Neurology

Normal acutely performed CT scan of the brain may give a false sense of safety prior to use of antiplatelets in transient focal (2017)

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Type of publication:
Conference abstract

Author(s):
*McNeela N.; *Srinivasan M.

Citation:
Cerebrovascular Diseases; Jul 2017; vol. 43 ; p. 116

Abstract:
Transient focal neurological episodes (TFNE) are frequently assumed to be transient ischaemic attacks (TIAs) in older patients who are then started on antiplatelets for stroke prevention. Imaging with a CT scan of the brain reported as normal or not suggesting haemorrhage can give a false sense of security with regard to therapeutic decision making. Current UK stroke guidelines do not emphasise the need for imaging (either CT or MRI) in transient ischaemic attacks with NICE guidance recommending treat with aspirin immediately and then refer to stroke services for further management. Imaging is then only recommended for patients where the vascular territory or pathology is uncertain with diffusion weighted MRI scans. In cases where MRI is contraindicated second line imaging is a CT head. We present two cases of patients who presented with symptoms of TFNEs treated as TIAs who then subsequently developed haemorrhagic strokes. The first case is of an 80 year old lady with new onset atrial fibrillation who presented with transient face and arm paraesthesia and dysarthria. Following a normal CT head she was started on anticoagulation and discharged home. She subsequently represented with a further two episodes and each time underwent a repeat imaging which again showed no abnormalities until she eventually succumbed to a massive right cortical intracranial haemorrhage. The second case involves a 68 year old gentleman with no significant past medical history other than a recent headache who presented with recurrent symptoms of left face and arm paraesthesia and dysarthria. A CT scan of the brain was normal and so he was treated with antiplatelets for a presumed TIA and discharged. However within six hours he deteriorated with dense left hemiplegia and reduced consciousness. A repeat CT showed a large right frontoparietal bleed with midline shift requiring referral to neurosurgeons. These cases highlight how a CT head in an acute presentation with transient symptoms can be misleading. One option would be consideration of blood sensing MRI scans in investigation of TFNE verses TIA diagnoses. As TFNEs often to present as descending paresthesia, we would recommend all patients with this presentation to undergo urgent inpatient MRI scans before being commenced on treatment.

An audit of the Shrewsbury and Telford two week wait CNS malignancy pathway referrals over six months (2015)

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Type of publication:
Poster presentation

Author(s):
*Metcalfe R, *Bowen J

Citation:
West Midlands Regional Neuroscience Meeting, 13 Nov 2015

Abstract:

An audit of the Shrewsbury and Telford two week wait CNS malignancy pathway referrals
over six months. By Metcalfe R*, Bowen J**
*Final year medical student, Keele University Medical School.
**Consultant Neurologist, Shrewsbury and Telford Hospital NHS trust (SaTH).
Word Count: 232 words.

Introduction:

  • The overall incidence of brain tumours in the U.K. is around 7/100,001
  • To promote early diagnosis a fast track “2 week wait” pathway exists for prompt diagnosis and initiation of management of brain/CNS tumours
  • In SaTH standardised suspected CNS malignancy referral proformas2 are faxed to meet 2 week targets appointments

Aim:

To undertake an audit to address the following:

  • Did referrals adhere to proforma criteria?
  • What proportion was seen within two weeks?
  • Is the process fit for purpose?

Methodology:

  • Case note review of all patients referred via the two week CNS Cancer pathway over a sixth month period from 1st July 2014 to 1st January 2015

Results:

  • Over the 6 months >98 % (120/122) referred via the two week wait pathway fulfilled the
    criteria on the proforma
  • Only 5.7% (7/122) were not seen within two weeks
  • 2 patients were diagnosed with brain metastases
  • No patients were diagnosed with a primary brain tumour

Conclusions:

  • Despite adherence of over 98% no case of primary brain tumour was detected over the six month period and 2 (1.6%) of patients referred had brain metastases
  • The current system is not effective at picking up brain tumours

Suggestions:

  • These results will be shared with local primary care groups and the referral criteria refined
  • A reaudit to assess impact of changes will be undertaken

References:
1. McKinney PA. J Neurol Neurosurg Psychiatry 2004;75:ii12-ii17
2. Shrewsbury and Telford Hospital NHS trust. Brain and CNS Cancer Two Week Wait
Referral Proforma. [internet] 2012 [Cited 6th October 2015] Available from:
www.sath.nhs.uk/Library/Documents/gpconnect/gpinfo/Brain%20and%20CNS
%20Cancer%20TWW%20Referral%20Proforma%20_V1_.pdf