Background: Unexplained significant variation may suggest a quality care problem in a health care system. The objective of this study was to determine the extent of variance in spine surgery Saskatchewan and determine possible causes. Methods: Provincial billing records for new spine surgery consultations from May 2011 through October 2012 were correlated with subsequent lumbar surgery. Two tertiary centers (TC1 and TC2) were compared with reference to the Health Region of origin of the patient. Wait times for surgery and utilization of spine pathway clinics was analyzed. Results: TC1 had significantly higher rates of spine fusion and lumbar spine surgery. The percentage of new referrals that went to surgery was 14.0% in TC1 and 11.8% in TC2 (p<0.0001, Z-Test). Population-based calculation of the rate of new referrals was 1581/482387 = 0.33% for TC1 vs. 970/601739 = 0.16% for TC2 (p<0.0001, Z-Test). Utilization of the spine pathway clinic was lower and wait times for surgery were longer in TC1. Conclusions: Causes of regional variation are unknown and likely multifactorial. In Saskatchewan, the most striking variance was that the rate of primary care referrals for lower back conditions in regions served by TC1 was double that for TC2. This could potentially be reduced through more regionally consistent utilization of the spine pathway.

Background: NeuroTouch simulator provides the potential to determine performance metrics, but validation and easily utilized software are essential before implementation of this platform into neurosurgical training. Objectives: Evaluate and validate neurosurgical performance metrics for simulated brain tumors resection. Develop software and a global web based system to allow utilization of these metrics. Methods: The bimanual resection of 8 simulated brain tumors with differing complexity was evaluated. Software was developed to automatically generate all the metrics from NeuroTouch data output including: blood loss, tumor percentage resected, total brain volume removed, maximum and sum of forces utilized, efficiency index, ultrasonic aspirator path length index (UAPLI), coordination index and ultrasonic aspirator bimanual forces ratio (UABFR). Six neurosurgeons and 12 residents were evaluated. Results: Resident performance was significantly more impaired than neurosurgeon by increasing tumor complexity. Significant differences were found between neurosurgeons, senior, and junior residents on efficiency index and UAPLI. UABFR outlined significant differences between senior and junior residents. Coordination index demonstrated significant differences between junior residents and neurosurgeons. Conclusions: Utilizing metrics employed the NeuroTouch platform differentiated novice from expert performance. Software was developed for metrics and will be made available online for all NeuroTouch users allowing global comparison of neurosurgical performance.

Introduction: Colloid cysts of the third ventricle are rare, histologically benign lesions that can be associated with obstructive hydrocephalus. Endoscopic removal developed as an alternative to microsurgical craniotomy as a less invasive surgical treatment. This review examines the endoscopic surgical experience for a consecutive series of patients with colloid cyst of the third ventricle. Methods: Patients with a diagnosis of “colloid cyst of the third ventricle” who were treated in Calgary between January 1994 and July 2014 were reviewed using a clinic database and registry. Results: 95 patients were identified. 30 patients without hydrocephalus underwent serial MRI and clinical observation with one patient developing hydrocephalus leading to surgical treatment. 65 patients underwent endoscopic treatment of their colloid cyst (male=34; female=31). The mean age at diagnosis was 45.5 years. 3 patients had been previously treated with other surgical approaches. All surgically treated patients had hydrocephalus and hydrocephalus resolved in all 65 patients. 1 patient sustained an injury to the internal capsule with transient hemiparesis. Mean followup was 8.2 years (range 0.1-19.3 years). 3 patients experienced colloid cyst recurrence treated with a second endoscopic removal. Conclusion: Endoscopic treatment of third ventricle colloid cysts can be performed with low risk as an alternative to microsurgical resection.

Objective: To identify clinical, radiological, and dosimetric predictors of meningioma response to stereotactic radiosurgery (SRS), and post-SRS adverse radiation events (ARE). Methodology: A retrospective review was conducted. Seventy-five patients had at least 24 months of clinical and radiological follow-up. Tumor control was defined as any volumetric/diametric change less than +10%. Volumetric measurements were made using T1-Gadolinium enhanced 3T MRI scans with ITK-SNAP2.2 software. Univariate statistics were used to identify predictors of post SRS AREs. Results: Females comprised 69.3% of patients, mean treatment age was 58.6 years, and median follow up was 36.2 months. Twenty-one patients had undergone prior surgical resection. Volumetric tumor control (52%) was inferior to diametric control (92%). Twenty-six patients (34.6%) experienced some form of new-onset complication after SRS: Headache (17.3%), cranial neuropathy (10.6%), speech impairment (2.7%), tremor (2.7%), and ataxia (1.3%). Fourteen patients (18.7%) experienced new onset T2 signal change signifying of edema; eight of these patients were symptomatic. Lower Conformity index (1.24 vs. 1.4), and higher treatment-volume ratio (TVR) (0.80 vs. 0.72) were significantly associated with development of edema after SRS (p<0.05, power > 0.8). Conclusion: Volume-based reporting of SRS outcomes for meningiomas is more accurate for reporting tumor control. Conformity index and TVR were identified as predictors of edema following radiosurgery.

Background: Traumatic brain injury (TBI) is the leading cause of traumatic death and disability worldwide. We examined nationwide trends in TBI-related hospitalizations and in-hospital mortality between April 2006 and March 2010 using a population-based database that is mandatory for all hospitals in Canada. Methods: Trends in hospitalization rates were analyzed using linear regression. Independent predictors of in-hospital mortality were evaluated using logistic regression. Results: Hospitalization rates remained stable for children and young adults, but increased considerably among elderly adults (ages 65 and older). Falls and motor vehicle collisions (MVCs) were the most common causes of TBI hospitalizations. TBIs caused by falls increased by 24% (p=0.01), while MVC-related hospitalization rates decreased by 18% (p=0.03). Elderly adults were most vulnerable to falls, and experienced the greatest increase (29%) in fall-related hospitalization rates. Young adults (ages 15-24) were most at risk for MVCs, but experienced the greatest decline (28%) in MVC-related admissions. There were significant trends towards increasing age, injury severity, comorbidity, hospital length of stay, and in-hospital mortality. However, multivariate regression showed that the odds of death decreased over time after controlling for relevant factors. Conclusions: Hospitalizations for TBI are increasing in severity and involve older populations with more complex comorbidities.

Background: Febrile infection-related epilepsy syndrome (FIRES) is a devastating entity characterized by acute onset of refractory epileptic status preceded by a febrile infection, for which no aetiology has been identified so far. Methods: We report the cases of two males presenting with typical FIRES, for whom extensive investigations revealed no specific aetiology. Failure of controlling seizures with multiple anticonvulsants as well as barbiturate coma lead to the decision to try immunotherapy. The first patient received plasma exchange after a negative trial of IVIGs, while the second received plasma exchange in the beginning. Results: Significant improvement in the seizure frequency and intensity was obtained following plasma exchange, and weaning of barbiturate coma was successful in the days following treatment. Both patients remain with significant temporal lobe epilepsy, requiring treatment with 3 anti epileptics. However, cognitive outcome is surprisingly good for both, both exhibiting normal IQs and normal everyday function, with the second patient showing even better recovery, possibly due to earlier treatment with plasma exchange. Conclusion: Our findings of favourable outcome with plasma exchange favours the auto-immune hypothesis often discussed in FIRES. While awaiting further insight onto the aetiology of this syndrome, we suggest a trial of plasma exchange in patients affected.

Background: Dysembryoblastic neuroepithelial tumors (DNETs) are benign tumors of the cerebral cortex that most commonly occur in children or young adults. Seizures are a frequent presenting feature, with an incidence of 80-100%, and are often an indication for surgical resection. Methods: We performed a retrospective chart review of children with DNETs who underwent epilepsy surgery between 1998 and 2014. Results: A total of 12 subjects were identified (6 males, 6 females), all of whom had seizures prior to surgical resection. Of these patients, 1 had infantile spasms, 2 had simple partial seizures and 10 had complex partial seizures. Tumors were located in the temporal (n=7), frontal (n=3) or parietal (n=2) cortex. These patients went on to have surgery on average 15 months after seizure onset, 3 had incomplete resections. At an average follow up of 6 years 4 months, all patients were class 1 on Engel’s Classification. All but one subject with rare non-disabling seizures were seizure free, with only 6 on medication. Follow up MR imaging revealed tumor recurrence in 1 subject. Conclusions: Despite differing seizure seminology and tumor location, surgical resection of these low-grade tumors resulted in excellent seizure outcome even in the setting of incomplete tumor resection.

Introduction: Evaluating the suitability for surgery in patients with epilepsy requires determining if the epilepsy is focal or generalized. Presurgical workups can indicate focal epilepsy in certain cases of generalized epilepsy (GE). The purpose of this study was to identify distinctive features which characterize patients with primary GE that mimics focal epilepsy. Method: We retrospectively identified 19 children with generalized interictal discharges during scalp video-EEG (SVEEG) and underwent invasive monitoring and/or epilepsy surgery. Two children did not undergo resective surgery due to final diagnosis of primary GE (Group A). Seventeen children underwent a resective surgery (Group B). Scalp video-EEG, MEG, MRI, and intracranial video EEG (IVEEG) were reviewed. Results: On (SVEEG), the frequency of generalized spike-and-waves (GSW) was 3Hz in Group A and 1.5-2.5Hz in Group B. Group A had only absence seizures , whereas 80% in Group B had multiple types of seizures. Both groups had lateralized MEG dipoles. One patient in Group A had a focal MRI abnormality. In Group A, IVEEG showed GSW of 3 Hz frequency with inconsistent leading. In Group B, IVEEG showed consistent localization of ictal and interictal high frequency oscillations. Conclusion: Children with generalized 3 Hz spike-and-waves and only absence seizures may be a contraindication of resective surgery even though some presurgical workup shows focality.

Background: Ciliary mutations cause multi-system disorders, often involving the CNS. We set to evaluate the prevalence of ciliary dysfunction in children with isolated neuroanatomical defects, by measuring nasal nitric oxide (nNO), a screening test for Primary Ciliary Dyskinesia (PCD). Study design: We measured nNO levels of 26 children with congenital midline CNS defects. We evaluated the effect of age, gender, and anomaly (brain, spinal cord, or combined) on measurements. We compared our results to the previously established normal range (153.6-509.9 nL/min), and to the cutoff for PCD (77 nL/min). Results: The range for nNO in our cohort was 56.5-334.7 nL/min, with age, gender, and anomaly not having a significant effect. The overall mean, 217.7 nL/min, was significantly lower than that of normal children, 314.51 nL/min (p<0.01). Four subjects (15.4%) had nNO levels below the lower end of normal, with two (7.7%) having values fitting the cutoff for PCD. Conclusions: We report an association between ciliary dysfunction and isolated midline neuroanatomical defects, not in context of any known syndrome. This suggests that genes causing isolated CNS defects, may be implied in the function of cilia. Longitudinal studies are required to investigate whether children with abnormal measurements suffer from any respiratory sequelae.

Background: For adolescents with epilepsy, there is often a poor system in place to meet their individualized transition needs. Our objectives were 1) to develop epilepsy-specific transition care management plans (TCMPs) to ensure access, and attachment to adult healthcare providers, and 2) to identify strategies for providing support during the transition period, including through the development of physician and patient (or caregiver) navigated web-based tools, resources and recommendations for health system improvements. Methods: Physicians and nurses with expertise in areas including adult and pediatric epilepsy, family medicine, psychiatry, and varied allied health professionals were engaged to generate epilepsy-related TCMPs. Results: Through an iterative process spanning the course of over a year, TCMPs were developed to cover areas including: treatment responsive and resistant epilepsy, ketogenic diet, epilepsy surgery, women’s issues, mental health, and psychosocial aspects of epilepsy. The TCMPs referenced established guidelines and best practices in the literature wherever possible. Caregiver roles and responsibilities were outlined, remaining cognoscent of available provincial resources. Conclusions: Epilepsy specific TCMPs can be developed through a collaborative approach between pediatric and adult healthcare providers, easing the patient experience, creating educated accountability, and providing a forum to identify and address gaps of care in adolescents with epilepsy.

Background: Tuberous sclerosis complex (TSC) is a neurocutaneous syndrome that can present with many disabling neurological symptoms, the most common being seizures. Although it is a chronic systemic syndrome, healthcare utilization and long-term outcome of subjects with TSC are not well defined. The goal of this study was to evaluate the direct cost and long-term outcome of TSC compared to other forms of epilepsy and healthy controls. Methods: Our provincial health care database was interrogated to determine use of medical services by patients with TSC, epilepsy and healthy controls from 1996-2011. Data on demographics, outcomes and health care utilization were analyzed. Results: 1004 TSC, 41,934 with epilepsy and 41,934 controls were identified. The prevalence of TSC was 1/7,872 compared to 1/189 for epilepsy. TSC experienced more hospitalizations, medical visits and prescription drug use, resulting in higher total health care costs. Their most common admission diagnosis was seizures and age at death was significantly lower: 61,3 years old for TSC vs 69,6 and 76,6 years old for epilepsy and controls, (p<0,001). Conclusions: TSC subjects have a significantly higher burden of disease than other subjects with epilepsy. These results stress the need for specialized services in this population through the lifespan.

Background: Children with perinatal stroke go on to develop most cognitive skills (e.g. language) due to brain plasticity; however, their performance is usually poor when compared to age-matched controls, indicating a reduced potential compared to uninjured children. To date, how plasticity after early injury affects the development of complex cognitive skills remains uncertain. Here, we use topographical orientation, which relies on integration of several cognitive processes underlain by widespread neural networks, as a model to test plasticity in complex behaviour. Methods: Children with perinatal stroke and age-matched controls were tested with a neuropsychological battery and a novel navigation task. In addition, for each patient, we obtained the most recent MRI scan to assess the effects of lesion characteristics on performance at the navigational task. Results: Children with history of injury performed worse than controls, and their scores were not different based on lesion’s laterality, location or functional region affected. In particular, involvement of regions known to contribute to spatial orientation did not result in significantly decreased performance. Conclusions: As seen in other skills, orientation was preserved, but decreased when compared to age-matched controls. Given its cognitive and neural complexity, topographical orientation may be used as a model for network plasticity after early injury.

Background: Cerebral proliferative angiopathy (CPA) is a rare vascular malformation with intervening normal brain tissue interspersed among abnormal vascular channels. There are 77 reported cases, the youngest being 9 years old, with persistent symptoms and recurring symptoms being rare. Methods: A three-year-old girl with CPA is described and compared to the literature. Results: A previously healthy girl with early left-handedness and a left forehead nevus flammeus presented with sudden onset of right arm and leg weakness, along with abrupt speech arrest and right homonymous hemianopia. Head CT Angiogram and MRI revealed an abnormal vascular network with densely packed, moderately enlarged vessels arising within the white matter with no dominant feeding vessel and both old and acute infarcts in the left hemisphere. Eye exam was unremarkable. The clinical and radiologic features were most consistent with a diagnosis of CPA. Her visual deficits and motor symptoms persisted, and she had a recurrent event shortly after. Conclusions: This is the youngest reported case of CPA, with novel features including radiologic evidence of previous infarcts, clinical recurrence of symptoms, and permanent deficits. This case demonstrates the need for further research into the surveillance and management of this rare entity, possibly unique in young children

Background: We present a case of paroxysmal tonic upgaze (PTU) of infancy treated with a daily low dose of Gravol ® to improve symptoms. Method: Case report Results: A one year-old boy presented with episodes of sustained conjugate upgaze that persisted for 30 to 45 minutes, varied in severity, and occurred with increasing frequency over the past two months. The episodes were worse when fatigued and were relieved by sleep. Pregnancy, delivery, and development were normal. Neurological examination between episodes was normal, as were EEG, brain MRI, and blood analysis. CSF neurotransmitter analysis showed serotonin and dopamine metabolites at lower levels of normal. The patient was diagnosed with paroxysmal tonic upgaze of infancy and was treated with 12.5 mg of Gravol ® daily with complete cessation of episodes. Conclusions: Paroxysmal tonic upgaze (PTU) of infancy is a disorder seen in infants where the eyes are forcibly deviated upwards for minutes to hours at a time. PTU often resolves spontaneously over several months, however episodes are extremely debilitating. Currently, treatments with levodopa have been tried with some success. Via its anticholinergic effects, Gravol may be a novel therapeutic option for PTU, negating the need to use serotonergic medications.

Background: Focal neurological deficits occur in approximately 15% of children with bacterial meningitis. However, cranial nerve involvement such as facial-nerve palsy is uncommon in non-tuberculous bacterial meningitis. Methods: Case Report. Review of the literature was conducted on Pubmed for the search terms: facial nerve palsy and meningitis. Results: We present the case of a 4-year old right-handed girl who presented with a new onset unilateral facial nerve palsy preceded by 5-day history of fever and headaches. The patient had meningeal signs and was identified to have Streptococcal Meningitis. MRI of the brain showed a large previously undiagnosed intranasal encephalocele. The facial palsy resolved within 7 days of antibiotic treatment. Conclusions: Our case represents an unusual combination of facial nerve palsy in context of Streptococcal Meningitis secondary to intranasal encephalocele.

Introduction: Ketamine, an N-methyl D-aspartate (NMDA) receptor antagonist, carries potential benefit in patients with neurological illness. The cerebrovascular/cerebral blood flow (CBF) response to ketamine has been poorly outlined in the literature. Methods: We performed a systematic review of the literature on the cerebrovascular/CBF effects of ketamine in both animal and human subjects. Results: We identified 38 animal studies, and 20 human studies. Within the animal studies, a variety of different models were utilized with the majority focusing changes in global CBF or regional cerebral blood flow (rCBF). Overall, ketamine led to an increase in either global CBF or rCBF, with a vasodilatory effect in medium cerebral vessels. With the human studies a total of 379 patients, 107 of which were control subjects, were studied. Most studies focused on either 131Xe CT or PET imaging with ketamine administration. There was a trend to an increase in global CBF and rCBF with ketamine administration. Conclusions: Animal models indicate an increase in global CBF and rCBF with ketamine administration. Human studies display an Oxford 2b, GRADE C, level of evidence to support an increase in global CBF and rCBF with ketamine administration in both healthy volunteers and elective surgical patients without neurological illness.

Background: In 2014, the Montreal Neurological Hospital reorganized its stroke unit, grouping together all strokes serviced by Neurology/Neurosurgery to ensure continuity of care. This unprecedented change created a new interdisciplinary /interdepartmental team which required a new form of communication to facilitate information dissemination and patient care in a timely manner. Method: Unlike typical rounds, the purpose of the daily huddle is to briefly set the patients’ goals of the day. The huddles are attended by all interdisciplinary team members, lasting approximately 30 minutes. The Assistant Nurse Manager leads the huddle in the morning in the nursing station to discuss the main issues. The huddle outcomes were assessed by: Length of stay (LOS), turnaround time to implement discharge, patient/family and team satisfaction. Results: Length of stay decreased by 4 days, delay to application to disposition was <24 hours. Interdepartmental team stated satisfaction in sharing their expertise in their different domains. Concerns were expressed if the huddle LOS exceeded 30 minutes. Eighty (80%) percent of patients/ families experienced satisfaction that information provided was given in a caring/timely manner. Conclusion: Daily huddles improved LOS and team learning was enhanced. However, huddles need to be more concise.

Background: Most individuals recover from a concussion within 7-10 days. However recovery may be very prolonged. Individuals who do not recover within the usual time are said to have postconcussion syndrome (PCS). The objective of this study was to examine the demography and predictors of PCS. Methods: This was a retrospective cohort study of 284 consecutive concussed patients 221 of whom had PCS on the basis of at least three symptoms persisting at least 1 month. A uniform, internationally accepted definition of concussion was used. Results: The 221 cases showed considerable heterogeneity in clinical features of PCS. They averaged 3.3 concussions with a range of 0 to 12+ concussions, and 62.4% occurred during sports and recreation. The median duration of PCS was 7 months at the time of examination, with 11.8% lasting more than 2 years. Surprisingly, 23.1% with PCS had only 1 concussion. The average age was 27 years (range 10-74). The average number of persistent symptoms was 8.1. 26.2% had a previous psychiatric condition, ADD/ADHD, a learning disability, or previous migraine headaches. The prevalence of arachnoid cysts and Chiari malformation in PCS exceeded the general population. Conclusions: In most of our cases, PCS was disabling, and lasted for months or years.

Background: Acute stroke care pathways are increasingly implemented to improve integration of best-practices, but evidence for impact on functional outcomes is not strong. Elements missing from care-pathways are those directly targeting improvement in function: sit-to-stand and time spent walking. The Stroke Team uses care-pathways to track functional capacity, what the patient can and cannot do, but performance on these key outcomes is difficult to track as the patient is observed by multiple people throughout the day. The purpose of this study is to demonstrate the feasibility and added-value of real-time tracking of patients’ mobility. Methods: A chart review was carried out to identify the extent to which functional capacity and performance is tracked routinely by the Stroke Team. Ethical approval was gained for routine use of accelerometers to be affixed to the unaffected thigh. Results: Swallowing, bladder control, toileting, and feeding were consistently tracked for ~90% of patients. Bed-mobility and capacity to transfer rarely tracked (<12%). Capacity for walking and sit-to-stand was noted but never frequency (performance). Conclusion: Our proof-of concept study will test 30 patients over the next 2 months and link real time performance on transitions and walking to stroke severity and outcome.

Background: Corpus callosotomy is a palliative surgical procedure involving partial or complete disconnection of the corpus callosum. It has been shown to improve outcomes of seizure control with in six months of the procedure. Here, we discuss a challenging case of intractable generalized epilepsy with a delayed response to corpus callosotomy. Methods: This report describes a 23 year old female with onset of seizures since age 16. Patient was followed over 7 year period for evolution of her seizures and treatment. Results: Patient experienced three different types of seizures including atypical absences, drop attacks and grand mal seizures. The most disabling type of seizures were the drop attacks associated with injuries. MRI showed bilateral subependymal heterotopia. Multiple EEG telemetry studies showed generalized spike waves without clear lateralization or focalization. Patient failed seven different antiepileptic medications, ketogenic diet and vagal nerve stimulation. Treatment with anterior corpus callosotomy started to show improvements at 18-24 months after the procedure with less severe drop attacks. Conclusions: Corpus callosotomy usually works few months after surgery. This is a very atypical case in whom callosotomy had a delayed response. This is rarely reported and we do not have a clear explanation. Delayed re-organization of the pathways associated with the seizure initiation may be a potential explanation.