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On Tuesday 7th October Queen Square Imaging Centre welcomed GPs to its educational evening at the National Hospital for Neurology and Neurosurgery.

This month we caught up with Dr Fergus Robertson, Interventional Neuroradiology Consultant at the National Hospital for Neurology and Neurosurgery and Great Ormond Street Hospital for Children, to talk about the work of his neurovascular group. Together with his team, he has been developing new techniques and conducting pioneering research into the treatment a number of complicated conditions.



Q: Thank you for speaking with us Dr Robertson. Please could you tell us a little about about your areas of expertise?

Dr Fergus Robertson: I’m partly a diagnostic radiologist, reporting MRI and CT scans of the nervous system. The rest of my time is spent treating vascular problems of the brain and spine. Often, patients arrive as emergencies to the hospital with brain haemorrhages or strokes but I also treat many with longstanding problems in a more elective, planned way.

Q: How have the facilities at Queen Square Imaging Centre aided your research?

FR: My work is precise, challenging and demands the highest quality imaging when planning treatments. With its state-of-the-art MRI scanner and specialist neuroimaging radiographers, the centre offers a fantastic image quality across the board. From my perspective, the spine and blood vessel imaging really is some of the best I’ve seen anywhere.

Another area where the QSIC staff excel is in their innovation. If I need something new or different, they’ll happily invest time and effort to deliver an imaging solution.

An example of this is the recent introduction of a new MR imaging sequence which can now demonstrate flow through the tiny blood vessels around the spinal cord. These vessels are surrounded by bone and have, in the past, been very difficult to image without directly injecting them in the angiography suite. Now we are able to see them on a non-invasive MRI study, reducing risk to the patient.

Q: How has the work of your neurovascular group been helping patients?

FR: Traditionally, patients with neurovascular problems were treated by neurosurgeons via open surgical operations. But over the last decade we have seen increases in endovascular treatments by neuroradiologists in the angiography suite.

One particular area where there has been a dramatic shift is in the treatment of cerebral aneurysms. These small swellings on cerebral blood vessels may rupture, often causing life-threatening brain haemorrhage. In the past these were predominantly treated with an open operation to place a metal clip across the aneurysm neck. Although the procedure is usually successful, it is lengthy and dangerous particularly in unstable patients.

Now with modern technology  a small tube can be passed via a small nick in the groin, through the blood vessels and into the brain under X ray guidance to pack the aneurysm with tiny platinum coils and prevent further bleeding. These endovascular procedures are generally less invasive, quicker and yield better outcomes than traditional surgery. Now 90 per cent of aneurysm patients at the National Hospital for Neurology and Neurosurgery are treated by the radiology team.

Q: What other areas of work does the group focus on?

FR: We have led the development of new stent treatments for more complicated aneurysms that were traditionally considered untreatable through endovascular techniques, either in view of their size or shape.

We treat a number of other vascular problems - arteriovenous malformations of the brain and spinal cord and also reduce the blood supply to tumours (embolisation) of the brain and spine, allowing surgeons to remove them more rapidly and with less blood loss.

Perhaps the largest growth area is the treatment of patients with stroke, one of the commonest problems in the UK. Many patients come to hospital with a blocked brain artery which leaves them with weakness, disrupted speech, loss of balance or other problems. Those who reach hospital in time are treated with clot-busting drugs. However, if these fail to open the blockage  or if they cannot be administered, an increasing number of patients are being transferred to the angiography suite at Queen Square where we are now able to open the blockage mechanically by removing the clot through the blood vessels. There are real challenges in selecting which patients are likely to benefit from treatment and in getting the blood vessel open before the brain is permanently damaged.

In addition we’re also able to treat patients who experience symptoms from narrowed blood vessels in the head (intracranial stenosis) by opening up the vessel with balloons or stents, also delivered via tubes from the groin. This helps to restore arterial blood flow to areas of the brain and prevent strokes. We’re also helping people experiencing venous pressure problems in the head (idiopathic intracranial hypertension) by opening up narrowed veins improving drainage of the brain and preventing disabling headaches and blindness.

We also work closely with our spinal surgeons performing minimally invasive, image-guided surgical procedures, such as vertebroplasty and kyphoplasty, in which we inject cement to strengthen diseased areas of the spine.

Q: What is the neurovascular group doing to share its work with other medical professionals and improve best practice in the field?

We have an active research programme that has matured over the last ten years to match a workload which has grown from a handful of cases in the early 2000s to nearly 500 procedures now carried out at Queen Square and Great Ormond Street each year. We were finally able to expand our consultant numbers in 2011 to cope with the clinical workload, allowing a greater focus on research themes. We regularly present our experiences at local, national and international meetings.

We operate in a high risk field and work continuously to improve the quality and safety of our service. We have an active, rolling program of audit and neuroradiology leads the National Hospital in this field. With the ongoing restructuring of Neurosurgical services across north London we are working more closely than ever with our colleagues at linked trusts such as the Royal Free Hospital, and Bart’s and the London.

I work in an exciting and rapidly-evolving field with constant opportunities to develop and improve our service. The first class support provided by all the staff at Queen Square is integral to our ongoing success.

In November and February we held the first two in a new series of educational events for GPs, organised in conjunction with the National Hospital for Neurology and Neurosurgery (NHNN).

We welcomed over 60 guests including London GPs, from both private and NHS practices, to enjoy lectures from some of the worlds leading neurologists and neurosurgeons.



In November and February we held the first two in a new series of educational events for GPs, organised in conjunction with the National Hospital for Neurology and Neurosurgery (NHNN).

We welcomed over 60 guests including London GPs, from both private and NHS practices, to enjoy lectures from some of the worlds leading neurologists and neurosurgeons.

The timetables included:

  • Epilepsy with Dr Dominic Heaney, Consultant Neurologist and Honorary Senior Lecturer at the National Hospital for Neurology and Neurosurgery
  • Headaches with Dr Manjit Matharu, Senior Lecturer at the Institute of Neurology and Honorary Neurologist at The National Hospital for Neurology and Neurosurgery
  • Spinal disorders with Mr David Choi, Clinical Senior Lecturer at the UCL Institute of Neurology
  • Stroke mimics with Dr Jeremy Rees, Consultant Neurologist at the National Hospital for Neurology and Neurosurgery
  • Numb tingly bits - What to do when and how? with Dr Michael Lunn, Consultant Neurologist, Clinical Lead in Neuroimmunology and Honorary Senior Lecturer at The National Hospital for Neurology and Neurosurgery
  • Advances in brain tumour and epilepsy surgery with Mr Andrew McEvoy, Consultant Neurosurgeon at The National Hospital for Neurology and Neurosurgery

Most GPs followed up the presentations by taking the opportunity to look around the new Queen Square Enterprises Private Consulting Rooms (PCRs) and to enjoy networking at a champagne reception.

We had some fantastic feedback from GPs with 100 per cent saying they would recommend future events to colleagues and everyone describing the event as "excellent" or "very good".

Some comments received included; "It was very informative and gave me the opportunity to listen to and meet high profile consultants" and "It was definitely worthwhile and I am looking forward to future events."

This month we caught up with Mr Andrew McEvoy, world-leading Consultant Neurosurgeon at The National Hospital for Neurology (NHNN) and Neurosurgery and Institute of Neurology (ION) in London. Mr McEvoy has been referring to Queen Square Imagine Centre for eight years and uses QS Enterprises' new Private Consulting Rooms.




Q: Thank you for speaking with us Mr McEvoy. Please could you tell us a little about about your areas of expertise?

A: I have the largest adult epilepsy surgical practice in the UK and do a huge amount of brain tumour surgery. I actually do the largest number of ‘awake’ craniotomies in the UK - for surgeries like this, the high-level of work done at Queen Square Imaging Centre (QSIC) is absolutely essential. Although my expertise is in brain tumours and epilepsy I also do more general neurosurgical work on spines, backs and the like.

Q: What keeps you coming back to Queen Square Imaging Centre?

A: I keep coming back to the QSIC for a number of reasons. One is that geographically it is obviously very helpful as it is located in the same square as me. Another is its excellence. If you were to ask anyone in the UK where the experts in neurosurgical and neurological illness are, then they would say here in Queen Square. The third is the quality of the staff doing the reporting - they are second to none. They are also extremely responsive and, especially when working in the private sector, people are likely to turn up and ask for a scan that morning and want the results immediately. The staff are very good at facilitating that and getting you a report very quickly.

The imaging centre’s facilities are also superb, as it has forms of private imaging that others don’t, such as functional imaging and diffusion tensor imaging.

Q: Why do you use Queen Square’s new Private Consulting Rooms?

A: I use the PCRs on a Tuesday morning. They are excellent - a really first class facility. They are well managed with good secretarial support. Patients have a lot of choice with private practices and sometimes as doctors you forget the little things that make a difference. I know where I would go to seek the most expert opinion, but patients look at other factors such as whether they are given a coffee or how quickly the staff answer the phone. I think sometimes doctors forget that and think, “but I’m the best”, forgetting that the patient does actually have a choice and their decision depends on the facilities too.

Q: How much of a role do you think patients play in the decision of which scanning facilities they will be referred to?

A: A lot of clinicians have been attracted to the new PCRs because of the work that comes from being associated with Queen Square. When someone is diagnosed with something like a brain tumour, the first thing they will do is search the internet and many of the people talking and writing about neurology and neurosurgery are at Queen Square. The patient will then seek a second opinion or a consultation with these people which will of course generate more imaging work for QSIC as they will send them to the people they trust to get the imaging done.

Q: You spoke at the second of QSIC’s educational events for GPs, which was held in February, how do you think GPs benefit from attending these events?

A: I don’t think GPs appreciate how much more effective surgery is at treating certain forms of epilepsy when compared to drugs. And often GPs worry too much about the perceived risks without considering the advantages. With refractory epilepsy there is a 70-80 per cent chance of curing patients with surgery, however by giving the patient another drug, the chances of  a cure are more like 3-4 per cent.

The key is for the surgeon to select patients who will benefit from surgery well and to have a good multidisciplinary team.

This month we caught up with Dr Ros Quinlivan, a consultant in Paediatric Neuromuscular Disorders who specialises in the transition from Great Ormond Street's paediatric to Queen Square's adult services.


Q: Thank you for speaking with us. Please could you tell us a little about your areas of expertise?

A: I have been a consultant in neuromuscular disease for 18 years. My initial training was in paediatrics, with later training in both paediatric and adult neuromuscular disease. I moved to UCLH in 2010, where I now lead the transition service for adolescents and young adults with neuromuscular disease at Great Ormond Street and Queen Square. There was a huge gap in this area, and there remains a gap in transition services for neuromuscular disease patients across the country. I am the joint coordinating editor for the Cochrane Neuromuscular Disease group. At present I am one of only two physicians appointed specifically for transition for neuromuscular disease patients.

Q: Why is there a need for a Neuromuscular Complex Care Unit (NMCCU) in London?

A: At present patients with neuromuscular diseases living in London frequently experience fragmented care provided across several hospital Trusts and primary care. The lack of appropriate hospital facilities and untrained staff often leads to poor patient experience, poor quality of care and absence of NICE compliance. There is frequently avoidable delay in treatment for predictable inter-current illnesses, often resulting in prolonged hospital stays and avoidable intensive care admissions.          
By designing a pre-emptive specialist care system the current fragmented care arrangements can be avoided. The pre-emptive elective centre will aim to reduce unplanned emergency admissions, improve patient experience and improve patient safety.
The unit is for patients with a range of neuromuscular diseases, not only those with Duchenne Muscular Dystrophy, although these patients are a driver behind the project as they are a growing group.

Q: What is the current average life expectancy for patients with Duchenne Muscular Dystrophy?

A: The latest available data is about life expectancy of Duchenne patients in Newcastle. The mean life expectancy for these patients was from mid to late 20s. In 1990 the life expectancy for these patients was only 19 years, so already there has been improvement. We hope that opening the NMCCU will improve patient life expectancy greatly so that improvement in life expectancy can continue.

Q: Is there an overseas example that has led to this new way of working?

A: In Denmark all patients with Duchenne dystrophy, both children and adults, receive care in a single centre. Here life expectancy has greatly improved, with average patient life expectancy is greatly increased with several patients living to late 40s.

Q: How much could the level of treatment offered at NMCCU save the NHS financially?

A: Its difficult to say until the unit is up and running. One area that the NHS will see financial reductions will be in outpatient appointments and their transport costs, as care will be rationalised to a one-stop visit.
With more pro-active and coordinated management of patients’ conditions we hope to reduce and prevent a great deal of avoidable emergency and intensive care admissions. This will both reduce the cost of unplanned visits to the NHS and dramatically improve patient experiences.

Q: Could this model be rolled out across the UK?

A: We’d definitely like the model to be rolled out to other parts of the country. Communication between the different hospitals that patients visit can be poor, although I can’t say that this is true for the whole of the UK, but certainly in London this is something that the NMCCU will improve. The increase in life expectancy seen in Denmark is certainly an excellent example of how coordinating care for patients in one centre can make an enormous difference to patient outcomes.  

Q: How will the success of this project be measured?

A: We will be actively auditing patients upon their admission. By doing this we will be able to find out how many times they have been seen in hospitals over the past three years, how many emergency admissions they have had, and other information about their patient experience and satisfaction. We will be looking at these factors over time in order to monitor improvements. An important factor that we will measure is the number of out-patient appointments a person has, a decrease in these appointments would certainly show that the project is successful.

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