BACKGROUND:Paraneoplastic syndromes occurring with germ-cell-tumors (GCTs) are rare but can be life-threatening. Anti-N-methyl-D-aspartate receptor (anti-NMDAR) encephalitis is the commonest GCT-associated paraneoplastic syndrome. We reviewed anti-NMDAR encephalitis associated with ovarian teratomas, aiming to identify key themes regarding presentation and outcomes of treatment. METHODS:A hybrid, thematic-based PRISMA-compliant review was undertaken. Firstly, a systematic review (English; 1998-2023) describing patients <45 y with ovarian teratomas associated with anti-NMDAR encephalitis identified 89 publications, describing 99 patients in sufficient detail. A thematic-based analysis was then undertaken; recovery from encephalitis was defined as: full: patient returning to pre-morbid baseline; partial: ongoing sequalae from disease; none: deterioration, relapse, and/or death. RESULTS:Ninety-six of 99 patients (97.0%) had surgery, of which 90 had recovery data. Of these, 12 (13.3%) had surgery alone and 78 (86.7%) adjuvant treatment [chemotherapy (n = 21), intravenous immunoglobulin (IVIG) ± methylprednisolone (n = 74), both (n = 17)]. Overall, 56/90 (62.2%) had full, 31/90 (34.4%) partial, and 3/90 (3.3%) no recovery. No differences were observed for full (range 53.0-62.2%) or partial (33.3-47.0%) recovery, with no predictors of full recovery by patient age, rapidity of presentation and/or diagnosis, imaging modality, nor use of adjuvant treatment. There was no difference in outcomes for those patients with oophorectomies compared with ovarian-sparing surgery. CONCLUSION:The addition of adjuvant chemotherapy or immunomodulatory treatments to surgery did not improve outcomes. Where possible, ovarian-sparing surgery should be offered. We recommend judicious use of additional treatments beyond surgery, where evidence remains sparse. A proposed diagnostic algorithm will facilitate prompt identification/treatment of anti-NMDAR encephalitis associated with ovarian teratoma.

Chimeric antigen receptor T cells (CAR-T cells) have revolutionised cancer treatment by offering personalised therapy of unprecedented efficacy to patients with relapsed B-cell malignancies and myeloma. CAR-T cells are designed selectively to target CD19 or other B-cell antigens with high affinity, leading to a potent immune response and effective killing of malignant B cells. More recently, CAR-T treatment has been shown to be safe and effective in a very limited number of patients with severe, refractory autoimmune conditions such as systemic lupus erythematosus, systemic sclerosis and myositis. This paper describes the early use and feasibility of CAR-T therapies in the treatment of refractory autoimmune neurological diseases.

AIM:Seizures are a common complication of brain metastases (BMs) and, in the UK, their diagnosis results in a driving ban enforced for 1-2 years with significant lifestyle implications. This driving ban is based on an estimated seizure risk ≥20%. However, the studies to support this figure are retrospective, heterogenous, and outdated. We present the interim analysis of the SAFER study, which reports for the first time the seizure rate in patients with BMs after stereotactic radiosurgery (SRS) from a prospective study. MATERIALS AND METHODS:The first 75 patients to be recruited to the SAFER study were included in this pre-planned interim analysis. The primary endpoint was the demonstration of a post-SRS seizure rate <20%, using an exact two-sided binomial test with an alpha of 0.05. RESULTS:Post-SRS seizure incidence was 10.7% (95% CI 4.7-19.9%). The cumulative incidence function, accounting for the competing risk of death, was also 10.7% (95% CI 5.0-18.8%). The new-onset seizure rate was 9.2% (95% CI 3.5-19.0%). Of those seizure-free at 6 months, the risk of experiencing a seizure by 12 months was 5.8% (3/52), and in those who were seizure-free by 9 months, no new seizures were observed by 12 months. CONCLUSION:This study is the first to prospectively evaluate seizures as a primary endpoint in patients undergoing SRS for BMs. Our results indicate a seizure rate that is considerably below 20% and reduces over time. These findings may change patient and clinician perceptions of post-SRS BM seizure risk and could have implications for UK driving regulations.

Background and purpose: Gliomas are characterised by a complex tumour microenvironment (TME) that contributes to treatment resistance and tumour heterogeneity. Therefore, the non-invasive interrogation of both the intracellular and extracellular compartments of gliomas remains a key unmet need. We investigated the feasibility and complementarity of combining diffusion-weighted MRI (DW-MRI) with biophysical modelling Vascular, Extracellular, and Restricted Diffusion for Cytometry in Tumours (VERDICT) and diffusion-weighted MR spectroscopy (DW MRS) for simultaneous characterisation of glioma tumour cells and the glioma TME. Methods: 14 patients with newly diagnosed glioma (WHO grades 2 to 4: 4 IDH wildtype and 10 IDH mutant) underwent DW-MRI at 3 T; DW-MRS was additionally acquired in 10 patients. Tumours were automatically segmented into enhancing, non-enhancing, and oedema regions using a validated pipeline. VERDICT models were fitted to multi-shell DW-MRI data to estimate intracellular volume fraction (fIC), cell radius, extracellular diffusivities, and free-water fraction (fFW). Single voxel DW-MRS provided metabolite-specific apparent diffusion coefficients (ADCs) for total N-acetylaspartate (tNAA), Creatine (tCr), and choline (tCho). T-tests assessed DW-MRI and descriptive statistics assessed DW-MRS parameters in tumour regions compared to normal appearing white matter (NAWM) and IDH mutation status. Pearsons correlations assessed associations between DW-MRS metabolite ADCs and DW-MRI parameters. Results: VERDICT-MRI distinguished high grade IDH-wildtype from lower grade IDH-mutant gliomas, with significantly higher fIC and lower extracellular diffusivities; in enhancing and non-enhancing regions of IDH-wildtype lesions. DW-MRS demonstrated a trend towards reduction in tNAA ADC in tumour versus contralateral NAWM, consistent with neuronal loss, and a trend towards increased tCho ADC, suggesting glial activation. A descriptive trend towards decreased tNAA ADC in IDH-wildtype tumours was observed. Significant positive correlations were identified between tumoral tCho ADC and VERDICT parameters fEES, extracellular diffusivity; and negative correlations for ADC and fFW, in non-enhancing tumour regions. Conclusion: This proof-of-concept study demonstrates the feasibility of combining multi b- value DW-MRI and DW-MRS within a clinically feasible protocol to simultaneously probe the extracellular and intracellular compartments of the glioma TME. VERDICT captured cell-level and extracellular matrix differences in IDH mutation status, while DW-MRS provided metabolite-specific indices of neuronal and glial compartment integrity. The correlation between tCho ADC and VERDICT metrics in infiltrative tumour regions supports the complementarity of these modalities. With this combined approach, it is possible to simultaneously characterise the tumour compartment and the tumour microenvironment in gliomas.

BACKGROUND AND PURPOSE:The number of people living with brain metastases (BMs) has increased in the last decade. Despite the large number of patients treated with stereotactic radiosurgery (SRS), there are very few prospective studies of the dose-response relationship to guide practice. We present preliminary dose-response data from a prospective observational study of post-SRS outcomes in patients with BMs (SAFER, IRAS 276567). MATERIAL AND METHODS:The first 91 patients who did not have prior radiotherapy or neuro-surgery, to reach 9-months post-SRS follow up in the SAFER study were included. Local control (LC) probability was calculated using Kaplan Meier methodology. Prescription doses were converted to Biologically Effective Doses (BED) using the linear quadratic cubic (LQC) equation, and an alpha-beta ratio of 10. Logistic regression was used for dose-response modelling on a per-lesion basis. RESULTS:The overall 9-month LC rate was 92.01 %. The dose-response curve demonstrated a significant relationship between LQC model BED10 and LC (odds ratio 1.145, slope 2.479, p = 0.0132). Based on the regression model, 71.50 % of those receiving LQC model BED10 35 Gy were predicted to have LC at 9 months. This increased to 97.4 % in those receiving LQC model BED10 55 Gy. CONCLUSION:This is a large prospective dataset on the dose-response relationship of BMs treated with SRS. Our results indicate an LQC model BED10 45 Gy is required to achieve 9-month LC of > 90 %. This is equivalent to single fraction-SRS doses > 20 Gy, or 3-fraction SRS doses > 27 Gy.

H3 G34R-mutated gliomas, also known as diffuse hemispheric gliomas, are rare, highly aggressive tumours predominantly affecting children and young adults. In paediatric and adolescent populations, the median time to progression is approximately 10 months, with a median overall survival of 17 months. However, survival outcomes in adult patients remain poorly characterised. This study aims to evaluate the clinical outcomes of adult patients with H3 G34R-mutant gliomas. We conducted a retrospective cohort study across 13 hospital sites, including patients with molecularly confirmed H3 G34R-mutant gliomas. Data were collected on demographics, tumour location, treatment, histopathology, and clinical outcomes, including overall survival (OS) and progression-free survival (PFS). A total of 28 patients were included, 1 of whom were lost to follow-up. Of the remaining 27, The median age at diagnosis was 27.5 years (range: 18–47 years). Most tumours (n=22) were located in the cerebral hemispheres, with the temporal lobe being the most frequently affected region (n=9), followed by the frontal (n=5), parietal (n=4), fronto-parietal (n=3), and fronto-temporal (n=1) lobes. However, not all tumours were confined to a single hemisphere—2 were intraventricular, and 3 exhibited extensive white matter infiltration. The median PFS was 16.2 months (range: 0.8–61.2 months), and the median OS was 18.1 months (range: 0.82–74.3 months). This study underscores key distinctions between adult and paediatric H3 G34R-mutant gliomas. Notably, not all tumours were confined to a single hemisphere; three cases exhibited diffuse infiltration resembling leukodys- trophy, suggesting a broader anatomical distribution. Over one-third of cases demonstrated overall survival exceeding 24 months, a significantly longer duration than typically expected. Variability in survival outcomes may reflect a rapidly progressive disease course following recurrence, however, this could also be influenced by cohort heterogeneity, follow-up completeness, and potential censorship effects.

The glioma tumor microenvironment (TME) plays a major role in tumourigenesis of gliomas, encompassing a complex network of cells and biomolecules that contribute to radio-resistance and poor outcomes. Diffusion-weighted (DW) MRI probes tissue microstructure non-invasively with high sensitivity but lacks cel- lular specificity. However, metabolite diffusion-weighted MR spectroscopy (DW-MRS) sensitises MR spectra to diffusion of intracellular metabolites, providing information about specific cellular morphology. Here we com- bine DW-MRI and DW-MRS to non-invasively characterise cell-specific TME changes in patients diagnosed with a spectrum of gliomas. 10 patients (5 male, mean age 47.7 years, range 22-76 years with newly diagnosed glioma were recruited and imaged on 3T Philips Ingenia CX system following informed consent. DW-MRS analysis: Data were combined per DW condition and averaged over gradient direction for b-value. The LCModel estimates for total NAA (tNAA), total creatine (tCr) and total choline (tCho) were used to calculate the ADC for these metabolites. DW-MRI analysis: NODDI model was fitted to the last two shells (b=711 and b=2500s/mm2) to estimate neurite orientation disperson index, odiNODDI and intra-neurite volume fraction ficvfNODDI. VERDICT model was fitted to b values using in-house Matlab code to obtain: intracellular signal fraction ficvfVERDICT, cell radius RVERDICT, ex- tracellular and extravascular signal fraction feesVERDICT, radial and axial extracellular diffusivities diVERDICT and dhVERDICT. Tumour tNAA’s ADC decreased compared to contralateral NAWM suggesting neuronal loss with a trend of de- creasing tNAA’s ADC with increased WHO grade. We also observed increased feesVERDICT, dhVERDICT and decreased ficvfNODDI with WHO grade suggesting TME-specific cellular loss. Tumour tCho’s ADC was slightly increased com- pared to NAWM suggesting glial activation/reaction but was stable across WHO grade. Combined DW-MRI and DW-MRS measurements potentially offer novel characterization of the glioma TME, essential for understanding mechanisms of radio-resistance and for developing more effective therapies.

Motivation: Early detection of low-grade glioma (LGG) malignant transformation (MT) is vital for treatment decisions, prognosis, quality of life and patient-centered care. Goal(s): To develop non-linear machine learning models using XGBoost algorithm to predict overall survival using clinical, molecular, genetic and radiomic data at MT. Approach: 553 LGGs with histology and MRI underwent in-house tumour segmentation pipeline with radiomic feature extraction and masked disconnectome of map components. Results: XGB Classifier model predicted OS > 5 years from MT with an accuracy of 64%. Age, IDH1 mutation, 1p/19q co-deletion, regularity of tumour shape, and disconnectome-related perilesional components were most predictive of survival. Impact: Understanding malignant transformation of low-grade gliomas is crucial for research and the development of new treatment strategies. Defining the radiological features at malignant transformation allows for a timely shift in the treatment plan with potential to improve repsonse to therapy.

Abstract BACKGROUND We previously reported on progression-free survival of our randomized phase 3 trial [Lancet Oncol. 2016;17:1521-1532]. Here we report results of long-term follow-up (FU) including overall survival (OS) and molecular subgroup analyses. METHODS 487 patients were randomized between 2005-2012 to either standard radiotherapy (RT, 50.4 Gy/ 28 fractions) or primary dose-dense temozolomide [TMZ] chemotherapy (75 mg/m² daily x 21/28 days, up to 12 cycles). Treatment at progression was at investigators discretion and commonly included cross-over to the alternative treatment modality. RESULTS At a median follow-up of 13 years, 68% of patients had died. Median age at inclusion was 45 years (range 18-75), 96% had a performance status of 0-1. There was no significant difference in PFS nor OS: PFS was 3.6 years (95% CI: 3.0-4.1) and 3.1 years (95% CI: 2.7-3.6), HR 1.12 (95% CI: 0.92-1.36); OS 6.6 years (95% CI: 5.8-7.5) and 8.0 years (95% CI: 6.9-9.1), HR 0.87 (95% CI: 0.69-1.09), for RT or TMZ, respectively. Subgroup analyses were performed for patients when available tissue allowed for molecular analyses (n=351/487,73%). In astrocytoma, IDHmt/1p/19q non-codeleted (n = 178), median OS with RT was 6.6 years (95% CI: 5.3-7.6) and with TMZ was 6.7 years (95% CI: 5.7-8.0); HR 0.98 (95% CI: 0.67-1.44). For oligodendroglioma, IDHmt/codeleted (n = 109) median OS with RT was 12.9 years (95% CI: 9.4 - NE) and with TMZ 14.9 years (95% CI: 10.1 - NE); HR 1.01 (95% CI: 0.56-1.81). For a heterogenous group of IDHwt tumors (n = 64), median OS with RT was 2.5 years (95% CI: 1.8-3.3) and with TMZ 4.7 years (95% CI: 2.2-7.2); HR 0.37 (95% CI: 0.18-0.77). CONCLUSIONS Primary treatment with RT or TMZ provided comparable PFS and OS. Choice of primary treatment can be tailored to individual tumor characteristics and patient preference.

•SMART (stroke-like migraine attacks after radiation therapy) syndrome is a rare, delayed complication of brain radiotherapy of unknown cause. It is characterised by a rapid onset of complex focal neurological impairment unrelated to tumour recurrence or ischaemic infarcts. Recovery may be incomplete. The interval between radiotherapy and the onset of SMART syndrome can range from 1 to 35 years.•The hallmark features on MRI are reversible abnormal signal on T2/FLAIR (fluid attenuated inversion recovery) sequences, associated with diffuse cortical/leptomeningeal enhancement, which persist for weeks to months.•Perfusion imaging usually shows increased cerebral blood volume (rCBV). There are no established disease-modifying treatments.•Parallels have been drawn with MELAS (mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes) syndrome, given the similar clinical and imaging features and postulated pathophysiology, which includes endothelial dysfunction, providing a rationale for treatment with L-arginine (a precursor for nitric oxide synthesis).•Here, we report a case treated with intravenous L-arginine (0.5 g/kg) with good response, reflected clinically by a measurable improvement in cognition, brain perfusion and EEG parameters, encouraging further clinical studies.

Abstract AIMS Histone G-34-mutant (H3 G34) gliomas are rare, aggressive infiltrating tumours of the cerebral hemispheres and are classified as WHO grade 4 paediatric type diffuse high-grade glioma. They most commonly affect children and adolescents. We describe the clinicopathological characteristics of adult H3 G34-mutant gliomas seen at the National Hospital for Neurology and Neurosurgery over the last 10 years. METHOD We retrospectively analyzed clinic radiological data on all cases identified from the neuropathology database. Data were extracted on patient demographics, clinical and radiological features and outcome. RESULTS Six patients (2 male, 4 female) were identified, The median age of onset was 26 years (range 17-38 years). One patient presented with a Motor Neurone Disease type syndrome (progressive asymmetric spastic tetraparesis and bulbar symptoms), two with cognitive decline and three with symptoms of raised intracranial pressure. All tumours were supratentorial - 2 patients had mass lesions typical of a high-grade glioma, 1 patient had imaging features consistent with an intraventricular ependymoma. 3 patients had imaging findings that suggested a non-tumour diagnosis with extensive white matter disease more in keeping with an inflammatory demyelinating process or a leucodystrophy. The median overall survival was 23 Months (range 10 - 68 months). CONCLUSIONS Adult Histone G34-mutant gliomas have a variable presentation and are associated with a prognosis similar to other high-grade gliomas. The diagnosis should be considered in the differential of patients presenting with a predominantly white matter disorder. Multi-centre studies are needed to better delineate the phenotype and prognostic features.

Brain Tumour Related Epilepsy (BTRE) has a significant impact on Quality of Life with implications for driving, employment, and social activities. Management of BTRE is complex due to the higher incidence of drug resistance and the potential for interaction between anti-cancer therapy and anti-seizure medications (ASMs). Neurologists, neurosurgeons, oncologists, palliative care physicians and clinical nurse specialists treating these patients would benefit from up-to-date clinical guidelines. We aim to review the current literature and to outline specific recommendations for the optimal treatment of BTRE, encompassing both Primary Brain Tumours (PBT) and Brain Metastases (BM). A comprehensive search of the literature since 2000 on BTRE was carried out in PubMed, MEDLINE and EMCARE. A broad search strategy was used, and the evidence evaluated and graded based on the Oxford Centre for Evidence-Based Medicine Levels of Evidence. Seizure frequency varies between 10 and 40% in patients with Brain Metastases (BM) and from 30% (high-grade gliomas) to 90% (low-grade gliomas) in patients with PBT. In patients with BM, risk factors include number of BM and melanoma histology. In patients with PBT, BTRE is more common in patients with lower grade histology, frontal and temporal tumours, presence of an IDH mutation and cortical infiltration. All patients with BTRE should be treated with ASMs. Non-enzyme inducing ASMs are recommended as first line treatment for BTRE, but up to 50% of patients with BTRE due to PBT remain resistant. There is no proven benefit for the use of prophylactic ASMs, although there are no randomised trials testing newer agents. Surgical and oncological treatments i.e. radiotherapy and chemotherapy improve BTRE. Vagus Nerve Stimulation has been used with partial success. The review highlights the relative dearth of high-quality evidence for the management of BTRE and provides a framework for further studies aiming to improve seizure control, quality of life, and indications for ASMs.

Low grade gliomas (LGG) represent 14.6% of gliomas and may remain stable years after initial diagnosis. MRI features suggesting malignant transformation (MT) include enlargement of non-enhancing areas and increasing enhancement but have low specificity. We report the first stages of a deep learning model to predict survival using radiomic feature extraction at MT, clinical and molecular genetics. Retrospective analysis of all LGGs treated at our institution (2005 - 2020) with histology, molecular genetics and MRIs. 766 patients: 457 IDH mutant astrocytomas, 251 IDH mutant 1p19q co-deleted oligodendrogliomas and 58 other gliomas; 398 male, 368 female; mean age 51 years; range 16-89. MRIs underwent in-house tumour segmentation pipeline with radiomic feature extraction of whole tumour (wt), enhancing (enh), non-enhancing (ne) component and oedema components. At MT, mean wt volume was 36404mm3 (SD 37213mm3) with mean 2D-diameter of 75.90mm (SD 27.23mm). Mean tissue compartmental volumes: enh 9539mm3 (SD 17578mm3), ne 26865mm3 (SD 33796mm3), and oedema 61067mm3 (SD 61535 mm3). 92 lesions contained no post-contrast enhancing tissue. Lesions were more commonly frontal or temporally based, with relative sparing of parietal and occipital lobes. No predilection for left or right hemisphere. Majority of LGGs demonstrate contrast enhancing lesions at MT in a frontal or temporal spatial distribution with no hemispheric predilection. We plan to extract the MRI features at MT to build a survival model with clinical, treatment and molecular genetic data. Defining the radiological features at MT would enable prognostication and support clinical decision-making in this patient group.

Introduction: Gliomatosis cerebri describes a rare growth pattern of diffusely infiltrating glioma. The treatment options are limited and clinical outcomes remain poor. To characterise this population of patients, we examined referrals to a specialist brain tumour centre. Methods: We analysed demographic data, presenting symptoms, imaging, histology and genetics, and survival in individuals referred to a multidisciplinary team meeting over a 10-year period. Results: In total, 29 patients fulfilled the inclusion criteria with a median age of 64 years. The most common presenting symptoms were neuropsychiatric (31%), seizure (24%) or headache (21%). Of 20 patients with molecular data, 15 had IDH wild-type glioblastoma, with an IDH1 mutation most common in the remainder (5/20). The median length of survival from MDT referral to death was 48 weeks (IQR 23 to 70 weeks). Contrast enhancement patterns varied between and within tumours. In eight patients who had DSC perfusion studies, five (63%) had a measurable region of increased tumour perfusion with rCBV values ranging from 2.8 to 5.7. A minority of patients underwent MR spectroscopy with 2/3 (66.6%) false-negative results. Conclusions: Gliomatosis imaging, histological and genetic findings are heterogeneous. Advanced imaging, including MR perfusion, could identify biopsy targets. Negative MR spectroscopy does not exclude the diagnosis of glioma.

BACKGROUND:Several commercial and academic autologous chimeric antigen receptor T-cell (CAR-T) products targeting CD19 have been approved in Europe for relapsed/refractory B-cell acute lymphoblastic leukemia, high-grade B-cell lymphoma and mantle cell lymphoma. Products for other diseases such as multiple myeloma and follicular lymphoma are likely to be approved by the European Medicines Agency in the near future.DESIGN:The European Society for Blood and Marrow Transplantation (EBMT)-Joint Accreditation Committee of ISCT and EBMT (JACIE) and the European Haematology Association collaborated to draft best practice recommendations based on the current literature to support health care professionals in delivering consistent, high-quality care in this rapidly moving field.RESULTS:Thirty-six CAR-T experts (medical, nursing, pharmacy/laboratory) assembled to draft recommendations to cover all aspects of CAR-T patient care and supply chain management, from patient selection to long-term follow-up, post-authorisation safety surveillance and regulatory issues.CONCLUSIONS:We provide practical, clinically relevant recommendations on the use of these high-cost, logistically complex therapies for haematologists/oncologists, nurses and other stakeholders including pharmacists and health sector administrators involved in the delivery of CAR-T in the clinic.

Checkpoint inhibitor immunotherapy has revolutionised cancer treatment. However, immunotoxicity due to dysregulated immune control can affect a range of non-cancer tissues causing dermatitis, colitis and endocrinopathies in up to 80% of exposed patients. Peripheral nerve neurotoxicity is rare (<5%) and described as GBS-like or CIDP-like in published case series. Here we present two cases of checkpoint inhibitor associated peripheral neuropathy suggesting this neuritis is a novel pathological entity. Case 1 55-year-old man treated with nivolumab and ipilimumab for renal cell carcinoma developed painful sensory predominant neuropathy after cycle 1. Gait impairment led to discontinuation by cycle 3. NCS revealed axonal loss and conduction slowing but no demyelinating features. He was treated with IVIg without response. Case 2 55-year-old woman with metastatic melanoma was treated with pembrolizumab for 16 months without complication. Within weeks of change to nivolumab she developed painful neuropathic symptoms causing difficulty walking. Neurophysiology was similar to case 1 but she improved to normal with high dose corticosteroids over 4 months. Both sural nerve biopsies showed active large fibre degeneration with diffuse, predominantly T cell inflam- matory infiltrate. No malignant cells. No evidence of a primary demyelinating pathology. This novel inflammatory neuropathy warrants recognition due to alternative treatment response.

Abstract AIMS Patients with gliomas often present with generalised seizures, but subsequently develop focal seizures on treatment. The occurrence of a single generalised seizure at onset precludes the return of a driving licence, even if a patient continues to have only focal aware seizures. We investigated seizure semiology over time, to determine how many patients with ongoing seizures may be safe to drive. METHOD We analysed clinical data of patients with histologically-confirmed IDH-mutant diffuse gliomas, diagnosed between 2004-2015. Seizures were classified as: 1 – focal / 2 - generalised; A – aware / B – unaware; M – motor / N – non-motor. Seizure type at diagnosis and last follow-up was recorded. RESULTS 189 patients were identified, of whom 140 presented with seizures (74%). 115 of these patients had a full data set. 59 (51%) presented with generalised seizures. 10% had only a single seizure at presentation, 55 % had further seizures then became seizure-free and 35% continued to have seizures at last follow-up. Of the 40 patients who continued to have seizures, 7 (17.5%) had 1AN, 16 (40%) had 1AM, 1 (2.5%) had 1BN and 5 (12.5%) had 1BM. 11 (27.5%) had generalised seizures. Of the 7 patients with 1AN seizures at last follow-up, 4 initially presented with a generalised seizure, 1 with 1AN, 1 with 1AM and 1 with 1BM. CONCLUSION Almost two thirds of patients became seizure-free and, of those that continued to have seizures, 57.5% developed only focal aware seizures. Current driving regulations may be unduly restrictive for patients with gliomas.

Radiation therapy is widely used for benign and malignant brain tumours as it is effective and well tolerated. However, damage to the surrounding healthy nervous system tissue leads to a variety of complications both in the short term and long term, ranging from mild and self-limiting to irreversible and fatal. Radiation neurotoxicity is due to a combination of early inflammation and oligodendroglial damage followed later by brain tissue necrosis, white matter damage, accelerated vascular disease and the development of secondary tumours. This article explains the basic principles of radiation physics, the different modalities used in clinical practice, how radiotherapy is planned and delivered and the scientific basis of radiation damage. The main body of the article focuses on the clinical features of radiation toxicity in the brain, spinal cord, cranial and peripheral nerves with an emphasis on the distinction between early and delayed complications.

Driving is an integral part of adult life and losing a driving licence is potentially a major problem. Many neurological conditions may impact on driving, either by increasing the risk of a sudden disabling event or by affecting cognition, vision, reaction speed, motor coordination, peripheral sensation or visuospatial processing. In the UK, the Drivers Medical Group of the Driver and Vehicle Licensing Agency (DVLA) decides whether an individual's medical condition meets the appropriate standards for driving. The licensing decision rests with the DVLA and is not at the clinician's discretion. However, clinicians must inform patients of their legal obligations towards the DVLA and how their neurological symptoms may restrict their driving. We discuss risk assessment, how chronic disabling neurological disease may impact on driving and the general principles of applying medical standards for fitness to drive. We also highlight how legal driving eligibility varies around the world. Finally, we discuss the practical applications relating to a specific case.