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PURPOSE: To externally validate the arteriovenous malformation-related intracerebral haemorrhage (AVICH), intracerebral haemorrhage (ICH), and novel haemorrhage presentation risk score (R2eD) in brain arteriovenous malformations. METHODS: Adult patients diagnosed radiologically with an arteriovenous malformation (AVM) at a tertiary neurosurgical centre between 2007 and 2018 were eligible for inclusion. Both the AVICH and ICH scores were calculated for AVM-related symptomatic haemorrhage (SH) and compared against the modified Rankin scale (mRS) at discharge and last follow-up, with unfavourable outcome defined as mRS > 2. R2eD scores were stratified based on presentation with SH. External validity was assessed using Harrel's C-statistic. RESULTS: Two hundred fifty patients were included. Mean age at diagnosis was 46.2 years [SD = 16.5]). Eighty-seven patients (34.8%) had a SH, with 83 included in the analysis. Unfavourable mRS outcome was seen in 18 (21.6%) patients at discharge and 18 (21.6%) patients at last follow-up. The AVICH score C-statistic was 0.67 (95% confidence interval [CI], 0.53-0.80) at discharge and 0.70 (95% CI, 0.56-0.84) at last follow-up. The ICH score C-statistic was 0.78 (95% CI 0.67-0.88), at discharge and 0.80 (95% CI 0.69-0.91) at last follow-up. The R2eD score C-statistic for predicting AVM haemorrhage was 0.60 (95% CI, 0.53-0.67). CONCLUSIONS: The AVICH score showed fair-poor performance, while the ICH score showed good-fair performance. The R2eD score demonstrated poor performance, and its clinical utility in predicting AVM haemorrhage remains unclear.

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The outcomes following re-operation for meningioma are poorly described. The aim of this study was to identify risk factors for a performance status outcome following a second operation for a recurrent meningioma. A retrospective, comparative cohort study was conducted. The primary outcome measure was World Health Organization performance. Secondary outcomes were complications, and overall and progression free survival (OS and PFS respectively). Baseline clinical characteristics, tumor details, and operation details were collected. Multivariable binary logistic regression was used to identify risk factors for performance status outcome following a second operation. Between 1988 and 2018, 712 patients had surgery for intracranial meningiomas, 56 (7.9%) of which underwent a second operation for recurrence. Fifteen patients (26.8%) had worsened performance status after the second operation compared to three (5.4%) after the primary procedure (p = 0.002). An increased number of post-operative complications following the second operation was associated with a poorer performance status following that procedure (odds ratio 2.2 [95% CI 1.1-4.6]). The second operation complication rates were higher than after the first surgery (46.4%, n = 26 versus 32.1%, n = 18, p = 0.069). The median OS was 312.0 months (95% CI 257.8-366.2). The median PFS following the first operation was 35.0 months (95% CI 28.9-41.1). Following the second operation, the median PFS was 68.0 months (95% CI 49.1-86.9). The patients undergoing a second operation for meningioma had higher rates of post-operative complications, which is associated with poorer clinical outcomes. The decisions surrounding second operations must be balanced against the surgical risks and should take patient goals into consideration.

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OBJECTIVE: Cardiopulmonary exercise testing (CPET) is often used to assess pre-operative fitness in elderly patients, in whom peripheral arterial disease (PAD) is highly prevalent, but may affect the results of CPET by early lactate release due to muscle ischemia. This study investigated the effect revascularization of PAD on oxygen delivery (VO2 ) during CPET. METHOD: We conducted a prospective cohort study of 30 patients, who underwent CPET before and after treatment of ilio-femoral PAD. The primary outcome measure was difference in VO2 at the lactate threshold (LT) before and after revascularization. Secondary outcome measures were the relationship between change in VO2 at LT and peak exercise and change in ankle-brachial index (ABI) differential. RESULTS: The study was approved by the North West-Lancaster Research and Ethics committee (reference 15/NW/0801) and registered in clinicaltrial.gov (reference NCT02657278). As specified in the study protocol, 30 patients were recruited but only 20 (15 men), with a mean age of 62 years, completed pre- and post-treatment CPETs. Twelve patients demonstrated an improvement in VO2 at LT after revascularization, but the difference did not achieve statistical significance (mean difference (95% CI) = 1.43 (-0.21 to 3.08) ml/kg/min; (p = 0.085). There was, however, a significant improvement in VO2 , VE/CO2 , workload and Borg breathlessness and leg fatigue score at peak exercise after revascularization. There was no significant correlation between change in VO2 at LT (r = -0.11, p = 0.65) or change in VO2 at peak and ABI differential (r = -0.14, p = 0.55). CONCLUSION: Revascularization of PAD led to significant improvement in multiple peak/maximal exercise parameters within a few weeks and without exercise training. We were unable to demonstrate a statistically significant improvement in VO2 at LT albeit in a majority of subjects this exceeded what we pre-defined as clinically significant.

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INTRODUCTION: Cardiopulmonary exercise test (CPET) is widely used in preoperative assessment and cardiopulmonary rehabilitation. The effect of peripheral arterial disease (PAD) on oxygen delivery (VO2) measured by CPET is not known. The aim of this study was to investigate the effect of PAD on VO2 measurements during CPET. METHODS AND ANALYSIS: We designed a prospective cohort study, which will recruit 30 patients with PAD, who will undergo CPET before and after treatment of iliofemoral occlusive arterial disease. The main outcome measure is the difference in VO2 at the lactate threshold (LT) between the 2 CPETs. The secondary outcome measure is the relationship between change in VO2 at the LT and peak exercise pretreatment and post-treatment and haemodynamic measures of PAD improvement (ankle-brachial index differential). For VO2 changes, only simple paired bivariate comparisons, not multivariate analyses, are planned, due to the small sample size. The correlation between ABI and VO2 rise will be tested by linear regression. ETHICS AND DISSEMINATION: The study was approved by the North West-Lancaster Research and Ethics committee (reference 15/NW/0801). Results will be disseminated through scientific journal and scientific conference presentation. Completion of recruitment is expected by the end of 2016, and submission for publication by March 2017. TRIAL REGISTRATION NUMBER: NCT02657278.

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