12 patients, and in these

the mean trajectory length using CAP was comparable to MP (31.7mm vs. 37.1mm; p=0.3), and mean

angle was similarly perpendicular from orthogonal (9.3° vs. 15.3° p=0.1), but the risk-metric was

significantly lower (0.16 vs. 0.48; p=0.03).

Conclusions. Computer-assisted planning for stereotactic brain biopsy appears feasible in most cases

and may be safer in selected cases.

WP1-16

Does time to diagnosis influence surgical decision making in primary malignant brain

tumours?

K. Zienius¹, R. Grant², P. Brennan¹

¹Centre for Clinical Brain Sciences, Edinburgh, University of Edinburgh, UK, ²Edinburgh Centre for

Neuro-oncology, Edinburgh, UK

Objectives. To assess whether time to diagnosis influenced surgical procedure and survival in primary

malignant brain tumours

Design. Retrospective cohort study of adult patients newly diagnosed with a primary intra-cerebral

tumour April 2010 - March 2015 referred to neuro-oncology centre in South-East Scotland

Subjects. 400 patients with primary malignant intracerebral tumours

Methods. Univariate logistic regression analysis and multivariate Cox regression survival analysis

were performed

Results. Our dataset included 229 Males (57.7%), mean age 62.05 (SD14.01). Time to diagnosis did

affect choice of surgical procedure. Patients undergoing biopsy had significantly longer TtD than

those undergoing resection (28 vs 21 days, MWU test, p=0.035). 233 (58.3%) patients were deceased

at 12 months. Having a cognitive first symptom (e.g confusion/memory changes) predicted not

getting any surgical procedure (OR 2.95 [95%CI 1.8-4.8]). Where surgery was performed, first

cognitive symptom was not predictive of type of surgery (biopsy vs debulking/excision) (OR 1.5

[95%CI 0.8-2.9] nor having tumour in the frontal lobe (OR 0.9 [95%CI 0.5-1.7]. In multivariate

analysis, increased hazard ratio of death at 12-month was significantly associated with a cognitive

first symptom (HR 1.4 [95%CI 1.0-1.9] and KPS<70 (HR 1.69[95%CI 1.2-2.4]).

Conclusions. Earlier diagnosis is associated with getting debulking surgery rather than biopsy, and

patient’s presenting symptoms influence surgical decision making and outcome.

WP1-17

Risk factors and patterns of progression in a surgical cohort of low grade glioma patients

S. Acharya, J. Lavrador, R. Visagan, V. Narbad, J. Jung, F. Vergani, R. Bhangoo, K. Ashkan

Kings College Hospital, London, UK

Objectives. To understand the risk factors for and patterns of progression of low grade glioma (LGG)

Design. Single centre retrospective cohort study

Subjects. Patients undergoing at least two neurosurgical procedures for LGG, the first being for

diffuse LGG (WHO 2). 22 patients included (14M; 8F); mean age at time of first operation 37.7 ±2.7

years. 20 patients had a Performance Status (PS) 0-1 and 2 patients had a PS 2.

Methods. All patients with LGG diagnosed in between 2009-2018 were retrospectively evaluated.

Variables of interest included demographics, staging, performance status, time to re-operation (TTR),

extent of resection, molecular genetics (1p19q co-deletion, IDH status). Tumour volumes were

estimated from MRI images by the validated ABC/2 equation. Statistical analyses were performed by

Stata13.0.

Results. The tumour progressed in WHO grade in 18 patients (WHO grade 3 (n=15); WHO grade 4

(n=3). Mean time to re-operation after the first surgery was 7.0 ± 1.2 years following gross total

resection (GTR) & 3.2 ± 0.7 years following subtotal resection (STR). Non-adjusted analysis of risk

factors for time to re-operation (TTR) showed absence of 1p19q co-deletion as a risk factor

(p=0.021). Adjusted analysis revealed that GTR, 1p19q mutation, PS 0 at 1st surgery and tumour

volumetric change decrease the risk for re-intervention (p< 0.05). Chemo-radiotherapy was not

associated with TTR

Conclusions. In our cohort, TTR in LGG was influenced by the amount of initial resection, 1p19q

deletion, PS and post-operative volumetric change

WP1-18

Risk factors and patterns of recurrence of low grade glioma: a systematic review

V. Narbad, J.P. Lavrador, A. Elhag, S. Acharya, J. Hanrahan, F. Vergani, R. Bhangoo, K. Ashkan

King's College Hospital, London, UK

Objectives. To review the risk factors and patterns of progression / recurrence of low grade glioma

(LGG).

Design. Systematic review of the published literature.

Subjects. Inclusion criteria were peer reviewed publications of cohort studies of recurrent /

progressive LGG. Studies of wider populations were included if relevant LGG data could be analysed

separately.

Methods. Medline and Cochrane databases were searched using MeSH and non-MeSH terms,

including “glioma”, “astrocytoma”, “oligoastrocytoma”, “diffuse glioma”, “oligodendroglioma”, “low

grade” and “disease recurrence” by two independent reviewers.

Results. Overall, 917 studies were screened, of which 57 studies met the inclusion criteria. The most

frequently described risk factor for recurrent LGG was suboptimal extent of resection (EOR) of the

initial tumour (in 20 studies); recurrence was also associated with the patient’s age (2), tumour

location (4), neurological status (3), tumour volume (6), bihemispherical tumour (3) and astrocytic

histology (6). IDH mutation was associated with recurrence in 1 out of 3 studies, but TP53 mutation

(2 of 4) and MGMT methylation status (4) were not. Malignant transformation was associated with

TP53 mutations (3), IDH mutation (1) and EOR (1). Favourable progression free survival (PFS) and/or

overall survival (OS) were associated with greater EOR (16), oligodendroglioma histology (2 of 4),

initial KPS (3) and the use of adjuvant therapies (9 of 14). IDH mutation was associated with

improved PFS and OS (3 of 4). TP53 mutation improved PFS in 1 of 3 studies. MGMT methylation and

1p/19q codeletion may predict treatment response but their effects on survival are unclear.

Conclusions. Astrocytoma histology, IDH and TP53 mutation statuses and surgical treatment (EOR)

are essential in determining the time to recurrence or progression in LGG.

WP1-19

Survival in melanoma brain metastasis in the era of targeted therapies

J. Merola¹, J. Powell², S. Kumar², C. Hayhurst³

¹University Hospital of Wales, UK, ²Velindre Cancer Centre, ³University Hospital of Wales, UK

Objectives. Melanoma brain metastases (BM) have historically poor overall survival (OS). Recently

introduced targeted therapies to control advanced disease have shown improving survival. Now

increasingly aggressive strategies are sought for BM. We review outcome in melanoma BM after

surgery or SRS and the survival impact of advanced systemic disease plus targeted therapy.

Design. Retrospective cohort study

Subjects. 111 patients referred to a regional neuro-oncology MDT with melanoma BM.

Methods. Retrospective study of all patients referred with melanoma BM. Demographic data, extent

of systemic disease and data on surgical and oncological management were collected. The primary

outcomes were OS and complications.

Results. Between 2012-2017 111 patients with melanoma BM were referred. 27(24%) patients were

accepted for surgical resection, 30(27%) for SRS. In the surgical cohort, 13(48%) had advanced

systemic disease at the time of presentation. Median OS in the surgical cohort was 9.5 months. 11

surgical patients who had targeted therapy for advanced disease survived a median OS of 13 months.

3 (11%) had surgical complications .

Conclusions. In the setting of novel agents survival in melanoma BM is improved even in patients

with advanced and uncontrolled systemic disease at the time of BM presentation, supporting an

aggressive approach to BM management.

WP1-20

Investigating immunotherapy as an adjunct to surgery for brain metastases

R. Zakaria, M. Jenkinson

The Walton Centre, Liverpool, UK

Objectives. Brain metastases (BM) are more common due to improved survival from solid organ

cancers. Immunotherapy is a promising treatment but little is known about the intracranial effects

and there are no predictive biomarkers of response.

Design. We examined a prospective database of BM patients to compare those treated with surgery

and immunotherapy versus surgery and standard adjuvant therapy.

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

Methods. Outcomes of 7 patients treated with surgery and immunotherapy were compared with

matched controls, as well as examining the timing of surgery, radiation therapy and immunotherapy.

Results. Patients received ipilimumab or pembrolizumab alone or in combination. Median overall

survival was greater in the group receiving immunotherapy (44 months vs. 14 months) despite no

significant difference in primary, age or RPA score but there was no difference in intracranial

progression. One patient with melanoma receiving ipilimumab prior to surgery underwent supra-

marginal resection and peritumoral tissue showed growth pattern, macrophage and T-cell infiltration

were all significantly different compared to matched melanoma cases not pre-treated with

immunotherapy.

Conclusions. Immunotherapy and surgery have been proposed to act synergistically on BM.

Immunotherapy certainly influences the BM microenvironment and prolongs overall survival. A

prospective biomarker study is planned to investigate the use of brain imaging as a predictor of

systemic response to immunotherapy.

WP1-21

Maximum safe resection of large medial temporal intrinsic tumours: does the outcome

justify the risk?

A. Kumaria, A. Paterson, S. Basu

Queen's Medical Centre, Nottingham, UK

Objectives. To analyse on the long-term outcomes in patients undergoing maximum safe resection

(MSR) for large intrinsic temporal tumours.

Design. Case series

Subjects. All patients undergoing MSR of large medial temporal intrinsic tumours between May 2006

and February 2012 at a tertiary neurosurgical centre with a minimum follow up of 6 years.

Methods. Retrospective review of hospital records.

Results. Fifty-one patients underwent MSR (28 male, 23 female); age range 20-80 years (mean age

55.3). There was no difference in laterality, although dysphasia was a feature in 32% of left-sided

lesions. Presenting features in general included seizures (46%), headaches (27%), hemiparesis (12%)

and visual field defects (6%). Surgery was generally well tolerated (median post-operative Karnofsky

score 92.5). No patients developed new dysphasia or weakness, but there was transient worsening

of existing hemiparesis (n=4) and dysphasia (n=2). Other complications included CSF

leak/pseudomeningocoele (n=2), oculomotor palsy (n=1) and wound infection (n=1).

Histopathological casemix was GBM (50%), WHO 3 gliomas (14%), WHO 2 gliomas (10%) and

metastases (4%). In total, 57% of patients received radiotherapy and 35% received chemotherapy.

Survival correlated with pathology; in glioblastoma patients it ranged from 2–19 months (mean 10.4

months). Survival in grade 3 tumours ranged from 10-38 months (mean 24.4 months). 60% of

patients with Grade 2 tumours are surviving symptom free with no histological upscale at 8-10 years

follow-up. No patient required a second debulking procedure.

Conclusions. MSR did not result in survival benefit in glioblastoma. MSR is justified in lesions with

pre-operative radiological features of Grade 2 glioma.

WP1-22

DuraGenᵀᴹ as an encapsulating material for neural stem cell delivery

L. Finch¹, S. Harris¹, C. Adams¹, J. Sen¹, J. Tickle¹, N. Tzerakis², D.M. Chari¹

¹Keele University, Stoke-on-Trent, UK, ²University Hospitals of North Midlands, Stoke-on-Trent, UK

Objectives. Achieving neural regeneration after spinal cord injury (SCI) represents a significant

challenge. Neural stem cell (NSC) therapy offers replacement of damaged cells and delivery of pro-

regenerative factors, but >95% of cells die when transplanted to sites of neural injury. Biomaterial

scaffolds provide cellular protective encapsulation to improve cell survival. However, current

available scaffolds are overwhelmingly not approved for human use, presenting a major barrier to

clinical translation. Surgical biomaterials offer the unique benefit of being FDA-approved for human

implantation. Specifically, a neurosurgical grade material, DuraGenᵀᴹ, used predominantly for human

duraplasty has many attractive features of an ideal biomaterial scaffold. Here, we have investigated

the use of DuraGenᵀᴹ as a 3D cell encapsulation device for potential use in combinatorial,

regenerative therapies.

Methods. Primary NSCs were seeded into optimised sheets of DuraGenᵀᴹ. NSC growth and fate

within DuraGenᵀᴹ were assessed using 3D microscopic fluorescence imaging techniques.

Results. DuraGenᵀᴹ supports the survival (ca 95% viability, 12 days) and 3D growth of NSCs. NSC

phenotype, proliferative capacity and differentiation into astrocytes, neurons and oligodendrocytes

were unaffected by DuraGenᵀᴹ.

Conclusions. A ‘combinatorial therapy’, consisting of NSCs protected within a DuraGenᵀᴹ matrix,

offers a potential clinically translatable approach for neural cell therapy.

WP1-23

Vascular collagen 4A1 in subcortical white matter of older people and primates

A. Shtaya1,2, N.E. Yeo1, M Whittaker1, E Pereira1,2, L R Bridges1,6, G Zamboni4, M M Esiri4, C W

Farris5, D L Rosene5 and A H Hainsworth1,3

1Molecular and Clinical Sciences Research Institute, St George’s, University of London, UK, 2Atkinson Morley Neurosurgery Centre, St George’s University Hospitals NHS Foundation

Trust, London, UK, 3Neurology, St George’s University Hospitals NHS Foundation Trust,

London, UK, 4Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, UK, 5Department of Anatomy & Neurobiology, Boston University School of Medicine, Boston,

USA, 6Cellular Pathology, St George’s University Hospitals NHS Foundation Trust, London, UK

Objectives. To test whether collagen 4A1 in cerebral small arteries associated with age, hypertension

or small vessel disease (SVD)

Design. Neuropathology cohort study

Subjects. Older people age >65 years with minimal Alzheimer’s Disease

Methods. We examined subcortical white matter in archived brain tissue from older people (n=34,

15F/19M, median age 84, range 65-99 y) and from experimental non-human primates (NHP, Macaca

mulatta) that were young adults (n=9, age 6.2-8.3 y) or older adults (n=8, age 17.0-22.7 y). Some of

the primates (5 young, 3 older) were chronically hypertensive. Vascular collagen 4A1

immunohistochemical labelling was examined qualitatively and quantified as percent area fraction

Results. Collagen 4A1 labelling was common in arterial myocytes and in the adventitial layer in

human and primate brain arteries, as well as in basement membrane, which frequently exhibited

replication. Among older people, collagen 4A1 associated with neuropathological SVD severity

(sclerotic index; r=-0.461, p=0.0409, least squares) and with radiological SVD severity (leukoaraiosis;

p=0.0455, 1-way ANOVA) but not with age or clinical history of hypertension. In NHP, age but not

hypertension was significantly associated with collagen-4A1 labelling (p=0.0396, 0.232 respectively,

2-way ANOVA)

Conclusions. In this small cohort, vascular collagen 4A1 was related to SVD severity in older humans,

in accord with genetic associations of COL4A1 with SVD phenotypes

WP1-24

4-year data on decompressive craniectomy following malignant ischaemic stroke

A. Zolnourian, M. Harris, D. Bulters, M. Waraich

University Hospital Southampton, Southampton, UK

Objectives. This study aims to assess and evaluate our local practice regarding decompressive

craniectomy in malignant ischaemic stroke over a 4-year period.

Design. A retrospective evaluation of practice in patients accepted in the tertiary neurosurgical

centre between 2014-2018.

Subjects. 49 patients were identified

Methods. Demographic data were obtained from the electronic records. CT scans were examined by

two independent clinicians. Other data include length of hospital stay, surgical complications, grade

of surgeon, cranioplasty, time to surgery, use of aspirin, best motor and RASS score prior to surgery

and 6-month mRS score.

Results. 49 patients underwent decompressive craniectomy. 15(30%) female and 34(70%) male.

Mean age 48 (23-66) with 19(39%) left-sided stroke. 42(85%) were referred from local DGHs.

36(73%) were operated within 48 hrs. Seven operations were performed by consultants, seven by

ST1-3, central training 19 and 16 were carried out by senior trainees. Average length of hospital stay

was 15 days (1-21). Cranioplasty was performed in 83% (34/41) of survivors. mRS at 6 months were

0-3 (19), 4-5(12), eight died and ten were lost to follow up.

Conclusions. Decompressive craniectomy in malignant ischaemic strokes are performed as life-saving

procedures. These are often reserved for patients younger than 60. Favourable outcomes were

observed in 39% of patients. Given the recent change in NICE guidelines, removal of age limit, careful

individual assessment of each patient should be considered prior to surgery.

WP1-25

Improving neurological examination in acute admission: the INSPECT method

M. Islam

Leicester Royal Infirmary, Leicester, UK

Objectives. Clerking proforma in the trust includes a detailed neurology examination which is

mandatory to fill up according to the trust guideline. Incomplete neurological examination at the

time of admission significantly increases length of hospital stay and hamper the overall prognosis.

Design. A retrospective study was conducted for 2 weeks on 60 patients clerked in AMU. A general

survey was conducted among 26 doctors to detect the possible reasons and suggestions.To ensure

every patient gets a quick and accurate neurological examination during clerking, we suggested a

new mnemonic method called 'INSPECT': I – Inspection ( GCS, GAIT) , N- Neck Rigidity, S –Speech,

sensory P- Pupil E- Eye movement , C –Cerebellar & Cranial Nerves, T- (Tone, Power, Reflexes)

Results. The primary audit revealed that the neurology proforma completed in 18.3% notes, Partially

completed – 43.2% Not completed – 38.5% and frequently missed examinations were Cranial Nerve

examination: 68.3%, Sensory : 56.2% Cerebellar: 42.1%, Motor power: 21% Doctor's survey revealed

reasons behind examinations not being carried out :Time consuming: 46.1% , Not relevant: 23.07 %

.Not enough training 15.38%

Conclusions. Results showed that only 18.3% patients had complete neurological examination,

mostly missed cranial nerves examination ( 68.3% ) Survey suggested time constraint is a major

issue ( 46.1% ) and quicker assessment and concise proforma will help. The suggested method will

be re-audited in 3 months time.