OBJECTIVE Despite the disabling deficits of motor apraxia and sensory ataxia resulting from intraoperative injury of the superior thalamocortical tracts (TCTs), region-specific electrophysiological localization is currently lacking. Herein, the authors describe a novel TCT mapping paradigm. METHODS Three patients, 1 asleep and 2 awake, underwent glioma resection affecting primarily the somatosensory cortex and underlying TCT. Stimulation was performed at the median, ulnar, and posterior tibial nerves. Parameters comprised single anodal pulses (duration 200–500 μsec, 2.1–4.7 Hz) with a current ranging from 10 to 25 mA. Recordings were captured with a bipolar stimulation probe, avoiding the classic collision technique. Positive localization sites were used to tractographically reconstruct the TCT in the third case. RESULTS Employing one electrophysiological paradigm, the TCT was localized subcortically in all 3 cases by using a bipolar probe, peak range of 19.6–29.2 msec, trough of 23.3–34.8 msec, stimulation range of 10–25 mA. In the last case, tractographic reconstruction of the TCT validated a highly accurate TCT localization within a specific region of the posterior limb of the internal capsule. CONCLUSIONS The authors describe the first electrophysiological technique for intraoperative localization and protection of the TCT in both asleep and awake craniotomies with tractographic validation, while avoiding the collision paradigm. None of the above paradigms have been previously reported. More data are required to further validate this technique.
BackgroundNeurology patients with complex diagnoses in a busy tertiary centre can undergo multiple investigations to reach a diagnosis and are usually discharged with pending results, as tests can take a considerable amount of time to be processed (and released).AimWe set up a Virtual Clinic to follow-up patients’ results post discharge to avoid loss to follow up and improve safety of patient care.MethodsWe identified a significant proportion of neurology inpatients who were not followed-up efficiently (30.8% over 3-month-period) and addressed this issue by initiating a Virtual Clinic. The clinic was run weekly by neurology junior doctors, with protected clinic hours. The outcome of the clinic was communicated to the referring neurology consultant. We compared the follow up rates in the three months pre-clinic (October to December 2019) to the three months after setting up the clinic (January to March 2020).ResultsUsing the PDSA methodology, we successfully managed to increase the follow-up for outstanding investigations to 68.8% from 30.8% (pre-clinic setup), via the implementation of the Neurology Virtual Clinic. We re-audited for another three-month period using the same methodology. For the period September to November 2020, this percentage increased further to 73.68%.ConclusionThis new service was effective at improving test result monitoring and decreased the number of investigations that were not followed up promptly. Most importantly improved the safety of our patients’ care.
BackgroundThe COVID-19 pandemic has changed delivery of care worldwide where face to face clinics had to adapt to telephone consultations. Management of neurological symptoms have traditionally relied on detailed physical assessments which poses challenges for remote consultations.AimTo evaluate patient-reported experience of acute neurology telephone clinics to better understand areas for improvement of this ongoing service.MethodWe formulated a voluntary, confidential, thirteen-question survey on patient experience. The questionnaire was devised based on the previously published King’s Patient Experience Measure in Neuro- oncology Questionnaire (Ashkan et al, 2021). Four domains were measured: clinic environment, patients’ questions/queries, follow-up and feedback.ResultsOur data showed that telephone clinics can achieve a high-degree of satisfaction, efficiency in communication and engagement (100%), addressing patients’ concerns (100%) with clear clinical outcomes (100%) and over 95% of patients feeling satisfied with the care they have received. Despite this, over 35% of patients would prefer a face to face consultation. Feedback suggested patients would be open to a blended model of face to face and telephone consultations.DiscussionIncorporating telephone consultations as part of a new model of care can improve equity of access for patients, in line with the NHS Long Term Plan. It is an efficient way of bringing care closer to the patient, which would be well suited in the new Integrated Care System.
A 36-year-old Spanish man, with a background of ketamine use, presented with a 10-day history of severe headache, photophobia, nausea, unsteadiness and slurring of speech. His CT head was normal. CSF white cell count was 151 (lymphocytes), protein 0.7, glucose 2.3 (serum 3.6). He was treated with IV acyclovir for two weeks with no clinical improvement.On examination he remained distressed by headache and photophobic with severe dysarthria, bidirec- tional nystagmus and ataxia.Blood tests were normal or negative including HIV, serology for syphilis, mycoplasma, lyme and brucella, ANA, ENA, dsDNA, ANCA, ACE, LGI1 and NMDA antibodies, anti-Hu, Ri and Yo. IGRA was positive. MRI brain scan was normal. Serial lumbar punctures showed a variable CSF white cell count, with a negative extended virology panel, TB PCR, bacterial cultures, cytology and immunophenotyping.There was no improvement with pulsed steroids or antimicrobial cover for listeria. After 5 plasma exchanges there was some improvement in his CSF white cell count and headache, but he remained very ataxic.An extended paraneoplastic panel revealed positive anti-Tr antibodies. This is a well recognised cause of paraneoplastic cerebellar degeneration, normally associated with Hodgkin’s lymphoma. There have been no previous reported cases of anti-Tr antibodies associated with meningitic symptoms.
A previously independent 82-year-old woman presented with 5 months of worsening confusion, mobility and cognitive decline, with deficits in orientation, language and executive function. A cerebral dural arteriovenous fistula was identified and successfully embolised, after which her cognitive ability and independence dramatically improved. Although rare, a dural arteriovenous fistula may mimic a rapidly progressive dementia, but its early recognition and treatment can completely reverse the dementia.
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