Abstract Background and aims Patients with CYP2C19 loss-of-function (LOF) Single Nucleotide Polymorphisms (SNPs) may be more likely to exhibit ‘Clopidogrel-High on-Treatment Platelet Reactivity’ (HTPR). Few studies concurrently assessed the influence of CYP2C19/other pharmacogenetic factors on Clopidogrel-HTPR status and outcomes in cerebrovascular disease (CVD) patients. Methods In the prospective Optimal Antiplatelet Therapy in TIA and Ischaemic Stroke-International pilot-observational study, 94 TIA-ischaemic stroke patients underwent centralised pharmacogenetics analysis to classify them as predicted CYP2C19 ‘Poor-Intermediate’, ‘Normal’ or ‘Rapid-Ultrarapid’ Clopidogrel Metabolisers. Analyses for candidate SNPs in RAD18, ASIC2 & CYP2C18, and a pilot Genome Wide Association Study (GWAS) were performed. Clopidogrel-treated patients were categorised into subgroups with/without HTPR at ‘high shear-stress’ (PFA-100® INNOVANCE PFA P2Y [Sysmex-Siemens]), & ‘low shear-stress’ (VerifyNow® PRUTest [Werfen], and PL-12/Aggrestar® ADP [Sinnowa]) assays. Results 29% (N=27) were predicted Poor-Intermediate, 37% (N=35) Normal & 34% (N=32) Rapid-Ultrarapid CYP2C19 Metabolisers. 7/21 (33%) Clopidogrel-treated Poor-Intermediate Metabolisers did not have Clopidogrel-HTPR on PFA-100 or VerifyNow assays; 3/21 (14%) did not exhibit Clopidogrel-HTPR on any of the 3 platforms. There was an association between rs10509646 SNP in the HHEX gene on chromosome 10 (pilot GWAS data) and on-treatment platelet reactivity, with shorter median PFA-100 closure times (P=0.0003), and higher mean P2Y12-Reactivity Units on VerifyNow (P=0.005) with homozygous ‘non-wild type’ vs. homozygous ‘wild type (normal)’ HHEX genotypes. Conclusions Almost 1/3 of our CVD population have CYP2C19 LOF SNPs, and up to 33% of these predicted Poor-Intermediate Metabolisers have adequate P2Y12-inhibition on Clopidogrel. Novel SNPs may influence Clopidogrel-HTPR status in CVD patients in Ireland. Conflict of interest No conflict of interest. Prof McCabe's research work is supported by grant funding from several charities and organisations, including the Meath Foundation; The Adelaide Health Foundation; an Enterprise Ireland Innovation Partnership Programme grant with Acquis BI Technology, Ltd.; the VNRF; and in-kind contributions from Werfen, Spain; Sysmex Ireland-UK; Sinnowa, China; Genomadix Inc., Canada and Acquis BI Technology Ltd. *denotes co-first authorship between DS and IN. These data are presented on behalf of the OATS-I Study Research Group, the following members also qualify for authorship on this abstract: Collins DR (4, 14), Ryan DJ (4, 14), McCarthy AJ (1, 3, 4 ), Murphy SM (1, 3), Egan B (15), O’Donnell MJ (16), de Borst GJ (17), Zgaga L (18), Walsh C (18, 19), Kelleher JD (20, 21), Macey C (22), Hennessy M (23, 24): (14) Age-Related Health Care Department, (15) Department of Vascular Surgery, TUH/AMNCH; (16) College of Medicine, Nursing and Health, University of Galway / University Hospital Galway, Galway, Ireland; (17) University Medical Centre Utrecht, Utrecht, Netherlands; (18) Department of Public Health and Primary Care, (19) Department of Biostatistics, (20) Department of Computer Sciences, (21) ADAPT SFI centre, Trinity College Dublin (TCD), Dublin, Ireland; (22) Irish Heart Foundation, Dublin, Ireland; (23) Wellcome-HRB Clinical Research Facility, St James's Hospital, Dublin, Ireland; (24) School of Medicine, Trinity College Dublin, Ireland

Abstract Background and aims International guidelines support discussion at a Neurovascular Multidisciplinary Meeting (NVMDM) to reach evidence-based decisions regarding revascularisation and/or optimal medical treatment of patients with atherosclerotic carotid artery stenosis. Data are limited on the impact the COVID-19 pandemic on performance metrics of a NVMDM. Methods This prospective audit/quality improvement project compared proportions of extracranial carotid stenosis patients in whom ‘consensus management decisions’ were reached at weekly Regional NVMDM during the ‘COVID-19’ main-pandemic (March 2020-September 2022) vs. ‘pre-COVID’ (September 2017-Febuary 2020) and ‘post-COVID’ (October 2022–February 2025) periods. We analysed adherence to NVMDM decisions in asymptomatic carotid stenosis [ACS], symptomatic carotid stenosis [SCS] and ‘indeterminate symptomatic status stenosis [ISS]’ patients, including intervals between symptom onset to NVMDM discussion +/- intervention, and post-NVMDM outcomes. Results Consensus decisions regarding management were reached in 97.9% (93/95) of COVID vs. 96.3% (104/108) of pre-COVID, and 100% (64/64) of post-COVID patients (P≥0.69). Adherence to NVMDM recommendations remained high during COVID (90.4%), pre-COVID (96.2%) and post-COVID (93.2%) periods, respectively (P≥0.10). Median intervals from index symptoms to revascularisation in 50-99% SCS patients were similar between the COVID (10.5d), pre-COVID (12.5d) and post-COVID (12.5d) periods (P≥0.24). Median intervals from NVMDM discussion to revascularisation were 3.5d (IQR: 1-7d) during the COVID period vs. 5.5d (IQR: 1-7d) during the pre-COVID period (P=0.58); vs. 3.5d (IQR: 1-7) during the post-COVID period (P=0.19). Conclusions One can maintain a high frequency of inter-speciality consensus re evidence-based management, adherence to treatment advice and guidelines regarding time-to-revascularisation of carotid stenosis patients throughout/after a pandemic. Conflict of interest No conflict of interest. Prof. McCabe's research work is supported by grant funding from several charities and organisations, including the Meath Foundation, Ireland; The Adelaide Health Foundation, Ireland; an Enterprise Ireland Innovation Partnership Programme grant with Acquis BI Technology, Ltd.; the VNRF, Ireland; and in-kind contributions from Werfen, Spain; Sysmex Ireland-UK; Sinnowa, China; Genomadix Inc., Canada and Acquis BI Technology Ltd. Note: The late Prof. Sean Tierney was instrumental to the successful conduct of our Neurovascular Multidisciplinary Meeting, and in collection and interpretation of data. The remaining members of the TUH/AMNCH Neurovascular Multidisciplinary Team who also qualify for authorship are: McCarthy AJ (1, 2, 3), Hayden D (2, 5), Coveney S (2, 5), Murphy SM (1, 3), O’Connell K (1, 2, 3), Bogdanova-Mihaylova P (1, 2, 3), Healy DA (4), Noor A (4), Walsh J (7), Ward P (7), McGrath R (7), Martin M (8), O Driscoll A (8), Smith DR (1, 3, 6), Naydonova I (1, 2, 3) and Mavridis T (1, 2): (7) Department of Radiology, Tallaght University Hospital (TUH) / The Adelaide and Meath Hospital, Dublin, incorporating the National Children’s Hospital (AMNCH) / Dublin, Ireland; (8) Naas General Hospital, Co. Kildare, Ireland

Data are limited on the impact of commencing antiplatelet therapy on von Willebrand Factor Antigen (VWF:Ag) or von Willebrand Factor propeptide (VWFpp) levels and ADAMTS13 activity, and their relationship with platelet reactivity following TIA/ischaemic stroke.In this pilot, observational study, VWF:Ag and VWFpp levels and ADAMTS13 activity were quantified in 48 patients ≤4 weeks of TIA/ischaemic stroke (baseline), and 14 days (14d) and 90 days (90d) after commencing aspirin, clopidogrel or aspirin+dipyridamole. Platelet reactivity was assessed at moderately-high shear stress (PFA-100® Collagen-Epinephrine / Collagen-ADP / INNOVANCE PFA P2Y assays), and low shear stress (VerifyNow® Aspirin / P2Y12, and Multiplate® Aspirin / ADP assays).VWF:Ag levels decreased and VWFpp/VWF:Ag ratio increased between baseline and 14d and 90d in the overall population (P ≤ 0.03). In the clopidogrel subgroup, VWF:Ag levels decreased and VWFpp/VWF:Ag ratio increased between baseline and 14d and 90d (P ≤ 0.01), with an increase in ADAMTS13 activity between baseline vs. 90d (P ≤ 0.03). In the aspirin+dipyridamole subgroup, there was an inverse relationship between VWF:Ag and VWFpp levels with both PFA-100 C-ADP and INNOVANCE PFA P2Y closure times (CTs) at baseline (P ≤ 0.02), with PFA-100 C-ADP, INNOVANCE PFA P2Y and C-EPI CTs at 14d (P ≤ 0.05), and between VWF:Ag levels and PFA-100 INNOVANCE PFA P2Y CTs at 90d (P = 0.03). There was a positive relationship between ADAMTS13 activity and PFA-100 C-ADP CTs at baseline (R2 = 0.254; P = 0.04).Commencing/altering antiplatelet therapy, mainly attributed to commencing clopidogrel in this study, was associated with decreasing endothelial activation following TIA/ischaemic stroke. These data enhance our understanding of the impact of VWF:Ag and VWFpp especially on ex-vivo platelet reactivity status at high shear stress after TIA/ischaemic stroke.

Background/aims Data are limited on the frequency of ‘consensus decisions’ between sub-specialists attending a neurovascular multidisciplinary meeting (MDM) regarding management of patients with extracranial carotid/vertebral stenoses and post-MDM ‘adherence’ to such advice. Methods This prospective audit/quality improvement project collated prospectively-recorded data from a weekly Neurovascular/Stroke Centre MDM documenting the proportion of extracranial carotid/vertebral stenosis patients in whom ‘consensus management decisions’ were reached by neurologists, vascular surgeons, stroke physicians-geriatricians and neuroradiologists. Adherence to MDM advice was analysed in asymptomatic carotid stenosis (ACS), symptomatic carotid stenosis (SCS), ‘indeterminate symptomatic status stenosis’ (ISS) and vertebral artery stenosis (VAS) patients, including intervals between index event to MDM + / − intervention. Results One hundred fifteen patients were discussed: 108 with carotid stenosis and 7 with VAS. Consensus regarding management was noted in 96.5% (111/115): 100% with ACS and VAS, 96.2% with SCS and 92.9% with ISS. Adherence to MDM management advice was 96.4% (107/111): 100% in ACS, ISS and VAS patients; 92% (46/50) in SCS patients. The median interval from index symptoms to revascularisation in 50–99% SCS patients was 12.5 days (IQR: 9–18.3 days; N = 26), with a median interval from MDM to revascularisation of 5.5 days (IQR: 1–7 days). Thirty patients underwent revascularisation. Two out of twenty-nine patients (6.9%) with either SCS or ISS had a peri-procedural ipsilateral ischaemic stroke, with no further strokes/deaths during 3-months follow-up. Conclusions The high frequency of inter-specialty consensus regarding management and adherence to proposed treatment supports a collaborative/multidisciplinary model of care in patients with extracranial arterial stenoses. Service development should aim to shorten times between MDM discussion-intervention and optimise prevention of stroke/death.

Background Headache disorders contribute a significant burden on Emergency Department (ED) accounting for 1-4% ED attendances. Tallaght University Hospital ED has increasing number of atrau- matic headache presentations and admissions with a striking average length-of-stay of three days pp. The total cost of such admission including MRI brain is >€2,600 pp. Aims To optimise the management of headache patients attending ED through facilitated access to outpatient MRIs and Rapid Access Headache Clinic. Methods We prospectively collected data on patient presentations to ED with primary and non-urgent secondary headaches, subsequent referral for expedited outpatient MRI brain and assessment in the Rapid Access consultant-led Headache Clinic. Data were analysed using descriptive statistics. Results 62 patients were referred through this initiative to date (02/09/2022–10/01/2023) and 51 (82.3%) were accepted [18M/33F]. Median age was 43y (IQR 31-51). All had normal neurological examination. Migraine was the most frequent headache diagnosis following neurology assessment (80.4%). 2/51 patients had significant intracranial abnormality on MRI not contributing to current presentation. Cost savings were > €2,400 pp. Feedback has yielded 100% patient satisfaction. Conclusion This initiative has resulted in avoided hospital admissions, significant cost savings and reduction in burden on ED, as well as better patient experience and satisfaction.

BackgroundRecently-released ‘Reticulated Platelets (RP)’ may contribute to High on-Treatment Platelet Reactivity (HTPR). Data in TIA/ischaemic stroke are limited.AimsAssess relationship between%RP fraction (%RPF) and ex-vivo Aspirin-HTPR status under high and low shear stress conditions after TIA/ischaemic stroke.MethodologyData from two prospective observational studies were collated on%RPF in TIA/ischaemic stroke patients at 14days (N=141) and ≥90days (N=68) on Aspirin alone/in combination with Dipyridamole or Clopidogrel using an ‘automated assay’ (Sysmex XE-2100TM/XN-9100TM). Aspirin-HTPR was defined at moderately-high shear stress as ‘closure times’ ≥176s on PFA-100® Collagen-Epinephrine assays, and at low shear stress as ‘Aspirin Reaction Units (ARU)’ ≥550 on VerifyNow® Aspirin assays. We compared ‘unad- justed%RPF’ between patients with vs. without HTPR; Spearman rank correlation assessed relationships between%RPF and platelet reactivity.ResultsAspirin-HTPR prevalence at 14d-≥90d, respectively, was 45.1%-33.8% on PFA-100, and 4.4%-12.3% on VerifyNow. In patients with vs. without HTPR on PFA-100,%RPF was not statistically-significantly higher at 14d (3.15 vs. 2.8%, P=0.2), but was higher at ≥90d (3.6 vs. 2.1%, P=0.002). There was a negative correlation between%RPF and PFA-100 closure times at ≥90d (Spearman-ρ=-0.267; P=0.036).DiscussionReticulated platelets contribute to Aspirin-HTPR under high shear stress conditions in the late phase after TIA/ischaemic stroke.

Post-mortem computed tomography (CT) can provide useful insights into coronial and forensic pathological investigation of the fire-damage victim. Understanding the pathological changes that can occur in fatalities caused by fire, particularly in relation to fire damage to the body, is paramount in attempting to distinguish ante-mortem and peri-mortem blunt traumatic injuries from fire-related damage to the body. Understanding the fire-damage features on postmortem CT may also assist in determining cause of the fire and associated fire-damage. Although the requirements of radiological evaluation in post-mortem imaging are very different to those of day-to-day clinical ante-mortem imaging, foremost is a high-resolution CT protocol of the entire body in order to fulfil the requirements and expectations of such imaging and radiological interpretation.(c) 2023 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.

Background/AimsData are limited on the influence of the COVID-19 pandemic on consensus deci- sion-making at a neurovascular multidisciplinary meeting (MDM) in patients with extracranial carotid/vertebral stenoses.MethodsThis prospective audit/quality-improvement project compared proportions of extracranial carotid stenosis patients in whom ‘consensus management decisions’ were reached at a weekly Neuro- vascular/Stroke Centre MDM in the COVID-19 ‘pandemic’ (March/2020-September/2022) vs. ‘pre-pan- demic’ period (September/2017-Febuary/2020). Adherence to MDM decisions was analysed in asymp- tomatic carotid stenosis [ACS], symptomatic carotid stenosis [SCS] and ‘indeterminate symptomatic status stenosis [ISS]’ patients.ResultsConsensus regarding management was 98% (97/99) in pandemic vs. 96.5% (111/115) in pre-pan- demic patients overall (P=0.59); i.e. 98% (51/52) with SCS, 100% (23/23) with ACS, and 98% (23/24) with ISS during the pandemic. Adherence-to-advice was 91% (90/99) in pandemic vs. 96.4% (107/111) in pre-pandemic patients (P=0.10); i.e. 88% (46/52) with SCS, 96% (22/23) with ACS, and 92% (22/24) with ISS during the pandemic. Comparing pandemic vs. pre-pandemic periods, median interval from index TIA/stroke-to-revascularisation for 50-99% SCS was 11 days (IQR:8.8-15.8d) vs. 12.5days (IQR:9-18d; P=0.30), and from MDM-to-revascularisation was 3d (IQR:1-7d) vs. 5.5d (IQR:1-7d; P=0.58).ConclusionsThe COVID-19 pandemic did not adversely influence frequency of consensus regarding management, adherence to MDM advice, or intervals-to-revascularisation in carotid stenosis patients.

Objective: The aim was to enhance understanding of the role of platelet biomarkers in the pathogenesis of vascular events and risk stratifying patients with asymptomatic or symptomatic atherosclerotic carotid stenosis. Data Sources: Systematic review conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Review Methods: A systematic review collated data from 1975 to 2020 on ex vivo platelet activation and platelet function/reactivity in patients with atherosclerotic carotid stenosis. Results: Forty-three studies met the inclusion criteria; the majority included patients on antiplatelet therapy. Five studies showed increased platelet biomarkers in patients with >= 30% asymptomatic carotid stenosis (ACS) vs. controls, with one neutral study. Preliminary data from one study suggested that quantification of "coated platelets" in combination with stenosis severity may aid risk stratification in patients with >= 50% - 99% ACS. Platelets were excessively activated in patients with >= 30% symptomatic carotid stenosis (SCS) vs. controls (>= 11 positive studies and one neutral study). Antiplatelet-High on Treatment Platelet Reactivity (HTPR), previously called "antiplatelet resistance", was observed in 23% - 57% of patients on aspirin, with clopidogrel-HTPR in 25% - 100% of patients with >= 50% - 99% ACS. Aspirin-HTPR was noted in 9.5% - 64% and clopidogrel-HTPR in 0 - 83% of patients with >= 50% SCS. However, the data do not currently support the use of ex vivo platelet function/reactivity testing to tailor antiplatelet therapy outside of a research setting. Platelets are excessively activated (n = 5), with increased platelet counts (n = 3) in recently symptomatic vs. asymptomatic patients, including those without micro-emboli on transcranial Doppler (TCD) monitoring (n = 2). Most available studies (n = 7) showed that platelets become more reactive or activated following carotid endarterectomy or stenting, either as an acute phase response to intervention or pen-procedural treatment. Conclusion: Platelets are excessively activated in patients with carotid stenosis vs. controls, in recently symptomatic vs. asymptomatic patients, and may become activated/hyper-reactive following carotid interventions despite commonly prescribed antiplatelet regimens. Further prospective multicentre studies are required to determine whether models combining clinical, neurovascular imaging, and platelet biomarker data can facilitate optimised antiplatelet therapy in individual patients with carotid stenosis.

Introduction: The optimal time interval after venepuncture to perform platelet function/reactivity testing at low shear stress on the novel AGGRESTAR PL-12® platelet function analyser in non-Chinese Cerebrovascular Disease (CVD) patients is unknown. Methods: Twelve TIA/ischaemic stroke patients were recruited to this cross-sectional, methodological study: 3 on aspirin monotherapy, aspirindipyridamole combination therapy, clopidogrel monotherapy and aspirinclopidogrel combination therapy, respectively. The PL-12 (‘mode 2’) was used to calculate the % maximum aggregation rate to fixed doses of arachidonic acid (%MARAA) and adenosine diphosphate (%MARADP). Samples were analysed every 15 minutes from 30-135 minutes, and every 30 minutes between 165-225 minutes after venepuncture to calculate the time interval providing optimal interassay Coefficients of Variation (CVs). Results: Mean CVs were ≤ 7.37% for the %MARAA assay in patients on aspirin monotherapy or combination therapy, and ≤ 10.24% for the %MARADP assay in patients on clopidogrel monotherapy or combination therapy if assays were performed between 90-120 minutes post-venepuncture. CVs ≤ 10% were also obtained from assays performed between 90-165 minutes postvenepuncture on aspirin monotherapy or combination therapy. Discussion: Reliable and reproducible platelet function/reactivity data can be obtained with the AGGRESTAR PL-12 analyser in non-Chinese CVD patients on commonly-prescribed antiplatelet monotherapy or combination therapy regimens between 90-120 minutes post-venepuncture.

The prevalence of ex vivo ‘high on-treatment platelet reactivity (HTPR)’ and its relationship with recurrent vascular events/outcomes in patients with ischaemic cerebrovascular disease (CVD) is unclear. A systematic review and meta-analysis was performed in accordance with the PRISMA statement. MEDLINE, EMBASE and Cochrane Library were searched for completed manuscripts until May 2019 on TIA/ischaemic stroke patients, ≥ 18 years, treated with commonly-prescribed antiplatelet therapy, who had platelet function/reactivity testing and prospective follow-up data on recurrent stroke/TIA, myocardial infarction, vascular death or other cerebrovascular outcomes. Data were pooled using random-effects meta-analysis. Primary outcome was the composite risk of recurrent stroke/TIA, myocardial infarction or vascular death. Secondary outcomes were recurrent stroke/TIA, severe stroke (NIHSS > 16) or disability/impairment (modified Rankin scale ≥ 3) during follow-up. Antiplatelet–HTPR prevalence was 3–65% with aspirin, 8–56% with clopidogrel and 1.8–35% with aspirin–clopidogrel therapy. Twenty studies (4989 patients) were included in our meta-analysis. There was a higher risk of the composite primary outcome (OR 2.93, 95% CI 1.90–4.51) and recurrent ischaemic stroke/TIA (OR 2.43, 95% CI 1.51–3.91) in patients with vs. those without ‘antiplatelet–HTPR’ on any antiplatelet regimen. These risks were also more than twofold higher in patients with vs. those without ‘aspirin–HTPR’ and ‘dual antiplatelet–HTPR’, respectively. Clopidogrel–HTPR status did not significantly predict outcomes, but the number of eligible studies was small. The risk of severe stroke was higher in those with vs. without antiplatelet–HTPR (OR 2.65, 95% CI 1.00–7.01). Antiplatelet–HTPR may predict risks of recurrent vascular events/outcomes in CVD patients. Given the heterogeneity between studies, further prospective, multi-centre studies are warranted.

Objective To review the management of temporal bone fractures at a major trauma centre and introduce an evidence-based protocol. Methods A review of reports of head computed tomography performed for trauma from January 2012 to July 2018 was conducted. Recorded data fields included: mode of trauma, patient age, associated intracranial injury, mortality, temporal bone fracture pattern, symptoms and intervention. Results Of 815 temporal bone fracture cases, records for 165 patients met the inclusion criteria; detailed analysis was performed on the records of these patients. Conclusion Temporal bone fractures represent high-energy trauma. Initial management focuses on stabilisation of the patient and treatment of associated intracranial injury. Acute ENT intervention is directed towards the management of facial palsy and cerebrospinal fluid leak, and often requires multidisciplinary team input. The role of nerve conduction assessment for immediate facial palsy is variable across the UK. The administration of high-dose steroids in patients with temporal bone fracture and intracranial injury is not advised. A robust evidence-based approach is introduced for the management of significant ENT complications associated with temporal bone fractures.

Objectives: This study aimed to compare the reporting of high-resolution computed tomography of temporal bones for otosclerosis by general radiologists and a neuroradiologist within a local National Health Service Trust.Methods: A retrospective case review of 36 high-resolution temporal bone computed tomography images obtained between 2008 and 2015 from 40 otosclerosis patients (surgically confirmed) was performed in a district general hospital setting. The main outcome measures were correct identification of otosclerosis by high-resolution computed tomography and adherence to the petrous temporal bone imaging protocol.Results: Correct diagnosis rates were significantly different when made by general radiologists vs a neuroradiologist (p < 0.0001; two-tailed Fisher's exact test). None of the high-resolution computed tomography scans adhered to the temporal bone imaging protocol.Conclusion: The use of high-resolution computed tomography for suspected otosclerosis is helpful for diagnosis, disease staging, obtaining informed consent, surgical planning and prognosis. This study suggests that radiological detection of otosclerotic changes by high-resolution computed tomography of the temporal bone is significantly better when performed by a dedicated neuroradiologist than by a general radiologist. Use of a standardised temporal bone computed tomography protocol is recommended to provide consistently high-quality images for maximising disease detection.

Pulsatile tinnitus: a review. Objectives: The aim of this review is to provide an up to date review of the causes, assessment, and management of pulsatile tinnitus. Methods: A search was performed of all studies, review articles, and case series looking at pulsatile tinnitus, published until the 1st January 2015. The search was performed using a keyword search strategy (pulsatile tinnitus, arteriovenous malformation) on PubMed, Medline/Old Medline and Cochrane Central databases. Results: Pooling the data from the studies in our literature review, with a total number of patients of 1,245 patients, we found that the most common Aetiologies for pulsatile tinnitus were idiopathic (32%), idiopathic intracranial Hypertension (28%), atherosclerosis of the carotid arteries (16%), Otosclerosis (11%), Glomus tumors (7%), and Arteriovenous malformations (2%). There is no consensus about first-line imaging modality, however, in reviewing the potential causes we suggested that the first line imaging for pulsatile tinnitus should be a delayed Computed Tomography (CT) Angiographic protocol. For the vast majority of pulsatile tinnitus with no identifiable cause, sound therapy is an effective management option if symptoms are persistent and bothersome. Cognitive Behavioural Therapy (CBT) should also be considered if there is significant anxiety or concurrent depressive illness. Conclusion: It is important to investigate patients with pulsatile tinnitus radiologically to rule out significant causes, and we recommend CT angiography as the first-line imaging modality. Where no cause is found and patients have persistent bothersome symptoms, consideration should be given for treatment with sound therapy and cognitive behavioural therapy.

Clinical OtolaryngologyVolume 42, Issue 3 p. 723-727 Correspondence: Our Experience Ultrasound-guided assessment of thyroid nodules based on the 2014 British Thyroid Association guidelines for the management of thyroid cancer – how we do it H. Kanona, Corresponding Author H. Kanona hkanona@yahoo.co.uk Department of Otolaryngology, Barts Health, Whipps Cross University Hospital, London, UKCorrespondence: H. Kanona, Department of Otolaryngology, Whipps Cross University Hospital, Barts Health, London, E11 1NR, UK. Tel.: 020 8539 5522; Fax: 020 3594 33278; e-mail: hkanona@yahoo.co.ukSearch for more papers by this authorJ.S. Virk, J.S. Virk Department of Otolaryngology, Barts Health, The Royal London Hospital, London, UKSearch for more papers by this authorC. Offiah, C. Offiah Department of Radiology, Barts Health, the Royal London Hospital, London, UKSearch for more papers by this authorP. Stimpson, P. Stimpson Department of Otolaryngology, Barts Health, Whipps Cross University Hospital, London, UK Department of Otolaryngology, Barts Health, The Royal London Hospital, London, UKSearch for more papers by this author H. Kanona, Corresponding Author H. Kanona hkanona@yahoo.co.uk Department of Otolaryngology, Barts Health, Whipps Cross University Hospital, London, UKCorrespondence: H. Kanona, Department of Otolaryngology, Whipps Cross University Hospital, Barts Health, London, E11 1NR, UK. Tel.: 020 8539 5522; Fax: 020 3594 33278; e-mail: hkanona@yahoo.co.ukSearch for more papers by this authorJ.S. Virk, J.S. Virk Department of Otolaryngology, Barts Health, The Royal London Hospital, London, UKSearch for more papers by this authorC. Offiah, C. Offiah Department of Radiology, Barts Health, the Royal London Hospital, London, UKSearch for more papers by this authorP. Stimpson, P. Stimpson Department of Otolaryngology, Barts Health, Whipps Cross University Hospital, London, UK Department of Otolaryngology, Barts Health, The Royal London Hospital, London, UKSearch for more papers by this author First published: 23 January 2016 https://doi.org/10.1111/coa.12621Citations: 5Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat Citing Literature Volume42, Issue3June 2017Pages 723-727 RelatedInformation

Introduction: Well known postoperative complications after thyroidectomy are haemorrhage, recurrent laryngeal nerve palsy and hypoparathyroidism when total thyroidectomy is the preferred treatment for thyroid cancer, multinodular goitre and Graves disease. Hence surgeons choose to perform hemithyroidectomy for benign thyroid disease to reduce the incidence of these complications.

Introduction: Salivary gland calculi are the commonest salivary gland disease, with 80% occurring in the submandibular gland. Although the precise aetiology remains unknown, formation occurs when three conditions are met; salivary stagnation, nidus and precipitation of salivary salts. We present a case of fascial space infection induced airway obstruction caused by a giant submandibular duct calculus.

Introduction: Cervical hyperostosis is a rare cause of dysphagia. The majority of cervical osteophytes are asymptomatic, occurring in patients with degenerative diseases. Some are associated with Diffuse Idiopathic Skeletal Hyperostosis (DISH), characterized by a tendency for ossification of ligaments, tendons and joint capsule insertions, most often affecting the thoracic spine, and less commonly the cervical region. Symptoms of cervical hyperostosis include dysphagia, hoarse voice, laryngeal stenosis, and dyspnoea in severe cases. Various treatment strategies from pharmacological to surgical management have been reported. We present a case report and literature review on the treatment of this rare condition.

Requests for imaging of patients complaining of deafness and other symptoms related to the petrous bone are becoming increasingly common. Although much of this work is related to the exclusion of vestibular schwannomas by MRI, high-resolution CT is available in most departments and is necessary for the evaluation of many conditions of the middle ear and bony labyrinth. In this pictorial review, some of the more unusual conditions that may be encountered in the middle and inner ear are presented, which might not be overly familiar to non-otological radiologists, illustrating the roles of CT and MRI.