Lesson of the month: Oxycodone-induced leukoencephalopathy: a rare diagnosis.

Oxycodone-induced leukoencephalopathy is a rare diagnosis that should be considered in unconscious patients with appropriate history. We describe a case of a 57-year-old unconscious woman who required intubation and did not respond to naloxone infusion. The unconsciousness was initially thought to be due to hypoxic brain injury. However, a further review of brain imaging showed characteristic features of oxycodone-induced leukoencephalopathy. We describe the pathological and radiological features of this condition, and provide a concise review of the limited literature on this condition. Accurate diagnosis of this condition will be valuable to clinicians and patients in terms of their medium-term and long-term prognosis, and potential for rehabilitation.

Improving Door to Needle time in Patients for Thrombolysis.

Ischaemic stroke can result in approximately 2 million brain neurones being damaged for each minute that it is left untreated. Various trials and studies such as the National Institute of Neurologic Disorders (NINDS) trial, the European Cooperative Acute Stroke Study (ECASS), ECASS II, and the Alteplase Thrombolysis for Acute Noninterventional Therapy in Ischemic Stroke (ATLANTIS) study have clearly demonstrated the beneficial effects of intravenous tissue plasminogen activator (tPA) for treatment of acute stroke. Therefore to minimise damage and improve clinical outcome, we need to identify patients who present within 4.5 hours of symptom onset and reduce the time taken to adminster a thrombolytic agent. This time is commonly referred to as the 'door to needle' (DTN) time. Our standard, set by the Clinical Commissioning Group (CCG) is to achieve a median time of scanning and thrombolysis within 55 minutes from the time that the patient enters the hospital. The aim of our QIP was to collect data on what the DTN time was during November 2015, December 2015, and January 2016 and to evaluate how this can be improved after each month. This Quality Improvement Project in the DTN time in patients for thrombolysis has identified areas in the pathway that leads to delays. One major contributing factor is the time for a doctor to come and assess and administer the thrombolytic agent to the patient. Change was implemented by ensuring that the core medical trainee on call is allocated to respond as a priority to all possible thrombolysis calls. This has resulted in a reduction of mean DTN time, from 74 minutes in November to 43 minutes in January. As well as improving patient outcomes, it is proposed that the implementation of change has benefitted the training experience and development of key skills of the core medical trainees.

Sudden loss of vision in a patient with significant ipsilateral internal carotid disease.

A 74-year-old man developed sudden onset of painless persistent partial loss of vision in the right eye 3 days after right total knee replacement. The initial investigation was for amaurosis fugax with a normal CT scan of the brain but the carotid Doppler confirmed >90% stenosis of the right internal carotid artery. Urgent ophthalmological review confirmed anterior ischaemic optic neuropathy. Subsequently, he lost his vision completely in the right eye. He had a previous high risk hemispheric transient ischaemic attack with carotid Doppler reported as normal.

Vertebral artery dissection: not a rare cause of stroke in the young.

We hereby describe a 42-year-old lady who developed vertebral artery dissection following a head injury. The clinical features and management of the condition are discussed.