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IntroductionUnderlying pathological mechanisms of cerebral vessel damage in dementia patients have been suggested to increase the risk of intracranial haemorrhage following thrombolysis for acute ischaemic stroke. This has not been demonstrated in earlier literature. Our study compared the throm- bolysis outcomes of stroke patients with and without cognitive impairment.MethodsA retrospective cohort analysis of stroke patients receiving thrombolysis was conducted. Cognitive impairment was defined as: a diagnosis of dementia, mild cognitive impairment, or clinical evidence of mild cognitive impairment. Outcome measures included haemorrhagic complications, NIHSS and mRS scores, and mortality.ResultsStatistical analysis included data from 428 ischaemic stroke patients, 62 of whom had cognitive impairment. Following thrombolysis, cognitively impaired stroke patients had greater increments in dis- ability level, an increased risk of haemorrhagic complications, and a lower likelihood of 90-day survival. Logistic regression modelling revealed the main predictors of these poorer outcomes to be age, time to thrombolysis, and NIHSS on admission. Two thirds of the variance in stroke outcomes remained unex- plained by our models.ConclusionConfounding variables were the main predictors of poorer thrombolysis outcomes in cogni- tively impaired stroke patients. A large portion of these poorer outcomes remains unexplained, leaving potential for further investigation.

IntroductionMechanical thrombectomy is now in routine use for acute ischaemic stroke. This service audit examines outcomes and complications in the Sheffield regional centre.MethodsData was collected retrospectively for all patients undergoing mechanical thrombectomy at Sheffield Teaching Hospitals from March 2020 – February 2021 using case notes and digital records. The data was analysed for the whole group (n=33), and for the subgroup of patients (n=8) aged over 80.Results33 patients, aged 31-87, underwent mechanical thrombectomy. 88% had successful revasculari- sation (TICI grade 2b/3). 48% had a good functional recovery (modified Rankin scale 0-2).6 patients had haemorrhagic transformation, though none met the SITSMOST criteria for symptomatic intracerebral haemorrhage secondary to procedure. 6 patients (18%) did not survive to 90 days.In the group aged over 80, outcomes were significantly worse. In this group the rate of successful revas- cularisation was 63%, and good functional recovery (mRS 0-2) was 13%. 90 day mortality was 38%.ConclusionsOutcomes from mechanical thrombectomy at Sheffield teaching hospitals are good, with nearly half of patients having a good functional recovery. However, outcomes in the subgroup of patients aged over 80 were significantly poorer, with high complication and mortality rates; this warrants further study.

IntroductionRecent years have seen an almost sevenfold rise in referrals to specialist memory clinics. This has been associated with an increased proportion of patients referred with functional cognitive disorder (FCD), that is, non-progressive cognitive complaints. These patients are likely to benefit from a range of interventions (eg, psychotherapy) distinct from the requirements of patients with neurodegenerative cognitive disorders. We have developed a fully automated system, ‘CognoSpeak’, which enables risk stratification at the primary–secondary care interface and ongoing monitoring of patients with memory concerns.MethodsWe recruited 15 participants to each of four groups: Alzheimer’s disease (AD), mild cognitive impairment (MCI), FCD and healthy controls. Participants responded to 12 questions posed by a computer-presented talking head. Automatic analysis of the audio and speech data involved speaker segmentation, automatic speech recognition and machine learning classification.ResultsCognoSpeak could distinguish between participants in the AD or MCI groups and those in the FCD or healthy control groups with a sensitivity of 86.7%. Patients with MCI were identified with a sensitivity of 80%.DiscussionOur fully automated system achieved levels of accuracy comparable to currently available, manually administered assessments. Greater accuracy should be achievable through further system training with a greater number of users, the inclusion of verbal fluency tasks and repeat assessments. The current data supports CognoSpeak’s promise as a screening and monitoring tool for patients with MCI. Pending confirmation of these findings, it may allow clinicians to offer patients at low risk of dementia earlier reassurance and relieve pressures on specialist memory services.

ObjectivesPatients with functional memory disorder (FMD) report significant memory failures in everyday life. Differentiating these patients from those with memory difficulties due to early stage neurodegenerative conditions is clinically challenging. The current study explored whether distinctive neuropsychological profiles could be established, suitable to differentiate patients with FMD from healthy individuals and those experiencing amnestic mild cognitive impairment (a-MCI).MethodsPatients with a clinical diagnosis of FMD were compared with patients with a-MCI, and healthy matched controls on several tests assessing different cognitive functions. Patients with clinically established mood disorders were excluded. Patients with FMD and a-MCI were broadly comparable on the level of their subjective memory complaints as assessed by clinical interview.ResultsThe neuropsychological profile of the FMD patients, although they expressed subjective memory and attention concerns during their clinical interview was distinct from patients with a-MCI on tests of memory [semantic fluency, age of acquisition (AoA) analysis of semantic fluency, verbal and non-verbal memory]. FMD patients did not differ significantly from healthy controls, but their scores on the letter fluency and digit cancellation tasks were not significantly different from those of the a-MCI patients indicating a possible sub-threshold deficit on these tasks.ConclusionWhilst subjective complaints are common within the FMD population, no objective impairment could be detected, even on a sensitive battery of tasks designed to detect subtle deficits caused by an early neurodegenerative brain disease. This study indicates that FMD patients can be successfully differentiated from patients with neurodegenerative memory decline by characterising their neuropsychological profile.

BACKGROUND: The early diagnosis of dementia is of great clinical and social importance. A recent study using the qualitative methodology of conversation analysis (CA) demonstrated that language and communication problems are evident during interactions between patients and neurologists, and that interactional observations can be used to differentiate between cognitive difficulties due to neurodegenerative disorders (ND) or functional memory disorders (FMD). OBJECTIVE: This study explores whether the differential diagnostic analysis of doctor-patient interactions in a memory clinic can be automated. METHODS: Verbatim transcripts of conversations between neurologists and patients initially presenting with memory problems to a specialist clinic were produced manually (15 with FMD, and 15 with ND). A range of automatically detectable features focusing on acoustic, lexical, semantic, and visual information contained in the transcripts were defined aiming to replicate the diagnostic qualitative observations. The features were used to train a set of five machine learning classifiers to distinguish between ND and FMD. RESULTS: The mean rate of correct classification between ND and FMD was 93% ranging from 97% by the Perceptron classifier to 90% by the Random Forest classifier.Using only the ten best features, the mean correct classification score increased to 95%. CONCLUSION: This pilot study provides proof-of-principle that a machine learning approach to analyzing transcripts of interactions between neurologists and patients describing memory problems can distinguish people with neurodegenerative dementia from people with FMD.

The file attached to this record is the author's final peer reviewed version. The Publisher's final version can be found by following the DOI link. Objective: Specialist services for dementia are seeing an increasing number of patients. We investigated whether interactional and linguistic features in the communication behaviour of patients with memory problems could help distinguish between those with problems secondary to neurological disorders (ND) and those with Functional Memory Disorder (FMD). Methods: In Part 1 of this study, a Diagnostic Scoring Aid (DSA) was developed encouraging linguists to provide quantitative ratings for 14 interactional features. An optimal cut-off differentiating ND and FMD was established by applying the DSA to 30 initial patient–doctor memory clinic encounters. In Part 2, the DSA was tested prospectively in ten additional cases analysed independently by two Conversation Analysts blinded to medical information. Results: In part one, the median score of the DSA was +5 in ND and -5 in FMD (p

IntroductionReferrals to specialist memory clinics have increased out of proportion to the incidence of dementia. Time and financial pressures are consequently exerted on a service striving to deliver high quality care. We have developed a fully automated ‘Digital Doctor’ with the aim of providing pre-clinic risk stratification and ongoing monitoring for patients with memory concerns.MethodsWe recruited 15 participants with Functional Memory Disorder (FMD), Mild Cognitive Impairment (MCI) and Alzheimer’s disease each as well as 15 healthy controls. Participants answered 12 questions posed by the ‘Digital Doctor’. Audio and visual data is analysed using diarization and automatic speech recognition tools and machine learning classifiers.ResultsThe ‘Digital Doctor’ can distinguish between neuro-degenerative dementia and FMD with an accuracy of 95%. We will have results of a 4-way classification accuracy (HC, FMD, MCI & AD) at time of conference.DiscussionWe demonstrate the potential value of the ‘Digital Doctor’ as a stratification and triage tool. Accuracy will be improved with greater number of users and inclusion of fluency and picture description data. Patients at low risk could avoid the burden of a clinic appointment, whilst patients with higher risk could benefit from a more streamlined service.

Objectives: In the UK dementia is under-diagnosed, there is limited access to specialist memory clinics, and many of the patients referred to such clinics are ultimately found to have functional (non-progressive) memory disorders (FMD), rather than a neurodegenerative disorder. Government initiatives on ‘timely diagnosis’ aim to improve the rate and quality of diagnosis for those with dementia. This study seeks to improve the screening and diagnostic process by analysing communication between clinicians and patients during initial specialist clinic visits. Establishing differential conversational profiles could help the timely differential diagnosis of memory complaints.\ud \ud Method: This study is based on video- and audio recordings of 25 initial consultations between neurologists and patients referred to a UK memory clinic. Conversation analysis was used to explore recurrent communicative practices associated with each diagnostic group.\ud \ud Results: Two discrete conversational profiles began to emerge, to help differentiate between patients with dementia and functional memory complaints, based on (1) whether the patient is able to answer questions about personal information; (2) whether they can display working memory in interaction; (3) whether they are able to respond to compound questions; (4) the time taken to respond to questions; and (5) the level of detail they offer when providing an account of their memory failure experiences.\ud \ud Conclusion: The distinctive conversational profiles observed in patients with functional memory complaints on the one hand and neurodegenerative memory conditions on the other suggest that conversational profiling can support the differential diagnosis of functional and neurodegenerative memory disorders.

The Acute neurology unit (ANU), located at the Royal Hallamshire Hospital, Sheffield is a regional centre for a population of approximately 1.5 million. We are unusual, as our neurologists manage both hyperacute stroke and hyperacute neurology. HASU is located within our ANU. We had 4026 neurology ward admissions, 3265 emergency cases and 761 elective cases last year. We receive acute admissions from Trust A and E, direct admissions from general practitioners and urgent transfers from DGHs.We provide 24 hour stroke thrombolysis and a weekday working hours thrombectomy service. Overnight thrombolysis is supervised through a regional ‘Telemedicine’ system. A 2 week survey in July 2017 showed that only 59% patients, who were referred with suspected stroke, had stroke/TIA. Neurological conditions, such as migraine, seizure, syncope, acute vestibulopathy, Bell’s palsy and medically unexplained symptoms were common ‘stroke mimics’. 46% of patients with ‘stroke mimic’ were discharged on the day of admission. Average length of stay was 3 days. A separate survey of acute neurology referrals showed that 58% of patients did not require admission and were managed through an ambulatory care pathway. Patient satisfaction regarding their rapid assessment and diagnosis was high. Co-location of ANU and HASU allows rapid and effective management of ‘stroke mimics’.

Background: Venous sinus disease must be excluded before diagnosing idiopathic intracranial hypertension but is found only rarely in typical cases. Magnetic resonance venography (MRV) is the technique of choice for investigating this, and provides images that are diagnostic and easy to interpret. However, recent work using more invasive techniques has documented pressure gradients and stenoses in the lateral venous sinuses in many cases of idiopathic intracranial hypertension. Objective: To examine the reason for this discrepancy and to establish whether there are characteristic appearances on MRV in idiopathic intracranial hypertension that are routinely overlooked in clinical practice. Methods: MRVs from 20 patients with idiopathic intracranial hypertension were reviewed, unblinded, by two neuroradiologists, and their appearances rated for focal narrowings and signal gaps. A control group of 40 asymptomatic volunteers, matched for age and sex with the patient group, was recruited prospectively for MRV, and their scans rated in the same way. Results: The lateral sinuses presented a range of appearances with quite different distributions in the two groups (p

with a mean of 12.6 years of education (8-17). The mean number of professional fights was 45.2 and years of professional fighting, 14.3. Impairments on cognitive tests were frequent, with 43% failing a psychomotor speed test, 57% failing a processing speed test and 28.6% failing a memory test. The memory test was failed by a similar proportion of active fighters, while less active fighters failed the tests involving speed. . When corrected for age and other relevant variables, thalamic volume did not differ between active and retired fighters, but a greater fight exposure was associated with smaller volumes (p1⁄4.0.031). Conclusions: Cognitive dysfunction is common in retired fighters, and may be associated with specific changes in the brain. Timed tasks are particularly vulnerable, whereas impairment in memory is seen similarly in younger, active fighters. Analysis of larger groups of fighters will further elucidate this relationship.

Introduction Conversation Analysis (CA) can help with the differential diagnosis of seizure disorders. We investigated if CA could be used in the memory clinic to distinguish neurodegenerative (NDD) from functional memory disorders (FMD). Methods We recruited consecutive, patients newly referred to the Neurology-led memory Clinic. Consultations were video & audio recorded. All participants underwent detailed Neuropsychology testing and MRI. Results 111 patients of 178 approached were recruited (20 ND, 24 FMD, 87 other). We identified profiles of 14 interactional features that can distinguish NDD from FMD consultations based on encounters with 15 patients with NDD and 15 with FMD. Features of NDD included an inability to answer compound questions fully, inability to give detailed examples of memory failures, shorter length of turn and reduced complexity of replies. Prospective analysis of an additional 10 encounters proved that Conversation Analysts could use these features to predict the diagnoses of FMD and ND with high sensitivity and specificity. Conclusions Simple differences in the communication behaviour of patients can help to distinguish between ND and FMD, suggesting that a targeted observation of interactional features could improve screening for ND in primary or secondary or care settings.

To evaluate the technical feasibility of an integrated ultrafast head magnetic resonance (MR) protocol using a sensitivity encoding (SENSE) technique for depicting parenchymal ischaemia and vascular compromise in patients with suspected recent stroke.23 patients were evaluated with the ultrafast MR protocol using T2, T1, fluid attenuated inversion recovery (FLAIR), 3D time of flight magnetic resonance angiography (MRA), and diffusion weighted imaging (DWI) sequences. These were compared with routine conventional MR sequences.One patient could not tolerate conventional imaging, although imaging using the three minute head SENSE protocol was diagnostic. Both conventional and ultrafast protocols were of similar diagnostic yield in the remaining patients. There were no significant differences in clinical diagnostic quality for the T1, T2, FLAIR, and DWI sequences. One MRA examination was of better quality when SENSE was used, owing to reduced motion artefacts and shorter imaging time.It is possible to undertake a comprehensive MR examination in stroke patients in approximately three to five minutes. Ultrafast imaging may become a useful triage tool before thrombolytic therapy. It may be of particular benefit in patients unable to tolerate longer sequences. Further work is necessary to confirm these findings in hyperacute stroke.

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.

Clarification of the pathophysiological mechanisms of intra-arterial thromboembolism may lead to novel treatments for cerebrovascular disease. There is increasing evidence for the role of von Willebrand factor (VWF) cleaving protease (ADAMTS-13) in modulating the thrombotic cascade in high flow arterial settings. VWF multimers are rich in ultra large forms (ULVWF) which can rapidly bind its primary platelet receptor resulting in spontaneous aggregation of platelets. Under normal conditions, these ULVWF are regulated by rapid proteolysis converting them to smaller, less active forms. The protease responsible for cleavage of ULVWF is ADAMTS-13. We measured the ADAMTS-13 antigen and ADAMTS-13 activity levels in the plasma of consecutive patients with transient ischaemic attack (TIA), compared with nonstroke controls, in a hospital based TIA clinic. This was compared with VWF levels. Samples were analysed in the acute phase and at 3 months postevent. In our pilot study patients with partial anterior circulation type TIAs had significantly reduced ADAMTS-13 activity compared to controls (p=0.0394). No significant differences were seen between high- and low-risk ABCD2 scored patients. We did not observe any significant changes in VWF levels in our study sample. Our pilot study suggests a potential role for altered ADAMTS-13 activity in the pathophysiology of TIA.

Hormone Therapy and the Brain: a Clinical Perspective on the Role of Oestrogen. By v w henderson. (Pp 112, £28.00). Published by Parthenon Publishing Group, Carnforth, 2000. ISBN 1–85070–078–8. The role of sex steroids in neurological disease is a topic of importance in our aging population and very worthy of discussion. This book is set out in chapters focusing on different individual subspecialties, including dementia, vascular disease, and epilepsy, with an initial backdrop …