Background: Delayed Cerebral Ischemia (DCI) is a complication of aneurysmal subarachnoid hemorrhage (aSAH) and is associated with significant morbidity and mortality. A paucity of high-quality evidence is available to guide the management of DCI. As such, our objective was to evaluate practice patterns of Canadian physicians regarding the management of aSAH and DCI. Methods: The Canadian Neurosurgery Research Collaborative (CNRC) performed a cross-sectional survey of Canadian neurosurgeons, intensivists, and neurologists who manage aSAH. The survey was distributed to members of the Canadian Neurosurgical and Neurocritical Care Societies, respectively. Responses were analyzed using quantitative and qualitative methods. Results: The response rate was 129/340 (38%). Agreement among respondents included the need for intensive care unit admission, use of clinical and radiographic monitoring, and prophylaxis for prevention of DCI. Indications for starting hyperdynamic therapy varied. There was discrepancy in the proportion of patients felt to require intravenous milrinone, intra-arterial vasodilators, or physical angioplasty for treatment of DCI. Most respondents reported their facility does not utilize a standardized definition for DCI. Conclusions: DCI is an important clinical entity for which no consensus exists in management among Canadian practitioners. The CNRC calls for the development of national standards in the diagnosis and management of DCI.

Background: Anti-N-Methyl-D-Aspartate (NMDA) receptor encephalitis is an autoimmune disease associated with antibodies against heteromers NR1 and NR2 subunits of the cell surface of the NMDA receptors, causing many psychiatric and neurological symptoms. This includes new-onset refractory status epilepticus. Methods: A 33-year-old previously healthy female developed new-onset refractory status epilepticus caused by anti- NMDA receptor encephalitis without the presence of tumours. Results: The clinical course was complicated by prolonged status epilepticus, which was refractory to many antiepileptic drugs (levetiracetam, phenytoin, carbamazepine, topiramate, lacosamide, valproic acid), ketamine, propofol, midazolam, including inhalation agents (isoflurane). Also, she received first (intravenous immunoglobulin, intravenous methylprednisolone, and plasmapheresis), second-line immunotherapy (rituximab) and prophylaxis bilateral oophorectomy without clinical or electrographic improvement. However, the patient drug-resistant status epilepticus markedly improved both clinically and electrographically following seven sessions of electroconvulsive therapy. Conclusions: Electroconvulsive therapy should be considered as adjuvant therapy for the treatment of immunotherapy resistant encephalitis.

ParrilloSJ, ChristensenD, TeitelbaumHS, GlassmanES. A Survey of Disaster Medical Education in Osteopathic Medical School Curricula. Prehosp Disaster Med. 2016;31(6):581–582.

Background: Vasospasm causing delayed ischemic neurologic deficit (DIND) remains a leading cause of devastating outcome after aneurysmal subarachnoid hemorrhage (aSAH). Therapy using intravenous milrinone (IVM) and intra-arterial milrinone (IAM) has been described. We report our results using IAM in patients with refractory and super refractory vasospasm (RV and SRV respectively). Methods: Retrospective single center study of all adult patients treated with IAM between 2006 and 2016 inclusively. IAM was used as part of the Montreal Neurological Hospital Protocol when the patients’ symptoms failed to respond to initial and higher IVM doses. We report their clinical outcomes. Results: IAM was used in 19 patients. The median loading dose was 8 mg and average maintenance dose was 0.78 mcg/kg/min. Angiographic improvement was seen in 15 (79%) and clinical improvement - within the first 48 hours - was seen in all patients. The median mRS was 3 at time of discharge and 1 three months later. Five patients lost follow up. Conclusions: IAM appears to be safe and effective in this small retrospective series of RV and SRV complicating aSAH. Angiographic and clinical improvements were observed. Further prospective studies are warranted to confirm these findings.

Millisecond pulsars (MSPs) are a class of radio pulsars with extremely stable rotation. Their excellent timing stability can be used to study a wide variety of astrophysical phenomena. In particular, a large sample of these pulsars can be used to detect low-frequency gravitational waves. We have developed a precision pulsar timing backend for the NASA Deep Space Network (DSN), which will allow the use of short gaps in tracking schedules to time pulses from an ensemble of MSPs. The DSN operates clusters of large dish antennas (up to 70-m in diameter), located roughly equidistant around the Earth, for communication and tracking of deep-space spacecraft. The backend system will be capable of removing entirely the dispersive effects of propagation of radio waves through the interstellar medium in real-time. We will describe our development work, initial results, and prospects for future observations over the next few years.

Background: Our goal was to perform a systematic review of the literature on the use of therapeutic hypothermia for refractory status epilepticus (RSE) and its impact on seizure control. Methods: All articles from MEDLINE, BIOSIS, EMBASE, Global Health, HealthStar, Scopus, Cochrane Library, the International Clinical Trials Registry Platform (inception to May 2014), reference lists of relevant articles, and gray literature were searched. The strength of evidence was adjudicated by two independent reviewers, using both the Oxford and GRADE methodology. Results: Overall, 13 studies were identified, with 10 manuscripts and 3 meeting abstracts. A total of 40 patients were treated. The common target temperature was 33 degrees Celsius, sustained for a median 48 hours. Patients displayed a 62.5%, 15% and 22.5% rate of seizure cessation, seizure reduction, and failure of treatment respectively. External cooling was utilized in the majority of cases. Deep venous thrombosis, coagulopathy and infections were the commonly reported complications. Two ongoing clinical trials were identified. Conclusions: Oxford level 4, GRADE D evidence exists to support the use of therapeutic hypothermia to control seizures in RSE. Further prospective study is warranted.

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.

Introduction: Our goal was to perform a systematic review of the literature on the use of intravenous lidocaine in adults for status epilepticus (SE) and refractory status epilepticus (RSE) to determine its impact on seizure control. Methods: All articles from MEDLINE, BIOSIS, EMBASE, Global Health, HealthStar, Scopus, Cochrane Library, the International Clinical Trials Registry Platform (inception to November 2014), and gray literature were searched. The strength of evidence was adjudicated using both the Oxford and GRADE methodology by two independent reviewers. Results: Overall, 13 studies were identified, with 11 manuscripts and 2 meeting abstracts. Seventy-six adult patients were treated for 82 episodes of SE/RSE. Patients had varying numbers of anti-epileptic drugs (AEDs), 1 to 12, on board prior to lidocaine therapy. During 69 of the 82 (84.1%) episodes of SE/RSE, phenytoin was on board. The dose regimen of lidocaine varied significantly. Overall, 70.7% of seizures responded to lidocaine, with complete cessation and greater than 50% reduction seen in 64.1% and 6.1% respectively. Patient outcomes were sparingly reported. Conclusions: There currently exists level 4, GRADE C evidence to support the consideration of lidocaine for SE and RSE in the adult population. Further prospective studies of lidocaine administration in this setting are warranted.

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: Donation after circulatory death (DCD) can reduce organ transplant waiting times. When defining death using circulatory criteria, brain function is usually not assessed. Residual brain function and the state of consciousness at the time of circulatory arrest is unknown. We have an ethical responsibility to ensure the donor is free of pain and psychological distress. Methods: We performed a scoping review of the literature to determine the time intervals associated with the loss brain function after circulatory arrest. Results: A total of 1133 articles were reviewed and 38 were included in the review. In humans, 8 studies showed loss of EEG activity under 30 seconds. Four studies revealed loss of EEG between 39.6 and 66 seconds. Clinically, loss of consciousness was shown to occur between 4 and 21 seconds. In animals, 13 studies also revealed loss of EEG under 30 seconds. In four other animal studies, EEG was lost between 37 and 120 seconds. Conclusion: The time required to lose brain function varied according to clinical context and method by which this function is measured. Existing literature is scarce and limited to observational studies and case reports.

Introduction: Decompressive craniectomy (DC) in severe traumatic brain injury (TBI) is controversial. The impact DC on cause of death is unclear in the literature to date. Methods: We performed an institutional retrospective review, from June 2003 to June 2013, of patients with severe blunt TBI undergoing DC whom subsequently died. We compared this group to a retrospectively matched cohort based: age, pre-hospital mRS, Marshall diffuse and TBI grades, Injury Severity Scores, and admission laboratory values. The goal was to determine the cause of death between those receiving DC and those managed medically. Results: Nineteen patients received DC and were compared to 16 retrospectively matched patients. The mean age of the DC and matched cohort were 47.1 and 43.6 years, respectively. The mean admission GCS/Marshall diffuse CT grades were 5.8/3.4 for the DC group, and 4.1/3.1 for the matched medical cohort. Overall, in the DC group 94.7% of the deaths occurred secondary to cardiac arrest after withdrawal of life sustaining treatment (WLST), with only 5.3% progressing to brain death. Alternatively, in the matched cohort 62.5% died of cardiac arrest post WLST, with 37.5% progressing to brain death. Conclusions: Progression to brain death appears to be more common in those severe blunt TBI patients treated medically compared to those undergoing DC.

Objective: Case report of NMDA receptor encephalitis in a young man with early refractory status epilepticus and atypical radiological findings. Background: Anti-NMDA receptor encephalitis is an autoimmune disorder due to antibodies to the NR1-NR2B heterodimer of NMDA receptor. On imaging, it typically presents with T2 hyperintensities in mesio-temporal lobes, cerebral cortex and basal ganglia. We present a case with a dramatic clinical evolution and novel imaging findings. Design/Methods: Case report and review of imaging. Results: 29-year-old male presented with mood disturbance followed by partial-complex seizures, facial dyskinesia and choreo-athetotic movements. Initial MRI showed subtle T2-hyperintensities in mesio-temporal lobes. Diagnosis of NMDA-receptor encephalitis was confirmed after CSF antibody detection. Prior to diagnostic confirmation, he developed refractory status epilepticus, and concomitant signs of herniation. A repeated MRI showed increased T2-hyperintensities of thalami and mesencephalon, with cerebellar involvement and transtentorial/foraminal herniation. Restricted diffusion was documented in the cerebellar cortex/thalami/putamina and caudate. IV corticosteroids and hypertonic fluid reversed herniation, and halted the seizures. Conclusions: To our knoweldge, we report the first case report of uncal and tonsillar herniation in NMDA-r encephalitis secondary to atypical, predominant cerebellar involvement. This case highlights life-threatening manifestation that physicians might encounter, and a possible role for high dose IV corticosteroids as an adjunct treatment for brain edema and seizures.

Background: There exists the role for novel agents in the management of refractory intracranial pressure (ICP) via targeting cerebral acidosis, hyperemia, and excitotoxicity. Objective: We performed 4 separate systematic reviews to determine the effect of tromethamine (THAM), indomethacin, and ketamine on ICP. Methods: All articles from MEDLINE, BIOSIS, EMBASE, Global Health, HealthStar, Scopus, Cochrane Library, the International Clinical Trials Registry Platform (inception to: February 2014 – THAM, July 2014 – Indomethacin, November 2013 - Ketamine), and gray literature were searched. The strength of evidence was adjudicated using both the Oxford and GRADE methodology. Results: Twelve articles were reviewed utilizing THAM while documenting ICP in neurosurgical patients. All but one study documented a decrease in ICP. Twelve original articles were reviewed utilizing indomethacin for ICP in neurological patients. All but one study documented a decrease in ICP. Seven articles were reviewed utilizing ketamine, documenting ICP in TBI patients, with 16 in non-trauma neurological patients. ICP did not increase in the studies during ketamine administration, and trended to decrease ICP. Conclusion: There exists Oxford level 2b, GRADE B evidence that THAM reduces ICP in the TBI and malignant ischemic infarct population. There exists Oxford level 2b, GRADE C evidence that indomethacin and ketamine reduce ICP in the adult severe TBI population.

Introduction: Our goal was to perform a systematic review of the literature on the use of intravenous lidocaine in pediatrics for status epilepticus (SE) and refractory status epilepticus (RSE) to determine its impact on seizure control. Methods: All articles from MEDLINE, BIOSIS, EMBASE, Global Health, HealthStar, Scopus, Cochrane Library, the International Clinical Trials Registry Platform (inception to November 2014), and gray literature were searched. The strength of evidence was adjudicated using both the Oxford and GRADE methodology by two independent reviewers. Results: Overall, 20 original studies were identified, with 19 manuscripts and 1 meeting abstracts. Two hundred and thirty-five pediatric patients were treated for 252 episodes of SE/RSE. Patients had varying numbers of anti-epileptic drugs (AEDs), 2 to 8, on board prior to lidocaine therapy. During 20 of the 252 (7.9%) episodes of SE/RSE, phenytoin was on board. The dose regimen of lidocaine varied, with some utilizing bolus dosing alone; others utilizing a combination of bolus and infusion therapy. Overall, 60.0% of seizures responded to lidocaine, with complete cessation and greater than 50% reduction seen in 57.6% and 12.3% respectively. Patient outcomes were sparingly reported. Conclusions: There currently exists level 2b, GRADE C evidence to support the consideration of lidocaine for SE and RSE in the pediatric population.

Background: Our goal was to perform a systematic review of the literature on the use of modern inhalational anesthetic agents for refractory status epilepticus and their impact on seizure control. Methods: All articles from MEDLINE, BIOSIS, EMBASE, Global Health, HealthStar, Scopus, Cochrane Library, the International Clinical Trials Registry Platform (inception to March 2014), reference lists of relevant articles, and gray literature were searched. The strength of evidence was adjudicated using both the Oxford and Grading of Recommendation Assessment Development and Education methodology by two independent reviewers. Results: Overall, 19 studies were identified, with 16 manuscripts and 3 meeting abstracts. A total of 46 patients were treated. Adult (n=28) and pediatric patients (n=18) displayed 92.9% and 94.4% seizure control with treatment, respectively. Isoflurane was used in the majority of cases. Hypotension was the only complication described. Conclusions: Oxford level 4, Grading of Recommendation Assessment Development and Education D evidence exists to support the use of isoflurane in refractory status epilepticus to obtain burst suppression. Insufficient data exist to comment on the efficacy of desflurane and xenon at this time.

Described by one unsympathetic observer in Buffalo as “Schools of Nonsense” and by one ardent participant in Milwaukee as “rebel factories,” the movement to establish Socialist Sunday schools (S.S.S.) in the United States during the early twentieth century is perhaps one of the best kept secrets of American socialist and educational historiography. This essay attempts to rectify that situation by analyzing an educational movement that falls outside of the traditional and progressive educational camps of the early 1900s. During these years numerous working-class radicals provided their children with a formal, weekend education that lacked the strong capitalistic biases dominant in the public schools.