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Natalizumab is one of the most effective therapies for relapsing-remitting multiple sclerosis. One complication is progressive multifocal leucoencephalopathy, a viral brain infection caused by John Cunningham virus (JCV). Monitoring of neurological symptoms, JCV serology and regular brain imaging are required to ensure safe use of this therapy. Local audit data from 2015 indicated poor compliance with safety monitoring: under 25% of investigations were within recommended timeframes. Subsequently, a protocol was implemented to improve monitoring, with specialist nurses coordinating requests for MRI scans and arranging JCV serology, with frequency determined according to JCV index. A re-audit assessed the impact of this protocol (n=155). Some 97.4% of patients were appropriately tested for JCV and 88.4% were imaged within the recommended interval. Additional work with the informatics and virology team ensured serology results became more easily accessible. The use of a standardised, nurse-led operating procedure has resulted in marked improvement in the safety monitoring of natalizumab.

Objective: An association between cerebral venous sinus thrombosis (CVST) and high altitude has been previously proposed, but limited published data exist to support this association. We investigated 28 cases of CVST occurring at high altitude and sought to describe patient demographics, altitude and acclimatization, hematological laboratory findings, neuroimaging, treatment, and prognosis in these cases. Methods: Twenty-eight cases of symptomatic CVST occurring at high altitude were identified between the months of August 2017 and December 2018, in collaboration with Military Hospital, Rawalpindi and Combined Military Hospital, Skardu (Pakistan). Follow-up visits were performed at 1 and 6 months. Results: Twenty-seven (96%) of the patients were males, and the mean age was 33 years. In total, 32.1% were smokers. The mean NIHSS score on presentation was 5.5. 85.7% of the cases occurred at altitude higher than 8,000 feet. On average 107.8 days were spent at a high altitude prior to CVST. Totally, 71.4% had acclimatized for >2 weeks. The mean hemoglobin (Hb) value was 16.7 g/dL and 50% had d-dimer levels higher than 1,000 ng/mL. On MRI, 25% showed signs of hemorrhage and 14.3% showed infarcts. Treatments provided include low-molecular-weight heparin and Rivaroxaban and were associated with good outcomes. Conclusion: CVST is not uncommon at high altitude (>8,000 feet). It is predominantly a male disease. Most patients have high Hb and high D-dimer levels. The overall outcome was good.

When an unidentified patient who cannot communicate presents with symptoms and signs suggesting an acute stroke, the decision to thrombolyse is a particular challenge. In a time-pressured environment, clinicians need clear thought processes for diagnosis and treatment. Ethical considerations, diagnosis, identity and previous history, contraindications, time of symptom onset (EDICT) can help decision-making in this situation.

Natalizumab is one of the most effective therapies for relapsing-remitting Multiple Sclerosis. One complication is Progressive Multifocal Leucoencephalopathy (PML), a viral brain infection in patients already infected with JC virus. Monitoring of neurological symptoms, JC virus serology and regular brain imaging are required to ensure safe use of this therapy. Local audit data from 2015 indicated poor compliance with safety monitoring, with less than 25% of patients undergoing required investigations within the recommended time intervals. Subsequently a protocol was implemented to improve monitoring, with specialist nurses coordinating the requests for MRI scans and arranging JC virus serology, the frequency of which was determined according to the JC virus index. The records of all patients receiving Natalizumab at the centre were audited to assess the impact of this protocol (n=155). 99.2% of patients were appropriately tested for JC virus and 95.3% were imaged within the recommended interval. Additional work with the informatics and virology team ensured serology results became more easily accessible. The use of a standardised nurse-led operating procedure has resulted in marked improvement in the safety monitoring of Natalizumab.

A 66-year-old man presented to the emergency department with paraesthesia starting in the first two fingers of his right hand, spreading up his right arm into the right side of his face and mouth over 10 min. During this, his mouth felt numb “like after a dental injection”. He had three further similar episodes in the emergency department. He had a past history of hypothyroidism and irritable bowel syndrome. After a CT scan of head (figure 1), he started treatment with an antiplatelet medication for a presumed transient ischaemic attack (TIA). An MR scan of brain the next day showed a small amount of subarachnoid blood in the left central (rolandic) sulcus (figure 2). We therefore stopped the antiplatelet treatment. Over the next month, he continued having almost daily episodes of tingling and numbness affecting his hand and face, each lasting 20 min. One episode affected his throat, leaving him unable to speak for several minutes (figure 3 and supplementary video on the website). Figure 1 Non-enhanced CT brain shows high attenuation acute subarachnoid blood within the left central sulcus. …

Introduction Quantitative Electroencephalography (qEEG) has been shown to distinguish AD patients from healthy controls (HC) at a group but not at an individual level. A novel qEEG data analysis method created at the University of Sheffield can measure linear and non-linear levels of brain synchronisation in the time domain. Methods Patients with AD and HV had resting state EEGs. The standard 10–20 international system of EEG electrode placement was used. All patients had MRI and detailed neuropsychology as part of the European VPH-DARE@IT project. Custom made software (Error Reduction Ratio-causality (ERR-causality) analysed average strength of linear and non-linear synchronization in bicentroparietal region. Results 10 HC and 10 AD EEGs were included. Mean ages were 58.1 (AD) versus 62.2 y (HV). Mean mini-mental state examinations were 17.5 (AD) and 28.50 (HV). The ratio of bi-centroparietal synchronisation between eyes open & eyes close (EO/EC) showed a striking difference between the two groups (AD ratio 0.814 versus HC ratio 0.282, p=0.0006). Conclusions These results suggest that patients with AD have higher levels of EO bi-centroparietal synchronisation & in particular the ratio between EO/EC synchronisation has potential to be used as a non-invasive and inexpensive biomarker or diagnostic tool for AD.

BackgroundAutologous haemopoietic stem cell transplantation (AHSCT) is an evolving therapy for multiple sclerosis (MS). Here we present the Sheffield experience since 2006.MethodsRetrospective review of MS cases referred for and treated with AHSCT. Toxicity, clinical and radiological outcome were assessed.Results14 patients (8 Rapidly evolving severe [REMS], 3 Relapsing Remitting [RRMS], 3 Secondary Progressive [SPMS]) were selected for AHSCT. One patient underwent AHSCT on a clinical trial (data excluded from analysis). Mean age 34.6 years (SD 8.69), median pretreatment EDSS 6.5 (IQR0.5). All had clinically and radiologically aggressive disease, non-responsive to standard treatment. Follow up range was 3 to 96 months.All patients were successfully mobilized, 2 patients progressed only to harvest (1 compliance issues, 1 leg ulcer). All patients were treated according to international guidelines. No excess toxicity or treatment related mortality was observed.Post-transplant MRI's showed no active disease. No patients with RRMS suffered relapse post-transplant, median reduction in EDSS scores was 2 at both 100 days (IQR 2) and at last follow up (IQR 2.5). EDSS scores stabilised in patients with SPMS.ConclusionAHSCT is an effective treatment with acceptable toxicity in patients with aggressive, inflammatory MS.

The 2009 Dementia strategy promoted a ‘memory clinic in every town’. We investigated the patient mix seen in a neurology-led memory clinic. Retrospective review (2004, 2006, 2012) attendees to memory clinic. Prospective review memory clinic from October 2012–Dec 2013. Survey to neurologists in Specialist Interest Group in Cognition (ABN). Survey of local GPs. Results Percentage of attendees with benign memory complaints increased from 30% & 32% in 2004 and 2006 to 55% in 2012. Oct 2012–Dec 2013 >50% attendees do not have dementia or MCI. 9 responders: A mean of 27% of attendees of neurology-led memory clinics in the UK have ‘benign memory complaints’. The following terms were used: ▸ Attentional amnestic disorder, ▸ Attentional cognitive complaints, ▸ Worried well, ▸ Subjective memory complaints, ▸ Subjective memory impairment, ▸ Normal cognitive ageing, ▸ Hypocondrial, ▸ ‘Stress related.’ 4. GPs used; ‘worried well’, ‘benign senescent forgetfulness’, ‘Possible dementia’, ‘mild neurocognitive disorder’ and ‘late life forgetfulness’ & treated with antidepressants but also referred to psychology or memory clinic. People attending memory clinic frequently do not have dementia and currently there is no consensus for diagnostic label or treatment.