ORCID Profile
0000-0001-9142-2708
Current Organisation
Royal Brisbane and Women's Hospital
Does something not look right? The information on this page has been harvested from data sources that may not be up to date. We continue to work with information providers to improve coverage and quality. To report an issue, use the Feedback Form.
Publisher: Wiley
Date: 07-2013
DOI: 10.1111/IMJ.12168
Abstract: Seizures are a commonly encountered medical problem. Seizure protocols have been shown to be effective by avoiding inappropriate over- and undertreatment, but are not presently utilised in many centres in Australia. We outline a stepwise approach to effective seizure management based on timely investigation and escalating treatment with an appropriate choice of medications. Because large-scale clinical trials are lacking, we base our approach on the underlying seizure pathophysiology and the pharmacological properties of the available drugs. Early management consists of finding and correcting possible reversible causes and ensuring patient safety. With ongoing seizure length, spontaneous resolution becomes unlikely, necessitating administration of anti-epileptic drugs. Benzodiazepines are the agents of first choice, with a preference of short-acting drugs. With ongoing seizures, other agents (i.e. valproate, levetiracetam, phenobarbitone, phenytoin) are utilised. Refractory status epilepticus requires aggressive treatment in an intensive care setting. Novel approaches and agents, including ketamine, topiramate, lacosamide, pregabalin and intravenous immunoglobulins, are discussed. We provide our own recently developed hospital protocol as a guide. This protocol relies on a time-based four-step escalating approach to seizure management, ranging from supportive management of the initial simple seizure to the use of multiple agents for established status epilepticus.
Publisher: Springer Science and Business Media LLC
Date: 24-04-2014
DOI: 10.1007/S00415-014-7329-4
Abstract: The idiomuscular response to direct percussion is rarely tested nowadays because of its uncertain mechanism and significance. While performing neurological examination, we observed a brisk ankle dorsiflexion response on direct muscle percussion of m. tibialis anterior in patients with acute inflammatory demyelinating polyradiculoneuropathy (AIDP). In contrast, in patients with upper motor neuron lesions, an ankle inversion response was seen. In this article we describe our findings in patients with bilateral lower limb weakness. We assessed 73 consecutive patients with bilateral lower limb weakness. A strong dorsiflexion response to percussion of m. tibialis anterior was seen in 11 out of 14 patients with AIDP (sensitivity 78.6%). None of the other patients showed a strong dorsiflexion response (specificity 100%). An inversion response was seen in 11 out of 13 patients with UMN involvement (sensitivity 92.3%). It was also noted in two of 46 patients without proven UMN involvement (specificity 96.7%). The idiomuscular response to percussion of m. tibialis anterior can be useful in the assessment of patients with lower limb weakness of unclear cause.
Publisher: Wiley
Date: 07-2018
DOI: 10.1111/IMJ.13765
Abstract: The present study aims to determine qualitative outcomes of presentations with acute recurrent seizures or status epilepticus to the emergency department of our institution after the introduction of a new seizure management protocol. We performed a retrospective analysis on two cohorts of patients for all presentations to the emergency department of our institution. Presentations were reviewed from January to July pre-protocol introduction and the same period post-protocol. Patients were included if they were treated for acute recurrent seizures or status epilepticus. The protocol applied a strict treatment regimen and used levetiracetam, valproate and phenobarbitone in place of phenytoin. A total of 77 patients was included from the pre-protocol cohort and 72 from the post-protocol group. There was a significant reduction in intensive care unit (ICU) admission (seven patients in cohort 1 and 0 patients in cohort 2) and adverse drug reactions (18 patients in cohort 1 and four patients in cohort 2). There was a trend towards fewer deaths. The introduction of the new seizure management protocol assessed in this study has resulted in fewer ICU admissions, adverse drug reactions and most importantly fewer patient deaths. This is likely attributable to a combination of improved efficacy of the newer antiepileptic agents and a clearly defined protocol directed therapy.
Publisher: BMJ Publishing Group Ltd
Date: 08-2021
Publisher: Elsevier BV
Date: 07-2016
DOI: 10.1016/J.JOCN.2015.10.042
Abstract: Optic neuritis (ON) is a common and important cause of vision loss or vision disturbances in the community, particularly amongst the young, and it is often associated with a persistent dyschromatopsia. Traditionally screening for dyschromatopsia has been carried out using pseudo-isochromatic Ishihara plates. These colour plates were originally developed for testing of colour blindness, and indeed have only more recently been applied to ON. As the Ishihara plate books used for testing are expensive, unwieldy, and are not commonly available in many clinics or wards, many neurologists and ophthalmologists have taken to using untested and unstudied downloadable software packages on portable electronic devices for testing. This study compared the efficacy of printed and iPad (Apple, Cupertino, CA, USA) versions of the Ishihara plates in screening for dyschromatopsia in patients who were suspected of having ON. The main finding was that dyschromatopsia testing using a commercially available application on an iPad was comparable to using the current pragmatic clinical benchmark, the pseudo-isochromatic plates of Ishihara. These findings provide support for the increasingly common practice of screening for dyschromatopsia using the iPad.
Publisher: BMJ
Date: 24-05-2018
DOI: 10.1136/JNNP-2018-ANZAN.58
Abstract: Glycine antibodies are associated with progressive encephalomyelitis with rigidity and myoclonus (PERM) but have been rarely reported to cause myasthenic-like symptoms. 1 We present a single patient seen at a tertiary neurology centre with fatigable muscle weakness and corticospinal tract dysfunction with positive glycine, VGKC and NMDA receptor antibodies, associated with an ovarian teratoma expressing neural tissue. A 32 year old female presented with fatigable muscle weakness. Physical examination was atypical for a disease of the neuromuscular junction with features of exaggerated reflexes and clonus. The weakness progressed over 1–2 weeks leading to respiratory failure. Investigations including MRI brain, repetitive stimulation and acetylcholine-receptor antibody studies were all within the normal limits. Studies for neuronal antibodies against intracellular targets were negative. Further investigation revealed positive autoantibodies against Glycine receptor, NMDA (N-Methyl-d-aspartate) receptor and VGKC (voltage-gated potassium channel) with an underlying ovarian teratoma. Complete clinical resolution was achieved with teratoma resection and 2 g/kg course of intravenous immunoglobulin. Histopathological examination of the tumour revealed a mature cystic teratoma with dystrophic calcification. The teratoma included skin, adipose tissue, intestinal type mucosa, and neuroglial tissue in which nerve fibres and ganglion cells are present. A lymphoid infiltrate was concentrated in areas of neural tissue within the teratoma. Muscle weakness, corticospinal tract dysfunction and respiratory failure have previously been reported in the context of anti-glycine antibodies. This is the first case where anti-glycine, anti-NMDA and anti-VGKC antibodies have been found in the context of an ovarian teratoma. The autoimmune nature of this condition is emphasised by the lymphoid infiltrate around the neural tissue expressed within the teratoma. 1. Carvajal-Gonzalez A, Leite MI, Waters P, Woodhall M, Coutinho E, Balint B, … Vincent A. Glycine receptor antibodies in PERM and related syndromes: characteristics, clinical features and outcomes. Brain2014 (Pt 8):2178–2192.
Publisher: Frontiers Media SA
Date: 29-10-2021
DOI: 10.3389/FNEUR.2021.765412
Abstract: Introduction: Electromagnetic imaging is an emerging technology which promises to provide a mobile, and rapid neuroimaging modality for pre-hospital and bedside evaluation of stroke patients based on the dielectric properties of the tissue. It is now possible due to technological advancements in materials, antennae design and manufacture, rapid portable computing power and network analyses and development of processing algorithms for image reconstruction. The purpose of this report is to introduce images from a novel, portable electromagnetic scanner being trialed for bedside and mobile imaging of ischaemic and haemorrhagic stroke. Methods: A prospective convenience study enrolled patients (January 2020 to August 2020) with known stroke to have brain electromagnetic imaging, in addition to usual imaging and medical care. The images are obtained by processing signals from encircling transceiver antennae which emit and detect low energy signals in the microwave frequency spectrum between 0.5 and 2.0 GHz. The purpose of the study was to refine the imaging algorithms. Results: Ex les are presented of haemorrhagic and ischaemic stroke and comparison is made with CT, perfusion and MRI T2 FAIR sequence images. Conclusion: Due to speed of imaging, size and mobility of the device and negligible environmental risks, development of electromagnetic scanning scanner provides a promising additional modality for mobile and bedside neuroimaging.
Publisher: BMJ
Date: 24-05-2018
DOI: 10.1136/JNNP-2018-ANZAN.57
Abstract: This case from a tertiary neurology centre reports a novel association between the emerging clinical entity of anti-contactin associated protein-2 (CASPR-2) antibody encephalitis and chronic lymphocytic leukaemia (CLL). We describe a 63 year old Maori male truck-driver who presented with progressive altered personality, speech, cognition and perception over 9 months. The patient also developed choreiform movements, broad-based gait, incontinence, sleep apnoea with type 2 respiratory failure and episodic loss of consciousness. 12 months prior, he had been diagnosed with low-risk CLL, for which he remained untreated. MRI of the brain revealed mid-sagittal bilateral mid-temporal T2/FLAIR hyperintensities. Cerebrospinal fluid examination showed a mononuclear pleocytosis (WCC 270×10^6/L) with 15% of these CD5/CD19/CD23 positive and 92% CD3/CD5 positive CD 19 negative on flow cytometry, protein was also elevated at 2600 mg/L. The interplay between CLL and inflammation is uncertain. Anti-Caspr2-antibody was identified in CSF and serum. The patient was treated with a combination of fludarabine, cyclophosphamide, rituximab, dexamethasone and intravenous immunoglobulin (IVIG). Clinical status improved and antibody titre decreased from 580 to 241 pM in three weeks and to 55pM (negative pM) at five months. Symptoms worsened when IVIG doses were missed. He returned home after inpatient rehabilitation, showed striking clinical improvement at 12 month follow-up and continues on maintenance IVIG therapy. Whilst paraneoplastic VGKC encephalitis has been described associated with a number of malignancies, this is the first reported case of CASPR-2 antibody present in association with CLL. . Van Sonderen A, Petit-Pedrol M, Dalmau J, Titulaer MJ. The value of LGI1, Caspr2 and voltage-gated potassium channel antibodies in encephalitis. Nature Reviews Neurology2017 (5):290–301. . Nogai H, Israel-Willner H, Zschenderlein R, Pezzutto A. Improvement in Paraneoplastic Limbic Encephalitis after Systemic Treatment with Rituximab in a Patient with B-Cell Chronic Lymphocytic Leukaemia. Case Reports in Haematology2013 :Article ID958704. . Van Sonderen A, Ariño H, Petit-Pedrol M, et al. The Clinical Spectrum of Caspr2 antibody-associated disease. Neurology2016 :521–528. . Gultekin SH, Rosenfeld MR, Voltz R, Eichen J, et al. Paraneoplastic limbic encephalitis: Neurological symptoms, immunological findings and tumour association in 50 patients. Brain2000 :1481–1494.
Publisher: BMJ
Date: 05-2017
Publisher: BMJ
Date: 05-2017
Publisher: BMJ
Date: 05-2017
Publisher: Elsevier BV
Date: 06-2013
Publisher: BMJ
Date: 24-05-2018
DOI: 10.1136/JNNP-2018-ANZAN.83
Abstract: We aimed to report a single patient seen at a tertiary neurology centre with a rarely described phenomenon of interaction between myasthenia gravis and a glucocorticoid secreting tumour. A 70 year old, otherwise healthy male underwent a CT imaging of his chest after being tr led by a cow. Apart from several rib fractures, this revealed a slightly lobulated but well-defined right adrenal mass. Further studies revealed elevated morning cortisol levels of 847 nmol/L (reference range 140–640 nmol/L). The mass was excised and was found to be a 60 mm by 30 mm by 25 mm lesion, which was well circumscribed. It comprised of clear cells with foamy cytoplasm and a lesser component of eosinophilic cells, consistent with a functional adrenal adenoma producing glucocorticoid. Within days of the resection the patient described becoming weaker with fatigable proximal weakness of both upper and lower limbs. Acetylcholine receptor antibodies were positive and a diagnosis of myasthenia gravis was made. Upon commencement of pyridostigmine at 60 mg TDS and prednisolone 10 mg OD the symptoms improved and the patient was able to resume his previous active lifestyle. The phenomenon of myasthenia gravis being suppressed by a functional adrenal adenoma has only previously been reported twice. 1 2 This case report adds to the literature and can be distinguished from the other two cases by the rapidity of onset of symptoms of myasthenia over days after tumour resection. It tells a cautionary tale of medical therapy disrupting the brittle balance of nature. . Petramala L, Marinelli C, Giallonardo AT, Concistre A, Lucia P, Venuta F, … Letizia C. A case report of subclinical hypercortisolism due to adrenal incidentaloma complicated by myasthenia gravis after adrenalectomy. Tumori2016 (Suppl.2). . Topham L, Chapman A, Gibbs C, Saha M. A patient with pemphigus foliaceus and myasthenia gravis treated by a cortisol-secreting adrenal adenoma. Br J Dermatol2015 (1):280–282.
Publisher: Elsevier BV
Date: 03-2015
Publisher: SAGE Publications
Date: 03-08-2018
Abstract: This report will detail a case of immune-mediated encephalitis in the context of daclizumab therapy. Daclizumab is a humanised monoclonal antibody which, prior to its recent worldwide withdrawal due to safety concerns, was utilised as a disease-modifying therapy in relapsing-remitting multiple sclerosis. The withdrawal of this therapy was prompted by concerns over 12 cases of serious immune-mediated adverse reactions in the central nervous system. We report an additional case, including clinical data and results of neuroimaging, cerebrospinal fluid (CSF) examination and brain biopsy.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 2022
DOI: 10.1161/STROKEAHA.122.040480
Abstract: Endovascular thrombectomy (EVT) access in remote areas is limited. Preliminary data suggest that long distance transfers for EVT may be beneficial however, the magnitude and best imaging strategy at the referring center remains uncertain. We hypothesized that patients transferred miles would benefit from EVT, achieving rates of functional independence (modified Rankin Scale [mRS] score of 0–2) at 3 months similar to those patients treated at the comprehensive stroke center in the randomized EVT extended window trials and that the selection of patients with computed tomography perfusion (CTP) at the referring site would be associated with ordinal shift toward better outcomes on the mRS. This is a retrospective analysis of patients transferred from 31 referring hospitals miles (measured by the most direct road distance) to 9 comprehensive stroke centers in Australia and New Zealand for EVT consideration (April 2016 through May 2021). There were 131 patients the median age was 64 [53–74] years and the median baseline National Institutes of Health Stroke Scale score was 16 [12–22]. At baseline, 79 patients (60.3%) had noncontrast CT+CT angiography, 52 (39.7%) also had CTP. At the comprehensive stroke center, 114 (87%) patients underwent cerebral angiography, and 96 (73.3%) proceeded to EVT. At 3 months, 62 patients (48.4%) had an mRS score of 0 to 2 and 81 (63.3%) mRS score of 0 to 3. CTP selection at the referring site was not associated with better ordinal scores on the mRS at 3 months (mRS median of 2 [1–3] versus 3 [1–6] in the patients selected with noncontrast CT+CT angiography, P =0.1). Nevertheless, patients selected with CTP were less likely to have an mRS score of 5 to 6 (odds ratio 0.03 [0.01–0.19] P .01). In selected patients transferred miles, there was a benefit for EVT, with outcomes similar to those treated in the comprehensive stroke center in the EVT extended window trials. Remote hospital CTP selection was not associated with ordinal mRS improvement, but was associated with fewer very poor 3-month outcomes.
Publisher: American Medical Association (AMA)
Date: 07-04-2020
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 03-2023
DOI: 10.1161/STROKEAHA.122.041061
Abstract: Intracranial occlusion site, contrast permeability, and clot burden are thrombus characteristics that influence alteplase-associated reperfusion. In this study, we assessed the reperfusion efficacy of tenecteplase and alteplase in subgroups based on these characteristics in a pooled analysis of the EXTEND-IA TNK trial (Tenecteplase Versus Alteplase Before Endovascular Therapy for Ischemic Stroke). Patients with large vessel occlusion were randomized to treatment with tenecteplase (0.25 or 0.4 mg/kg) or alteplase before thrombectomy in hospitals across Australia and New Zealand (2015–2019). The primary outcome, early reperfusion, was defined as the absence of retrievable thrombus or % reperfusion on first-pass angiogram. We compared the effect of tenecteplase versus alteplase overall, and in subgroups, based on the following measured with computed tomography angiography: intracranial occlusion site, contrast permeability (measured via residual flow grades), and clot burden (measured via clot burden scores). We adjusted for covariates using mixed effects logistic regression models. Tenecteplase was associated with higher odds of early reperfusion (75/369 [20%] versus alteplase: 9/96 [9%], adjusted odds ratio [aOR], 2.18 [95% CI, 1.03–4.63]). The difference between thrombolytics was notable in occlusions with low clot burden (tenecteplase: 66/261 [25%] versus alteplase: 5/67 [7%], aOR, 3.93 [95% CI, 1.50–10.33]) when compared to high clot burden lesions (tenecteplase: 9/108 [8%] versus alteplase: 4/29 [14%], aOR, 0.58 [95% CI, 0.16–2.06] P interaction =0.01). We did not observe an association between contrast permeability and tenecteplase treatment effect (permeability present: aOR, 2.83 [95% CI, 1.00–8.05] versus absent: aOR, 1.98 [95% CI, 0.65–6.03] P interaction =0.62). Tenecteplase treatment effect was superior with distal M1 or M2 occlusions (53/176 [30%] versus alteplase: 4/42 [10%], aOR, 3.73 [95% CI, 1.25–11.11]), but both thrombolytics had limited efficacy with internal carotid artery occlusions (tenecteplase 1/73 [1%] versus alteplase 1/19 [5%], aOR, 0.22 [95% CI, 0.01–3.83] P interaction =0.16). Tenecteplase demonstrates superior early reperfusion versus alteplase in lesions with low clot burden. Reperfusion efficacy remains limited in internal carotid artery occlusions and lesions with high clot burden. Further innovation in thrombolytic therapies are required.
Publisher: American Chemical Society (ACS)
Date: 20-11-2013
DOI: 10.1021/EF401541B
Publisher: Elsevier BV
Date: 2015
Publisher: BMJ
Date: 02-2022
DOI: 10.1136/BMJOPEN-2021-055461
Abstract: Stroke reperfusion therapies, comprising intravenous thrombolysis (IVT) and/or endovascular thrombectomy (EVT), are best practice treatments for eligible acute ischemic stroke patients. In Australia, EVT is provided at few, mainly metropolitan, comprehensive stroke centres (CSC). There are significant challenges for Australia’s rural and remote populations in accessing EVT, but improved access can be facilitated by a ‘drip and ship’ approach. TACTICS (Trial of Advanced CT Imaging and Combined Education Support for Drip and Ship) aims to test whether a multicomponent, multidisciplinary implementation intervention can increase the proportion of stroke patients receiving EVT. This is a non-randomised controlled, stepped wedge trial involving six clusters across three Australian states. Each cluster comprises one CSC hub and a minimum of three primary stroke centre (PSC) spokes. Hospitals will work in a hub and spoke model of care with access to a multislice CT scanner and CT perfusion image processing software (MIStar, Apollo Medical Imaging). The intervention, underpinned by behavioural theory and technical assistance, will be allocated sequentially, and clusters will move from the preintervention (control) period to the postintervention period. Proportion of all stroke patients receiving EVT, accounting for clustering. Proportion of patients receiving IVT at PSCs, proportion of treated patients (IVT and/or EVT) with good (modified Rankin Scale (mRS) score 0–2) or poor (mRS score 5–6) functional outcomes and European Quality of Life Scale scores 3 months postintervention, proportion of EVT-treated patients with symptomatic haemorrhage, and proportion of reperfusion therapy-treated patients with good versus poor outcome who presented with large vessel occlusion at spokes. Ethical approval has been obtained from the Hunter New England Human Research Ethics Committee (18/09/19/4.13, HREC/18/HNE/241, 2019/ETH01238). Trial results will be disseminated widely through published manuscripts, conference presentations and at national and international platforms regardless of whether the trial was positive or neutral. ACTRN12619000750189 UTNU1111-1230-4161.
No related grants have been discovered for Helen Brown.