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IntroductionAtraumatic needles are associated with a decreased incidence of postdural-puncture headache. They also reduce the need for additional treatment and have similar efficacy to conventional needles. The aim of this Quality Improvement Project (QIP) was to encourage the use of atraumatic needles in Neurology ambulatory care by developing a sustainable Lumbar Puncture (LP) training method.MethodsA specialised atraumatic needle training video was guru.kumar@nhs.net created for junior doctors starting in Neurology. This accompanied further teaching and opportunities to practice LPs on a simulation mannequin under supervision. Atraumatic needles were added to standard stock and supply was ensured.Two audit cycles recorded the number of LPs performed using an atraumatic needle. Patient age, body mass index, length of stay, pain experienced and any need for image guidance were also recoded. Junior doctor confidence was measured before and after training.Results81 LPs were performed in the first cycle, 83 in the second. Atraumatic needle use increased from 26% to 50% between cycles. Junior doctor confidence increased with training from 2/10 to 8/10 (p=0.02).ConclusionsDedicated induction teaching and observed simulation practice increased junior doctors’ confidence in, and frequency of, the use of atraumatic needles.

Background Management of Idiopathic Intracranial Hypertension (IIH) aims to reduce intracranial pressure (ICP). Acetazolamide is the most commonly used drug, with class 1 evidence demonstrating modest improvement in patients with mild visual loss. Other drugs used include Topiramate, Furosemide, Amiloride and Octreotide, despite little mechanistic or clinical evidence to support their use. The aim of this study was to ascertain which of these drugs has the greatest effect on lowering ICP in-vivo. Methods Using a validated epidural ICP recording method we measured changes in ICP in conscious female rodents after subcutaneous administration of these drugs at clinically equivalent and supra-clinical doses over 2 hours (peak plasma concentrations). Results At clinical doses, Topiramate lowered ICP by 32% (p=0.0009) compared to a 25% reduction for Acetazolamide (p=0.0081). Post-hoc analysis showed no significant difference between the two (p=0.85). Furosemide, Amiloride and Octreotide had no significant effect. Conclusion Our in-vivo studies have demonstrated that, at clinically equivalent doses, Topiramate significantly lowers ICP and is as effective as acetazolamide. Topiramate may have additional advantages in IIH, including its migraine prevention properties and weight loss effects. These findings support the need for future randomised controlled trials evaluating the therapeutic efficacy of topiramate in IIH.

Current therapies for reducing raised intracranial pressure (ICP) in conditions such as idiopathic intracranial hypertension (IIH) have limited efficacy and tolerability; therefore there is an urgent need to develop novel therapies. Glucagon-like peptide-1 receptor (GLP-1R) agonists are used therapeutically to treat diabetes and promote weight loss but have also been shown to affect fluid homeostasis in the kidney. The GLP-1R is also present in the choroid plexus, therefore we investigated whether Exendin-4, a GLP-1R agonist, is able to modulate cerebrospinal fluid (CSF) secretion at the choroid plexus and subsequently reduce ICP. We used in vitro models of the choroid plexus to demonstrate the presence of the GLP-1R and, after Exendin-4 treatment, showed a two fold increase in cAMP, a downstream signaling molecule. We also determine that treatment with Exendin-4 reduces Na+ K+ ATPase activity, a key regulator of CSF secretion. Finally, we demonstrate that administration of Exendin-4 in normal and raised ICP (hydrocephalic) rats significantly reduces ICP. These findings provide the first proof of concept that GLP-1R agonists can affect CSF secretion and ICP. Repurposing existing GLP-1 drugs may represent a novel therapeutic strategy for conditions of raised ICP including IIH, hydrocephalus and traumatic brain injury.