Background: Atrial fibrillation (AF) is associated with increased risk of ischemic stroke. In Canada, the contemporary burden of AF-related stroke is incompletely characterized. Our objective was to determine temporal trends in hospital admissions and in-hospital mortality for AF-related stroke in Canada from 2007 to 2015. Methods: We conducted a retrospective cohort study using Canadian national administrative data to identify admissions to hospital for stroke with comorbid AF between 2007 and 2015. We analyzed temporal trends in age- and sex-standardized proportion of admissions with comorbid AF and associated in-hospital mortality. Results: There were 222,100 admissions to hospital for ischemic (182,990) or hemorrhagic (39,110) stroke. The age-sex adjusted proportion of ischemic stroke admissions with comorbid AF increased from 16.2% to 20.5% (p for trend = 0.02) between 2007 and 2015, and was stable among hemorrhagic stroke. In-hospital mortality for ischemic stroke with comorbid AF decreased from 21.6% to 15.0% (p for trend = 0.001). Conclusions: Rates of hospital admission for ischemic stroke with comorbid AF have increased, while associated in-hospital mortality has decreased. These results identify AF as an important continued focus for stroke prevention. Our findings provide insight into current trends and highlight the need for continued focus on AF-related stroke.

Most basic science research has focused on overt stroke caused by blockage of major blood vessels. Less attention has been paid to small vessel disease giving rise to covert stroke that often leads to vascular cognitive impairment (VCI). One reason for this may be the relative lack of relevant animal models. This talk will describe a model of VCI induced in middle-aged Sprague-Dawley rats exposed to a diet high in saturated fats, salt and refined sugar (HFSS). In Experiment 1, rats fed HFSS and subjected to a small mediodorsal (MD) thalamic stroke with or without concomitant cerebral hypoperfusion experienced significant executive dysfunction. In Experiment 2, dietary influences on functional, physiological and anatomical parameters were assessed. We found significant hypertension, blockage of brain microvessels (2-photon microscopy) and white matter atrophy in HFSS diet animals. As in Experiment 1, profound, specific set-shifting executive dysfunction was noted following both small MD infarcts (0.332 mm3) and the HFSS diet. In summary, these data describe a middle-aged animal model of VCI that includes clinically-relevant metabolic disturbances and small vessel disease and as such may be helpful in developing new cognitive therapies.

Background: The relationship between vascular disease and Parkinson’s disease (PD) is controversial. We performed a cross-sectional study to investigate the association of two common vascular diseases (stroke and coronary artery disease [CAD]) with Parkinson’s disease. Methods: We identified 63 and 62 PD cases in two population-based cohorts (Malu rural community and Wuliqiao urban community) and collected information of PD and non-PD by means of questionnaires. Logistic regression analysis was used to investigate the association between stroke, coronary artery disease and PD, after adjusting for age, sex, hypertension, diabetes mellitus, hypercholesterolemia, smoking status, alcohol consumption, tea consumption and body mass index. Results: After adjustment for potential confounders, we found that CAD and stroke were associated with PD in the Malu rural community (CAD: odds ratio [OR]=7.11, 95% confidence intervals [CI]: 3.09-16.40, p<0.001; stroke: OR=6.77, 95% CI: 3.09-14.81, p<0.001) and stroke was associated with PD in the Wuliqiao urban community (OR=2.58, 95% CI: 1.36-4.89, p=0.004), especially in women. In a subgroup analysis of PD with age- and sex-matched controls, the results were similar in the Malu rural community (CAD: OR=12.72, 95% CI: 2.92-55.32, p=0.001; stroke: OR=6.26, 95% CI: 1.83-21.42, p=0.003), whereas in the Wuliqiao urban community the results were different in that CAD (but not stroke) was found to be associated with PD (CAD: OR=2.44, 95% CI: 1.09-5.47, p=0.03; stroke: OR=1.79, 95% CI: 0.77-4.17, p=0.18). Conclusions: Our study suggested that stroke and CAD are associated with PD in two Chinese population-based cohorts, indicating a probable vascular component in the pathogenesis of PD.

Adult Glioblastomas (GBMs) remain one of the least curable brain cancers despite the discovery and use of DNA alkylating agent Temozolomide (TMZ). TMZ provides a moderate survival benefit to sensitive patients whose O6-methylguanine-methyltransferase (MGMT) gene is silenced by promoter methylation. Unfortunately, TMZ potential is stunted because of the rapid onset of tumour recurrence and acquired resistance believed to result from the upregulation of DNA damage repair by the base excision repair (BER), mismatch repair (MMR), or homologous recombination (HR) systems. Our laboratory previously demonstrated that cell lines obtained from recurrent, TMZ-resistant GBMs could be re-sensitized to TMZ when treated with an inhibitor of poly (ADP-ribose) polymerase-1 (PARP-1) – a protein instrumental in the recruitment of BER machinery. From this preliminary research, we postulate that PARP-1 inhibition may not only be used to overcome established resistance in GBM but may also be used to prevent its emergence altogether. To test this hypothesis, we utilized the MGMT-methylated GBM cell line U251N and developed an in vitro model of inducible TMZ resistance. We verified that prolonged treatment of U251N cells with TMZ resulted in the emergence of resistant colonies that resembled recurrent GBM clinically observed in TMZ-treated patients. However, when the parental U251N line was co-treated with TMZ and PARP-1 inhibitor ABT-888, resistant colonies failed to appear. Therefore, PARP-1 inhibition may possess the potential to maintain tumour sensitivity to TMZ as well as evade the otherwise inevitable development of resistance in GBM.

JC virus is the etiological agent of progressive multifocal leukoencephalopathy, a white matter demyelinating disease that mostly affects immunocompromised patients. JC virus can also infect neurons and meningeal cells and cause encephalitis, meningitis and granule cell neuronopathy. We report a patient with JC virus granule cell neuronopathy, without concomitant progressive multifocal leukoencephalopathy, presenting as inaugural acquired immune deficiency syndrome-related illness. This patient’s human immunodeficiency virus infection remained undiagnosed for several months after neurological symptoms onset. We review JC virus pathophysiology, clinical manifestations, treatment and prognosis, and emphasize the importance of considering human immunodeficiency virus infection and related opportunistic infections in the differential diagnosis of new-onset isolated cerebellar disease.

Because most tested drugs are active against only one of the damaging processes associated with stroke, other mechanisms may cause cellular death. Thus, a combination of protective agents targeting different pathophysiological mechanisms may obtain better effects than a single agent. The major objective of this study was to investigate the effect of combination therapy with vascular endothelial growth factor (VEGF) and nerve growth factor (NGF) after controlled ischemic brain injury in rabbits. Methods: Animals were randomly assigned to one of the following groups: sham group, saline-treated control group or NGF+VEGF-treated group. Animals received an intracerebral microinjection of VEGF and NGF or saline at 5 or 8 hours after ischemia. The two specified time points of administration were greater than or equal to the existing therapeutic time window for monoterapy with VEGF or NGF alone (3 or 5 hours of ischemia). Infarct volume, water content, neurological deficits, neural cell apoptosis and the expression of caspase-3 and Bcl-2 were measured. Results: Compared with saline-treated controls, the combination therapy of VEGF and NGF significantly reduced infarct volume, water content, neural cell apoptosis and the expression of caspase-3, up-regulated the expression of Bcl-2 and improved functional recovery (both p<0.01) when administered 5 or 8 hours after ischemia. The earlier the administration the better the neuroprotection. Conclusions: These results showed that the combination therapy with VEGF and NGF provided neuroprotective effects. In addition, the time window of combination treatment should be at least 8 hours after ischemia, which was wider than monotherapy. RÉSUMÉ:Les effets d’une polythérapie combinant agents neuro-protecteurs et agents vasoprotecteurs dans les cas d’ischémie cérébrale.Contexte:Étant donné que la plupart des médicaments préalablement testés tendent à n’agir contre seulement un des processus de dommage associés aux AVC, il est possible que d’autres processus entraînent une mort cellulaire. À cet effet, il se pourrait qu’une combinaison d’agents protecteurs ciblant divers mécanismes physiopathologiques permette d’obtenir de meilleurs résultats qu’un simple agent. Après avoir suscité de façon contrôlée des lésions cérébrales ischémiques chez des lapins, l’objectif principal de la présente étude a donc été de se pencher sur l’impact d’une polythérapie combinant la protéine dite « facteur de croissance de l’endothélium vasculaire » (ou « VEGF » en anglais) avec le « facteur de croissance des nerfs » (ou « NGF » en anglais). Méthodes: Les animaux ont été attribués au hasard à l’un des groupes suivants : ceux ayant reçu un traitement fictif ; ceux, du groupe témoin, ayant bénéficié d’un traitement à base de solution saline ; et finalement ceux ayant été traités au moyen des VEGF et NGF. À noter que les lapins ont reçu une micro-injection intracérébrale de VEGF et de NGF ou de solution saline 5 heures ou 8 heures à la suite de leur AVC. Ces deux délais d’administration des VEGF et NGF sont équivalents ou supérieurs aux délais actuels d’administration des VEGF ou NGF à titre de monothérapie (3 heures ou 5 heures à la suite d’un AVC). Tant le volume des infarctus, le contenu en eau, les déficits neurologiques ainsi causés, l’apoptose des neurones que l’expression des protéases caspase 3 et des protéines Bcl-2 ont été mesurés. Résultats: Si on la compare au traitement à base de solution saline administré au groupe témoin, la polythérapie à base de VEGF et de NGF, lorsqu’administrée 5 heures ou 8 heures à la suite de l’AVC, a su réduire de façon notable le volume des infarctus, le contenu en eau, l’apoptose des neurones et l’expression des protéases caspase 3. Elle a également permis de réguler à la hausse l’expression des protéines Bcl-2 en plus d’entraîner une amélioration de la récupération fonctionnelle (p < 0,01 pour ces deux aspects). Ainsi donc, plus tôt l’on opte pour cette polythérapie, meilleure sera la neuroprotection encourue. Conclusions: Ces résultats démontrent que la polythérapie à base de VEGF et de NGF procure des effets neuroprotecteurs. Quant au délai d’administration de ce traitement combinatoire, il devrait être d’au moins 8 heures à la suite d’un AVC, ce qui est plus élevé que la monothérapie.

Introduction: Engaging residents across a multiyear training spectrum is challenging given the heterogeneity of experience and limited time available for educational activities. A “flipped classroom” model, in which residents prepare ahead of time for mentored topic discussions, has potential advantages. Methods: We implemented a curriculum consisting of topics distributed across the specialty. Weekly, each resident was randomly assigned to research a specific aspect of an assigned topic appropriate to his or her level of experience: junior residents about what characterizes each clinical entity, midlevel residents about when to intervene, and chief residents about how to administer treatment. Residents completed an anonymous survey 6 months after implementation. Board examination performance was assessed before and after implementation. Results: A total of 12 residents participated in the program. Weekly, 1.75±0.40 hours were spent in preparation, with senior residents reporting less time than junior residents. All residents indicated that the accumulation of experience across 7 years of residency was a major advantage of this program, and all preferred it to lectures. Performance on the board examination significantly increased after implementation (from 316±36 to 468±45, p<0.05). Conclusions: The flipped classroom is a viable approach to resident education and is associated with increased engagement and improved performance using validated knowledge-assessment tools.

Background: Secondary neurotransmitter deficiencies have been reported in several reviews. Our primary aim was to assess the relationship among epilepsy, antiseizure medications, and specific neurotransmitter abnormalities. We also evaluated movement disorders and brain abnormalities via magnetic resonance imaging scans in patients with secondary neurotransmitter defects. Methods: This is a retrospective case series of 376 patients who underwent neurotransmitter analysis at BC Children’s Hospital between 2009 and 2013, for a variety of neurological presentations. The biochemical genetics laboratory database was interrogated for results of cerebrospinal fluid neurotransmitter analyses. Clinical data for patients with abnormal results were collected from the hospital charts. Statistical analysis included one-way analysis of variance, chi-square, and a two-way contingency table. Results: Abnormal neurotransmitter values were identified in 67 (17.8%) patients, two (0.53%) of which were attributable to a congenital neurotransmitter disorder and 11 (16.9%) secondary to other genetic diagnoses. Of 64 patients with secondary abnormal neurotransmitter values, 38 (59%) presented with epilepsy and 20 (31%) with movement disorders. A combination of epilepsy and movement disorder was less frequent. Discussion: Acknowledging the limitations of this retrospective chart review, we conclude that, in our cohort, in addition to patients with movement disorders, a considerable number of patients with epilepsy and epileptic encephalopathy also showed secondary neurotransmitter mono-amine abnormalities. There is no clear relation, however, between clinical phenotype and type of neurotransmitter affected. In addition, no association was identified between the type of antiseizure medications and affected neurotransmitter type. We outline the need for prospective studies to further enrich our understanding of the relation between epilepsy and neurotransmitters with a focus on improving treatments and patient outcomes.

The objective of this study was to describe the provision of Physical Medicine and Rehabilitation acute care consultations in the United States and Canada. Physical Medicine and Rehabilitation department chairs/division directors at academic centers in Canada and the United States were mailed an 18-item questionnaire. Seven of 13 (54%) Canadian and 26/78 (33%) American surveys were returned. A majority of Canadian and American academic institutions provide acute care consultations; however, there were some national differences. American institutions see larger volumes of patients, and more American respondents indicated using a dedicated acute care consultation service model compared with Canadians.

Exactly 200 years ago, the London surgeon-apothecary James Parkinson (1755-1824) published a 66-page-long booklet entitled An Essay on the Shaking Palsy, which contains the first clear clinical description of the shaking palsy or paralysis agitans, which we now refer to as Parkinson’s disease. However, the value of this essay was not fully recognized during Parkinson’s lifetime, which spanned the American Revolution, the French Revolution, and the Napoleonic Wars. James Parkinson was one of the most singular figures of his time and place. He was successively or concomitantly a virulent political activist, a popular medical writer, a scholarly medical contributor, a highly appreciated parish doctor, a prominent amateur chemist, a devoted madhouse doctor, and a renowned paleontologist. It is that branch of geology that brought Parkinson fame during his lifetime. He was an insatiable collector of fossils, minerals, and shells that came to form the core of the museum that he set out at his home in Shoreditch, England. These specimens are beautifully illustrated in his Organic Remains of a Former World (1804-1811), a three-volume treatise that rapidly became a standard paleontology textbook. Parkinson was a founding member of the Geological Society of London, and in recognition of his contribution to the nascent field of paleontology his name was given to many fossils, particularly ammonites (e.g. Nautilus parkinsoni). Hence, we owe much to Mr. Parkinson, the Paleontologist, as he used to be referred to after his death, for such a vast and multifaceted contribution to natural science and medicine.

This open study investigated the clinical effects of 10-week selegiline administration in six patients in vegetative state and in four patients in a minimally conscious state, at least 6 months after onset. Clinical outcome was assessed by Coma Recovery Scale-Revised once a week during selegiline administration and 1 month later. Three patients stopped treatment because of possible side effects. After treatment and at 1 month of follow-up, four patients showed improvements in clinical diagnosis, and three patients showed an increase in arousal level only. Selegiline might represent a relatively safe option to enhance arousal and promote recovery in brain-injured patients with disorders of consciousness.

Background: There is no available estimate of the incidence and mortality of epilepsy in all age groups in the Canadian population. This study aimed to measure the incidence, prevalence, mortality and the secular trends for epilepsy in Saskatchewan between 2005 and 2010. Methods: A population-based cohort study was established from Saskatchewan’s provincial health administrative data. The population was followed until termination of coverage, death, or 31 December 2010. Individuals with epilepsy were identified based on ICD codes algorithms from 2005 to 2010. Results: The age-standardized incidence of epilepsy was 62 per 100,000 person-year. The age-standardized incidence rate of epilepsy in self-declared Registered Indians was 122 per 100,000 person-year. There was a significant decrease in the incidence of epilepsy for all groups over the study period. The age-standardized prevalence of epilepsy was 9 per 1,000 people. There was a significant increase in the prevalence of epilepsy over this time period. The adjusted mortality rate was 0.023 per 1000 person-year, and the all-cause Standardized Mortality Ration for epilepsy was 2.45. The SMR remained constant over the six-year period of the study. Conclusions: This study is the first in Canada to measure the incidence and all-cause mortality of epilepsy in all age groups.

Amyotrophic lateral sclerosis (ALS) and frontotemporal dementia (FTD) represent a disease continuum with common genetic causes and molecular pathology. We recently identified mutations in the T-cell restricted intracellular antigen-1 (TIA1) protein as a cause of ALS +/− FTD. TIA1 is an RNA-binding protein containing a low complexity domain (LCD) that promotes the assembly of membrane-less organelles, such as stress granules (SG). Whole exome sequencing of two family members with fALS/FTD revealed a novel missense mutation in the TIA1 LCD (P362L). Subsequent screening identified five more TIA1 mutations in six additional ALS patients, but none in controls. All mutation carriers presented with weakness, behavioral abnormalities or language impairments and had a final diagnosis of ALS +/− FTD. Autopsy on five TIA1 mutation carriers showed widespread neurodegeneration with TDP-43 pathology. Round eosinophilic inclusions in lower motor neurons were a consistent feature. Cellular assays revealed abnormal SG dynamics in the presence of TIA1 mutations. In summary, missense mutations in the LCD of TIA1 are a newly recognized cause of ALS/FTD with TDP-43 pathology and strengthen the role of RNA metabolism in the pathogenesis in this disease.

Purpose: We identified key clinicopathologic features of brain metastasis (BM) patients who are long-term survivors (LTS). Methods: We screened a prospective database of 1892 patients (treated 2006-2017), identified 92 (5%) who lived > 3 years following BM diagnosis, and performed per patient analyses. Results: Median age at diagnosis of BM was 57 years (range 19-77), 77% were women. The most common tumors were lung (50%), breast (26%), thyroid (7%) and skin (5%). 42% had tumors with drug-targetable oncoproteins (e.g. EGFR mutant) and 15% expressed hormonal receptors. ECOG was <2 in 70%. 47% had stage IV disease at diagnosis (75% with brain as the first site). 55% had controlled extracranial disease at the time of BM diagnosis. Median BM diameter was 1.5 cm (range 0.2-7) and 62% had a single lesion. Treatment was with surgery, radiosurgery, whole brain radiation (WBRT), or systemic therapy alone in 38%, 62%, 52%, and 4%, respectively. 53% received targeted- or immuno-therapy. Median follow up was 63 months (range 36-113). 61% failed intracranially at a median 24 months (range 1-99). 5 and 10- year survival (from BM diagnosis) was 82%, and 34%, respectively. Neither upfront WBRT nor other variables tested correlated with improved survival. In patients who died, an MRI was available within 3 months from death in 57%; of those 55% had no active intracranial disease, suggesting that the majority of deaths were non-neurologic. Conclusion: In general, LTS of BM had a limited number of BM, inactive extracranial disease, and drug targetable mutations.

Background: Neurosurgical residents face a unique combination of challenges, including long duty hours, technically challenging cases, and uncertain employment prospects. We sought to assess the demographics, interests, career goals, self-rated happiness, and overall well-being of Canadian neurosurgery residents. Methods: A cross-sectional survey was developed and sent through the Canadian Neurosurgery Research Collaborative to every resident enrolled in a Canadian neurosurgery program as of April 1, 2016. Results: We analyzed 76 completed surveys of 146 eligible residents (52% response rate). The median age was 29 years, with 76% of respondents being males. The most popular subspecialties of interest for fellowship were spine, oncology, and open vascular neurosurgery. The most frequent self-reported number of worked hours per week was the 80- to 89-hour range. The majority of respondents reported a high level of happiness as well as stress. Sense of accomplishment and fatigue were reported as average to high and overall quality of life was low for 19%, average for 49%, and high for 32%. Satisfaction with work-life balance was average for 44% of respondents and was the only tested domain in which significant dissatisfaction was identified (18%). Overall, respondents were highly satisfied with their choice of specialty, choice of program, surgical exposure, and work environment; however, intimidation was reported in 36% of respondents and depression by 17%. Conclusions: Despite a challenging residency and high workload, the majority of Canadian neurosurgery residents are happy and satisfied with their choice of specialty and program. However, work-life balance, employability, resident intimidation, and depression were identified as areas of active concern.

Wilder Penfield and the Montreal Neurological Institute (MNI) are inextricably linked. It was Penfield’s unique idea to create a building with an academic atmosphere wherein basic neuroscience and clinical care of neurological patients would benefit from interaction and mutual support. It is clear that without Penfield that there would be no MNI; however, the role of another Canadian icon, Sir Arthur Currie, in the development of the MNI has heretofore been barely mentioned. The thesis of this paper is that Currie had a critical role in the gestation of the MNI that has generally been ignored.

Task-specific dystonia is characterized by abnormal repetitive movements or postures in a specific body part that is triggered and ends with a task, such as writing. Failing medications, surgery, specifically disruption of key nuclei in the thalamus, can provide excellent symptomatic relief. Transcranial magnetic resonance (MR)-guided focused ultrasound is an emerging incision-less thermoablation technique. We describe MR-guided focused ultrasound tandem ablation of the ventral intermediate and ventralis oralis posterior nuclei in a 60-year-old patient with writer’s cramp. The clinical improvement was immediate with incremental benefit from the latter lesion, which was sustained at 6 months follow-up.