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­ A 7-year-old boy with a background of autism presented to the paediatric emergency department with his left arm ‘feeling strange’ then became difficult to rouse. On examination, he was found to have left arm weakness and a left-sided facial droop without forehead muscle involvement. Three hours later, his symptoms had completely resolved and he was suspected to have had a first seizure. He was admitted for observation and an electroencephalography which showed slower rhythms in the right posterior quadrant, which was reported as within normal appearances for his age. He was discharged home the following day. Three days later he became lethargic and vomited. His parents reported dysphasia with use of single-word phrases only, he also appeared confused. He re-presented to the paediatric emergency department, where he was found to have increased tone in the left arm, ankle clonus and an upgoing plantar reflex on the left hand side. Questions What are the differential diagnoses and what investigations should be considered? What type of imaging modality has been used for figures 1 and 2 and what do they show? What type of imaging is used in figures 3 and 4 and what do they show? What is the difference between moyamoya disease and moyamoya syndrome? Histologically in what way does MMD affect the cerebral vasculature? What are the different types of MMD? What are the management strategies used in MMD? Figure 1 MRI angiogram (MRA) showing the internal carotid arteries (ICA). The left ICA is extremely stenotic at the skull base. The right ICA is occluded at the skull base. The basilar artery is occluded. Figure 2 MRI angiogram demonstrating extensive reconstitution of the intracranial internal carotid arteries via collateralisation from recurrent facial, orbital and skull base branches of the eonline xternal carotid arteries. Supply to the posterior circulation is via the posterior communicating arteries, and also via multiple small collaterals arising from the distal vertebral arteries, the posterior inferior cerebellar arteries (PICA) and deep cervical branches. Figure 3 Fluid-attenuated inversion recovery (FLAIR) MRI image demonstrating multifocal bilateral acute infarcts of varying sizes, the largest of which affects the posterior right hemisphere. Many of the infarcts are watershed in distribution. Figure 4 T2 MRI image demonstrating multifocal bilateral acute infarcts of varying sizes, the largest of which affects the posterior right hemisphere. Answers can be found on page 2.

Objective The aim of this study was to describe the burden of patients presenting to the emergency department (ED) with symptoms occurring after receiving a COVID‐19 vaccination Methods This was a retrospective cohort study performed over a four‐month period across two EDs. Participants were eligible for inclusion if it was documented in the ED triage record that their ED attendance was associated with receipt of a COVID‐19 vaccination. Data regarding the type of vaccine (Comirnaty or ChAdOx1) was subsequently extracted from their electronic medical record. Primary outcome was ED length of stay (LOS) and secondary outcomes included requests for imaging and ED disposition destination. Results During the study period of 22 Feb 2021 to 21June 2021, 632 patients were identified for inclusion in this study, of which 543 (85.9%) had received the ChAdOx1 vaccination. The highest proportion of COVID‐19 vaccine related attendances occurred in June 2021 and accounted for 21 (8%) of 262 total daily ED attendances. Patients who had an ED presentation related to ChAdOx1 had a longer median ED LOS (253 vs 180 minutes, p<0.001) compared to Comirnaty and a higher proportion had haematology tests and imaging requested in the ED. Most patients (588 (88.8%)) were discharged home from the ED. Conclusion There was a notable proportion of ED attendances related to recent COVID‐19 vaccination administration, many of which were associated with lengthy ED stays and had multiple investigations. In the majority of cases the patients were able to be discharged home from the ED.

Objective: A supraglottic airway device (SAD) may be utilised for rescue re-oxygenation following a failed attempt at endotracheal intubation with direct or video laryngoscopy. However, the choice of subsequent method to secure a definitive airway is not clearly established. The aim of the present study was to compare two techniques for securing a definitive airway via the in-situ SAD. Methods: A randomised controlled trial was undertaken. The population studied was emergency physicians (EPs) attending a cadaveric airway course. The intervention was intubation through a SAD using a retrograde intubation technique (RIT). The comparison was intubation through a SAD guided by a flexible airway scope (FAS). The primary outcome was time to intubation. The trial was registered with ANZCTR.org.au (ACTRN1262100 0995875).Results: Four EPs completed intubations using both methods on four cadavers for a total of 32 experiments. The mean time to intubation was 18.2 s (standard deviation 8.8) in the FAS group compared with 52.9 s (standard deviation 11.7) in the RIT group; a difference of 34.7 s (95% confidence interval 27.1-42.3, P < 0.001). All intubations were completed within 2 min and there were no equipment failures or evidence of airway trauma. Conclusion: Successful tracheal intubation of cadavers by EPs is achievable, without iatrogenic airway trauma, via a SAD using either a FAS or RIT, but was 35 s quicker with the FAS.