Background: Deliberate practice is one aspect of gaining competency in surgical skills. We have previously integrated a vascular microsurgery module into our residency training curriculum, and have recently described our experience with constructing patient-specific spine models for simulating lumbar spinal durotomy repair. The goal of this project is to develop the necessary infrastructure to facilitate practice on the spine model during residency. Methods: A 3D-printed plastic lumbar spine model was created from a patient computed tomography scan. L2 was manually laminectomized, and paraspinal tissues were simulated using Polyvinyl Chloride (PVC) Plastisol. Harvested bovine pericardium was sewn into tubular form as a dural substitute. The pericardial tubes were tied at either end and attached to intravenous tubing to create a closed loop water system. Results: We are developing a video tutorial describing how to setup and use the model. Residents will be recorded while performing a 1.5 cm durotomy and repair using a surgical microscope available in our training laboratory (Drake-Hunterian Neurovascular Laboratory, London, Ontario, Canada). Residents are asked to grade the realism of the model using a questionnaire. Metrics of quality are to be determined. Conclusions: Our proposed model is a cost-effective, easy-to-prepare lumbar spinal simulator that facilitates microsurgical practice during neurosurgical residency.

Background: Industry involvement in neurosurgical research is common, creating financial conflicts of interest (COIs). Most journals require voluntary disclosure of financial COIs. In 2013, the Sunshine Act (SA) was passed in the US, mandating industry disclosure of all payments to physicians. The accuracy of voluntary disclosure can now be determined by comparing voluntary author disclosure with industry data. Methods: We reviewed disclosure statements and calculated rates of voluntary disclosure in major neurosurgical journals before (2011) and after (2013) the Sunshine Act to determine if voluntary disclosure increased after its implementation. We then determined the accuracy of voluntary disclosure in 2013, comparing voluntary disclosure with industry disclosure on the Open Payments Database (OPD). Mean, median and range of industry payments to neurosurgeons were calculated Results: Voluntary disclosure significantly increased in JNS-Spine only (10.7% to 35.4%,p<0.001) after implementation of the SA. The average rate of non-disclosure in all journals studied was 38.3% (Range 33.8%-42.2%)

$32,598,522.97 of industry payments were provided to 656 authors in the five-month period studied (Average $49,692.87/author) Conclusions: Voluntary COI disclosure in JNS- Spine increased after implementation of the Sunshine Act. Industry payments to physicians publishing in neurosurgery journals are common and rates of non-disclosure of COIs are high. The ethical implications of COIs and non-disclosure are discussed.

Background: Training of surgical residents based on the traditional Halstedian model is becoming increasingly scrutinized. The emergence of competency-based training has put pressure on training programs to provide high-fidelity simulation sessions that compliment residents’ training in the operating room. Here we present a novel combination of perfused cadaveric avian wing model in conjunction with live rats for neurosurgical resident training. Methods: The brachial artery of cadaveric duck wing was cannulated and connected to a roller pump. The duck wings remain perfused while residents performed microvascular anastomoses of the brachial and ulnar arteries. This took place prior to live rat modules. Results: The duck wing brachial artery diameter measured 1.5-2.0 mm, similar to the proximal middle cerebral artery in humans. The ulnar artery diameter measured 1.0-1.5 mm, similar to the cortical vessels. 8 interrupted stitches were placed during anastomosis using a 10-0 Nylon suture. Residents who performed the duck wing module felt more comfortable when they moved onto the live rat model with a shallower learning curve. Conclusions: The perfused cadaveric avian wing model provides intermediate to high fidelity simulation that complements the live rat model well. The number of rats needed for neurosurgical simulation training could be reduced via the use of avian wings.

Background: The Canadian Neurosurgery Research Collaborative (CNRC) is a new consortium of neurosurgery residency programs set-up to facilitate the planning and implementation of multi-center studies. As a trainee-led organization, it will focus on resident-initiated, resident-driven projects. The goal of this study is to assess the demographics of Canadian neurosurgery residents, with particular focus on their academic and subspecialty interests. Methods: After approval by the CNRC, an online survey will be sent to all Canadian neurosurgery residents and fellows with reminders at 2, 4 and 6 weeks. Anonymous, basic demographic data will be collected. Specific interest towards the various subspecialties, research and academic vs community practice will be measured. The data will be crossed with the ongoing Canadian Neurosurgery Operative Landscape study to assess the impact of case volume on academic and subspecialty interests. Results: This is the first study providing a snapshot of Canadian neurosurgery residents at all levels of training. The study is ongoing and the official results will be presented at the meeting. As one of the first CNRC studies, it will also demonstrate the effectiveness of the collaborative. Conclusions: Understanding the demographics and interests of Canadian neurosurgery residents will allow the CNRC to better fulfill its mission.

Background: Current selection methods for neurosurgical residents lack objective measurements of psychomotor performance. This pilot study was designed to answer three questions: 1) What are the differences in bimanual psychomotor performance among neurosurgical residency applicants using the NeuroVR (formerly NeuroTouch) neurosurgical simulator? 2) Are there exceptionally skilled medical student applicants? 3) Does previous surgical exposure influence surgical performance? Methods: Medical students attending neurosurgery residency interviews at McGill University were asked to participate. Participants were instructed to remove 3 simulated brain tumors. Validated tier 1, tier 2, and advanced tier 2 metrics were utilized to assess bimanual psychomotor performance. Demographic data included weeks of neurosurgical elective and prior operative exposure. Results: Sixteen of 17 neurosurgical applicants (94%) participated. Performances clustered in definable top, middle, and bottom groups with significant differences for all metrics. Increased time spent playing music, increase applicant self-evaluated technical skills, high self-ratings of confidence and increased skin closures statistically influenced performance on univariate analysis. A trend for both self-rated increased operating room confidence and increased weeks of neurosurgical exposure to increase blood loss was seen in multivariate analysis. Conclusions: Simulation technology identifies neurosurgical residency applicants at the extremes of technical ability and extrinsic and intrinsic applicant factors appear to influence performance.

Background: Anticholinergic and sedating medications are generally contraindicated in those with cognitive decline. We examined trends in medication use by patients presenting to a rural and remote memory clinic (RRMC) between March 2004 and June 2015 to determine whether patterns of medication use have changed. Methods: The first 445 patients seen at the RRMC between 2004 and 2015 were included in this analysis. Medication lists were collected at the patient’s initial visit, and it was noted whether patients were taking anticholinergic or potentially sedating drugs. Statistical analysis (Spearman’s Correlation) was conducted to examine trends in medication use over time. Results: Ninety-one patients (20.5%) were taking at least one anticholinergic medication. There was a statistically significant decline (25.0% in 2004 to 12.5% in 2014) in percentage of patients presenting with anticholinergic medications over the eleven years of this study (Spearman’s correlation coefficient=-0.64, p=0.035). Conclusions: The most encouraging statistic to come from this study is a decline in anticholinergic medication use in this rural population. Prescribers must be properly informed to ensure that the number of medications per patient does not continue to rise, that medications are used only as necessary, and that potentially deleterious medications are avoided.

Background: Septo-Optic Dysplasia is a rare disorder with developmental malformations that was first reported by De Morsier.SOD associated with refractory epilepsy has not been well studied. We report six cases with SOD in patients with malformation of cortical development(MCD) and medically refractory epilepsy that underwent video-EEG telemetry. Methods: Six cases of SOD plus were admitted to the Epilepsy Monitoring Unit at London Health Sciences Centre because of medically refractory epilepsy. Functional hemispherectomy in one patient resulted in significant reduction of her seizures while insertion of a vagus nerve stimulator was not successful in controlling seizures in another patient. Right temporal resection for one patient resulted in about 60% reduction in her seizures. The remaining three patients were not surgical candidates and they remained on antiepileptic drugs. Results: MCD was present in 4/6 patients. Bilateral optic nerve hypoplasia was found in 50% of the patients. EEG was abnormal in all cases(6/6).Intractable epilepsy was found in 6/6 patients. Conclusions: SOD plus was associated with medically refractory epilepsy.

Background: Regulation of drivers licences aims to strike a balance between autonomy and public safety. In Newfoundland and Labrador, an individual experiencing seizures must have a 6-month seizure-free interval before a driving licence is reinstated, although exceptions apply. There is a paucity of data surrounding driving safety in people with epilepsy. Methods: The Department of Motor Vehicles and Registration extracted data from the charts of drivers experiencing seizures for the period between 2010-2014, inclusive. Two groups were examined: drivers aged 16-24 (n=104) and 75+ (n=115). Given that mandatory reporting is required in Newfoundland and Labrador, this theoretically represents a population-based study. Results: Overall, 5.1% of the population experienced a motor vehicle collision, and collisions were more frequent among younger drivers. Significantly more people in the 75+ category had a medical history that could have contributed to seizures. Only 37.6% of the overall sample had their first seizure reported. This was not different between age groups or seizure types (generalized vs. focal). Though the age groups differed with respect to seizure type, this did not affect driving safety, as measured by motor vehicle collisions and driving disobedience. Conclusions: We found a high rate of driving disobedience despite the requirement for mandatory reporting and seizure type did not affect driving safety.

Background: About 35% of patients with epilepsy may develop drug-resistant epilepsy (DRE). Identifying risk factors associated with DRE will allow us to identify earlier patients in the course of the disease. Methods: This is a case-control study nested within a cohort. Chart reviews of subjects who full fill inclusion criteria were completed. Inclusion criteria included age>18 years, focal epilepsy determined by clinical correlation and EEG. DRE was determined by ILAE criteria. Results: 149 subjects were included. Seventy had DRE (cases), and seventy-nine did not have DRE (controls). DRE group had a mean age of 41 years (SD+14.8) compared to the control group (49+17.5) (p=0.003). DRE group had a mean age at diagnosis of epilepsy of 19+15.3 compared to the control group with a mean of 33.6+21. (p=<0.001). The main risk factors identified in this study were; cortical dysplasia OR 8.67 (CI 1.04-72.3, p=0.026); mesial temporal sclerosis (MTS) (OR 2.69; CI 1.12-6.47; p=0.024); and presence of complex partial seizures (OR 2.04. Conclusions: Young age at diagnosis of focal epilepsy, diagnosis of cortical dysplasia, MTS, and presence of complex partial seizures are risk factors for DRE

Background: Polymicrogyria (PMG), a malformation of cortical development, describes an area of cerebral cortex with excessively small convolutions. This study examines the clinical spectrum of epilepsy associated with PMG, a condition which commonly presents as medically-refractory epilepsy. Methods: All patients investigated in the Epilepsy Monitoring Unit from 2006 to 2015 at our centre and identified to have PMG by MRI were studied by retrospective chart review. Results: We identified 8 patients (4 male), mean age 33 years (range: 28 to 46). Seven had childhood onset of epilepsy. All experienced focal-onset seizures; 6 had occasional evolution to generalized, bilaterally convulsive seizures. PMG was associated with schizencephaly in 3 cases. Five patients were investigated with intracranial electrodes. Two patients underwent resective surgery, 1 achieved seizure-freedom, and 1 had class III (ILAE classification) following parietal corticectomy. Two patients underwent placement of vagus nerve stimulation and one a stimulator of the anterior nuclei of the thalami. Conclusions: Medically-refractory cases of PMG should be considered for presurgical evaluation, despite only a small portion being amenable to resective surgery. Extensive cortical malformation on MRI made intracranial electrodes necessary to identify the epileptic zone. Epilepsy surgery remains an important consideration given the possibility of seizure-freedom, as achieved in our patient.

Background: SIRPIDS were first described in 2004 in patients admitted in an intensive care unit. Despite few studies attempting to better characterize SIRPIDS, their pathophysiology and clinical implication remain uncertain. Methods: Adult patients hospitalized in an intensive care unit with alteration of consciousness who underwent EEG recording in three separate centers were included in this retrospective study. Demographic data and EEG findings were noted. Characteristics of SIRPIDS were documented. The main outcome measures included the incidence of SIRPIDS, association of SIRPIDS with mortality and other EEG characteristics, EEG and clinical predictors of mortality. Results: 416 patients were included and SIRPIDs were identified in 43 patients (10.3%). The proportion of patients with SIRPIDs was not significantly different across the three sites (p=0.3351). Anoxia (p=0.0009), antiepileptic medications (p=0.0109), electrographic seizures (p=0.0259), triphasic waves (p=0.0012) and epileptiform discharges (p=0.0242) were independently associated with the presence of SIRPIDs. Older age (p=0.0050), anoxia (p=<0.0001) and absence of EEG reactivity (p<0.0001), but not SIRPIDs (p=0.1668), were independently associated with in-hospital mortality. Conclusions: In critically ill patients undergoing EEG, SIRPIDs occurred in 10% and were associated with other electrographic abnormalities previously reported to indicate poor prognosis. SIRPIDs were not independently associated with in-hospital mortality.

Background: Deep brain stimulation for epilepsy is becoming an effective option for the treatment of refractory epilepsy. This is the case of a 19-year-old male patient who has had refractory seizures since 2.5 years old. Seizures occur up to 100 times per day, including gelastic, complex partial, and generalized tonic-clonic types. Methods: Continuous video-EEG monitoring, technetium 99 m ECD SPECT, PET-CT and 3T MRI are used for localization. Depth electrodes are implanted in right frontal orbital, cingulate and lateral frontal regions. Results: Video-EEG records 79 seizures arising from the right frontocentral region. Clinically, patient assumes a fencing posture, with left arm extension. Some seizures undergo secondary generalization. SPECT reveals subtle asymmetric hyperperfusion in right mesial frontal area, while PET-CT and MRI do not show focal lesion(s).Stereo-EEG recording and stimulation confirm seizure onset and trigger zone in the premotor cingulate posterior region. Treatment with stimulation in this region at 130-150 Hz, 4-5 mA, and pulse duration 0.1 ms reduces seizure frequency from 100/day to 3/week. Seizures last only 2-3 seconds, without postictal confusion leading to improvements in neuropsychological function. AED dosages are not reduced. Conclusions: Successful intracranial EEG localization of otherwise non-lesional non-resectable seizure focus permits the use of deep brain stimulation that effectively reduces refractory seizure frequency.

Background: The clinical identification of hippocampal sclerosis (HS) is important in predicting surgical outcomes in patients with temporal lobe epilepsy (TLE). In cases where gross hippocampal sclerosis is not identifiable clinically, a more detailed analysis of hippocampal subfields using ultra-high-field magnetic resonance imaging (MRI) may reveal areas of abnormality, which was the focus of our study. Methods: Patients (N=13) with drug-resistant TLE (9 no-HS, 4 HS) and 20 age-matched healthy controls were scanned and compared using a 7T MRI protocol. Using a manual segmentation scheme to delineate hippocampal subfields, subfield-specific volume changes were studied between the two groups. In addition, radiological patient assessment at 7T was correlated with measured subfield changes. Results: Volumetry of the hippocampus at 7T in HS patients revealed significant ipsilateral subfield losses in CA1 and CA4DG. Volumetry also uncovered subfield volume losses in 33% of no-HS patients, which had not been detected conventionally. Furthermore, 89% of no-HS patients showed abnormality (internal architecture or size) at 7T, identified by radiologists blinded to the patient’s initial classification. Conclusions: These preliminary findings indicate that hippocampal subfield volumetry assessed at 7T may be superior to conventional visual inspection by a neuroradiologist in the identification of hippocampal pathologies in TLE.

Background: Seizures and epilepsy are well-recognized complications after stroke. However, the reported incidence varies and so does their management. Methods: We conducted a systematic review and sought observational studies that reported incidence of seizures and/or epilepsy following arterial ischemic stroke in adults, and those that reported the management of epilepsy, specifically the use of EEG to determine the diagnosis, timing of initiation of anti-epileptic drug (AED), and the treatment response to AEDs. We systematically searched in Medline including Pre-Medline and EMBASE databases from their inception to October 1, 2015. First the titles and then the articles were reviewed and rated by two independent reviewers, and disagreements were resolved by consultation with a third reviewer. A pre-set data abstraction form was used for extracting the information of interest. Results: A total of 11,815 titles were found from the initial search strategy across all databases following de-duplication. Of these 130 studies are included for full text review. The adjudication process is underway and the reviewers are sifting through these studies to select the studies that will be included in the final review. Conclusions: Understanding incidence and management of post-stroke epilepsy is important to improve the quality of life of stroke survivors.

Background: Bilateral facial paralysis is a rare manifestation of Human Immunodeficiency Virus (HIV). Few cases of HIV seroconversion syndrome presenting with aseptic meningitis and facial diplegia have been previously reported. Methods: Case Report. Case Description: A 44-year-old male with uncontrolled hypertension who presented with 5-day history of migrainous headache, bucco-labial dysarthria, meningismus and dysguesia. Three weeks prior to presentation, he suffered a transient febrile illness preceded by an unprotected sexual encounter while vacationing in Côte d’Ivoire. Examination was significant for hypertensive urgency, bilateral lower motor neuron (LMN) facial paralysis, and meningeal irritation. Investigations revealed acute on chronic renal impairment and left ventricular hypertrophy. Brain MRI (without contrast) revealed microhemorrhages with dystrophic calcifications and microangiopathic changes. CSF analysis revealed 55 WBC (lymphocytic), normal glucose, and 0.67g/L protein. The infectious work-up was positive for HIV, which was confirmed by Western Blot (WB). CD4 count was 176 cells/μL and the viral load was 419,289 copies/ml. Lyme antibodies were also positive by enzyme-linked immunosorbent assay (ELISA), but negative by WB. Discussion: Facial diplegia is a rare manifestation of HIV, and can be indicative of a seroconversion syndrome. This case illustrates another layer of complexity; deciphering acute from chronic systemic manifestations of hypertension, and appreciating falsely positive Lyme antibodies by ELISA during acute HIV seroconversion.

Background: Lemierre’s syndrome is a rare but serious complication of bacterial oropharyngeal infection. It is characterized by local spread of the primary infection, thrombophlebitis of the internal jugular vein, and septic metastases resulting in significant multi-system complications. Methods: A case report. Results: A previously healthy 63 year-old female presented to our emergency room with four-day history of sore throat, headache, fever and malaise. Initial examination revealed evidence of left tonsillar swelling and cervical lymphadenopathy. The patient rapidly deteriorated within hours of presentation and developed septic shock that was complicated by an acute kidney injury and disseminated intravascular coagulation (DIC). CT of the head and neck revealed a deep abscess within the left masticular triangle extending to surrounding soft tissue as well as C1-C3 epidural space. An extensive bilateral internal jugular vein thrombosis was noted; extending into the sigmoid and cavernous sinuses bilaterally. A thrombosis of the superior sagittal sinus and parafalcine subdural hematoma were also demonstrated. Blood cultures grew Group C Streptococcus. As the deep abscess was not amenable to surgical drainage, the patient was treated with broad-spectrum IV antibiotics. Anticoagulation was also commenced after management and resolution of the DIC. Conclusions: Lemierre’s syndrome remains relevant nowadays and awareness of its potential neurological complications is warranted.

Background: Orthostatic symptoms including dizziness, light-headedness and syncope can be major causes of disability in patients with dysautonomia. Currently there is no validated tool capable of discriminating orthostatic from non-orthostatic constitutional symptoms. Therefore, we developed the Orthostatic Discriminant and Severity Scale (ODSS) to help make this distinction. Objective: Demonstrate validity and reliability of the ODSS. Methods: Convergent and clinical validity were assessed by correlating Orthostatic scores with previously validated tools (Autonomic Symptom Profile (ASP), composite scores of the Orthostatic Hypotension Questionnaire and the total Composite Autonomic Severity Score (tCASS), respectively). Test-retest reliability was calculated using an intra-class correlation coefficient. Results: Orthostatic scores from 23 controls and 5 patients were highly correlated with both the Orthostatic Intolerance index of the ASP (r=0.724;p<0.01) and the composite OHDAS and OHSAS (r=0.552;p<0.01 and r=0.753;p<0.01, respectively), indicating good convergent validity. Orthostatic scores were significantly correlated with tCASS (r=0.568;p<0.01), and the systolic blood pressure change during head-up tilt (r=-0.472;p=0.013). In addition, patients with Neurogenic Orthostatic Hypotension had significantly higher Orthostatic scores than controls (p<0.01) indicating good clinical validity. Test-retest reliability was strong (r=0.954;p<0.01) with an internal consistency of 0.978. Conclusions: Our results, though preliminary, provide empiral evidence that the ODSS is capable of producing a valid and reliable orthostatic score.

Background: NMDA receptor encephalitis (NMDARE) is associated with pre-existing psychiatric symptoms and seizure disorders. It is not typically associated with elevated ICP. Diagnostically, EEG findings in NMDARE are characteristic as are the pathological features of ovarian teratomas associated with this disease. We report a patient who tested positive for NMDARE however presented with features not known to be associated with the disease including elevated ICP, atypical EEG findings and grossly atypical features on pathological section. Results: A 26 year old woman presented with psychiatric symptoms and status epilepticus. On examination, she was found to have papilledema and eleveated ICP on measurement. Her imaging and EEG demonstrated atypical findings, not consistent with NMDARE. CT scan of the abdomen demonstrated an adnexal mass. CSF studies eventually tested positive for NMDARE and following removal of her ovarian teratoma, the pathology demonstrated atypical findings for lesions associated with NMDARE classically. Conclusions: NMDARE is a new entity, which has historically shown a typical clinical course. Our case demonstrates a previously undescribed presentation of NMDARE with elevated ICP, atypical EEG findings and unique pathology of the associated ovarian teratoma.

Background: Post concussion syndrome (PCS) can affect up to 30% of patients with concussion. Biomarkers of this condition would be beneficial for diagnosis and management. We hypothesized that eye tracking parameters would correlate with microstructural changes of white matter integrity, as measured by diffusion tensor imaging (DTI), in patients with PCS. Methods: Sixty patients with PCS and at least 2 concussions participated in our prospective study. Attention and executive function were tested using Visual Attention Scanning Technology (VAST). In a matching task, the normalized number of visits to master image before making the first selection is used as a surrogate of working memory. We related performance on VAST to white matter integrity using Tract-Based Spatial Statistics of diffusion tensor imaging data. Results: 60 participants (mean age 34.3 years, SD 13.8) had a mean of 4 concussions. There were negative correlations between fractional anisotropy (FA) of the genu, body, and splenium of the corpus callosum and normalized number of visits to master image before first selection (r=-0.432, p=0.001; r=-0.504, p<0.001; and r=-0.388, p=0.002; respectively). A negative correlation was also seen between right cingulum FA and the global processing index (r=-0.349, p=0.006). Conclusions: Impaired performance on eye tracking measures of attention and executive function may reflect alterations in white matter tracts.

Background: Clarithromycin is a macrolide antibiotic, which has been successfully used for treating narcolepsy without cataplexy and primary hypersomnia. Sleep-paralysis has not been reported as a side effect of this medication. Methods: We report a 44-year-old right-handed female, who presented with three episodes of paralysis over 2-day. Each spell occurred upon awakening or while falling asleep lasting less than 2-minute. Only one episode was accompanied by tingling and numbness. She denied cataplexy, sleep attacks, hypnopompic and hypnagogic hallucinations. She had no history of similar episodes. She had never experienced migraine with or without aura. She was obese and suffered nocturnal snoring. She had recently been started on Clarithromycin for pneumonia. Her neurological examination was normal. Results: Brain MRI was normal. Stroke work up including carotids CT angiogram, 24-hour Holter monitoring and echocardiogram were unremarkable. Polysomnogram when she was not on Clarithromycin indicated mild obstructive sleep apnea and no narcolepsy. She had no further episodes of sleep paralysis after Clarithromycin was discontinued. Conclusions: We believe that administration of Clarithromycin was the cause of sleep paralysis. We hope that this case report increases awareness about this particular side effect of Clarithromycin and leads to further investigation about the etiology of sleep paralysis.