Search

Purpose Surgical indications for lumbar spinal stenosis are controversial, but most agree that leg dominant pain is a better predictor of success after decompression surgery. The objective of this study is to analyze the ability of the Nerve Root Sedimentation Sign (SedSign) on MRI to differentiate leg dominant symptoms from non-specific low back pain. Methods This was a retrospective review of 367 consecutive patients presenting with back and/or leg pain. Baseline clinical characteristics included Oswestry disability index (ODI), visual analog pain scores, EuroQol Group 5-Dimension Self-Report (EQ5D) and Saskatchewan Spine Pathway Classification (SSPc). Inter- and intra-rater reliability for SedSign was 73% and 91%, respectively (3 examiners). Results SedSign was positive in 111 (30.2%) and negative in 256 (69.8%) patients. On univariate analysis, a positive SedSign was correlated with age, male sex, several ODI components, EQ5D mobility, cross-sectional area (CSA) of stenosis, antero-posterior diameter of stenosis, and SSPc pattern 4 (intermittent leg dominant pain). On multivariate analysis, SedSign was associated with age, male sex, CSA stenosis and ODI walking distance. Patients with a positive SedSign were more likely to be offered surgery after referral (OR 2.65). The sensitivity and specificity for detecting all types of leg dominant pain were 37.4 and 82.8, respectively (ppv 77.5%, npv 43.8%). Conclusions Patients with a positive SedSign were more likely to be offered surgery, in particular non-instrumented decompression. The SedSign has high specificity for leg dominant pain, but the sensitivity is poor. As such, its use in triaging appropriate surgical referrals is limited.

BackgroundTreated aneurysms must be followed over time to ensure durable occlusion, as more than 20% of endovascularly treated aneurysms recur. While digital subtraction angiography (DSA) remains the gold standard, magnetic resonance angiography (MRA) is attractive as a non-invasive follow-up technique. Two different MRA techniques have traditionally been used: time-of-flight (TOF) and contrast-enhanced (CE) MRA. We analysed data from studies comparing MRA techniques with DSA for the follow-up of aneurysms undergoing endovascular treatment. Subgroup analysis of stent-assisted coiling (SAC) and flow diversion (FD) techniques was completed.MethodsComprehensive searches using the Embase, PubMed, and Cochrane databases were performed and updated to November 2018. Pooled sensitivity and specificity were calculated using aneurysm occlusion status as defined by the Raymond–Roy occlusion grading scale.ResultsThe literature search yielded 1579 unique titles. Forty-three studies were included. For TOF-MRA, sensitivity and specificity of all aneurysms undergoing endovascular therapy were 88% and 94%, respectively. For CE-MRA, the sensitivity and specificity were 88% and 96%, respectively. For SAC and FD techniques, sensitivity and specificity of TOF-MRA were 86% and 95%, respectively. CE-MRA had sensitivity and specificity of 90% and 92%.ConclusionMRA is a reliable modality for the follow-up of aneurysms treated using endovascular techniques. While the data are limited, MRA techniques can also be used to reliably follow patients undergoing FD and SAC. However, clinical factors must be used to optimize follow-up regimens for individual patients.

Moyamoya disease (MMD) was first described in the Japanese population, and remains significantly more common in Asia. The etiology of the disease remains unknown, but it is a chronic cerebrovascular disorder that manifests as progressive stenosis and occlusion of the large intracranial arteries, and formation of abnormal collateral vascular supply as a compensatory mechanism. The disease has since been recognized as a clinical entity in non-Asian populations, but its true incidence in these populations remains unclear. MMD in the USA is of growing interest in recent years, and multiple authors have contributed series of long-term outcomes after treatment for MMD, which are now available.

People of Aboriginal (Indigenous) ancestry are more likely to experience traumatic spinal cord injury (TSCI) than other Canadians; however, outcome studies are limited. This study aims to compare Aboriginal and non-Aboriginal populations with acute TSCI with respect to preinjury baseline characteristics, injury severity, treatment, outcomes and length of stay.This was a retrospective analysis of participants with a TSCI who were enrolled in the prospective Rick Hansen Spinal Cord Injury Registry (RHSCIR), Saskatoon site (Royal University Hospital), between Feb. 13, 2010, and Dec. 17, 2016. Demographic, injury and management data were assessed to identify any differences between the populations.Of the 159 patients admitted to Royal University Hospital with an acute TSCI during the study period, 62 provided consent and were included in the study. Of these, 21 self-identified as Aboriginal (33.9%) and 41 as non-Aboriginal (66.1%) on treatment intake forms. Compared with non-Aboriginal participants, Aboriginal participants were younger, had fewer medical comorbidities, had a similar severity of neurologic injury and had similar clinical outcomes. However, the time to discharge to the community was significantly longer for Aboriginal participants (median 104.0 v. 34.0 d, p = 0.016). Although 35% of non-Aboriginal participants were discharged home from the acute care site, no Aboriginal participants were transferred home directly.This study suggests a need for better allocation of resources for transition to the community for Aboriginal people with a TSCI in Saskatchewan. We plan to assess outcomes from TSCI for Aboriginal people across Canada.Au Canada, les personnes d’origine autochtone sont plus susceptibles que les autres de vivre un traumatisme médullaire. Malgré cela, il y a peu d’études sur les conséquences de cet événement. Notre étude visait à comparer les cas de traumatisme médullaire aigu dans les populations autochtones et non autochtones sur plusieurs plans : les caractéristiques initiales des patients, la gravité du traumatisme, la nature du traitement, les issues cliniques et la durée de séjour.Nous avons fait une analyse rétrospective des dossiers de personnes ajoutées au Rick Hansen Spinal Cord Injury Registry (RHSCIR) [Registre des traumatismes médullaires Rick Hansen] entre le 13 février 2010 et le 17 décembre 2016 pour l’établissement de Saskatoon (l’Hôpital universitaire Royal). Nous avons comparé les renseignements de base des patients ainsi que les données sur le traumatisme et la prise en charge afin de cerner toute différence entre les populations.Sur les 159 traumatisés médullaires admis à l’Hôpital universitaire Royal pendant la période à l’étude, 62 ont consenti à l’utilisation de leurs données. Parmi eux, 21 s’étaient identifiés comme Autochtones (33,9 %) sur le formulaire d’hospitalisation, et 41 comme non-Autochtones (66,1 %). Par rapport aux non-Autochtones, les Autochtones étaient plus jeunes, avaient moins de comorbidités, présentaient une atteinte neurologique de gravité comparable et connaissaient à peu près le même tableau clinique. Toutefois, le délai avant leur retour en communauté était significativement plus long (médiane : 104,0 jours contre 34,0 jours; p = 0,016). Aucun participant autochtone n’a été renvoyé directement à la maison, alors que 35 % des participants non autochtones sont retournés chez eux en quittant les soins de première ligne.Cette étude montre qu’il faut améliorer la répartition des ressources de retour dans la communauté pour les traumatisés médullaires autochtones de la Saskatchewan. Enfin, nous comptons examiner les répercussions cliniques du traumatisme médullaire chez les Autochtones de partout au Canada.

The Solitaire (Medtronic Inc, Mansfield, Massachusetts, USA) is a stentriever device for endovascular treatment of acute ischemic stroke. Temporary endovascular bypass and mechanical thrombectomy are well-described applications of this device. However, few reports of permanent stent placement have been published. We present a series of five cases in which the Solitaire stent was implanted to restore distal flow after failure of conventional mechanical thrombectomy. All patients presented with large vessel occlusions with thrombi that were resistant to retrieval or suction-aspiration. Immediately after implantation the patients were given a loading dose of abciximab and then transitioned to dual antiplatelet therapy within 24 hours. Our series suggests that permanent deployment of the Solitaire may be considered as a bailout technique in the treatment of cerebral large vessel occlusion. Long-term antiplatelet therapy is required after deployment.

We report a 41- year-old, left-handed patient with drug-resistant right temporal lobe epilepsy (TLE). Presurgical fMRI was conducted to examine whether the patient had language functioning in the right hemisphere given that left-handedness is associated with a higher prevalence of right hemisphere dominance for language. The fMRI results revealed bilateral activation in Broca's and Wernicke's areas and activation of eloquent cortex near the region of planned resection in the right temporal lobe. Due to right temporal language-related activation, the patient underwent an awake right-sided temporal lobectomy with intraoperative language mapping. Intraoperative direct cortical stimulation (DCS) was conducted in the regions corresponding to the fMRI activation, and the patient showed language abnormalities, such as paraphasic errors, and speech arrest. The decision was made to abort the planned anterior temporal lobe procedure, and the patient instead underwent a selective amygdalohippocampectomy via the Sylvian fissure at a later date. Post-operatively the patient was seizure-free with no neurological deficits. Taken together, the results support previous findings of right hemisphere language activation in left-handed individuals, and should be considered in cases in which presurgical localization is conducted for left-hand dominant patients undergoing neurosurgical procedures., Highlights • The report evaluates evidence for the possibility of right hemisphere language activation in a left-handed right TLE patient • The results of the fMRI tasks showed bilateral speech regions, such as left and right Broca's area and Wernicke's area • The results support previous findings of right hemisphere language activation in left-handed individuals • The report discusses the value of fMRI of language tasks for presurgical planning in epilepsy cases • Report highlights how fMRI findings can alter surgical strategy and how intraoperative brain mapping validates these findings

Introduction Endovascular therapy has revolutionized acute stroke management associated with large vessel occlusion (LVO). The province of Saskatchewan currently has 8 primary stroke centers (PSC) and 1 comprehensive stroke center (CSC) spread over a large geographical area. Seventy three percent of the population lives outside the Saskatoon metropolitan area, which houses the province’s single comprehensive stroke centre. Geography remains a significant barrier to providing endovascular therapy in a timely manner to eligible patients, knowing that the time to recanalization is a vital variable in clinical outcome. We aim to quantify the distance and time to transfer of patients to the CSC, and determine factors associated with clinically significant evolution of infarct during transfer. Methods We completed a retrospective analysis of all acute stroke patients with LVOs who were transferred from PSCs to the CSC for possible endovascular therapy in Saskatchewan from July 2016 – July 2018. Along with patient, imaging, and outcome specific factors, detailed transfer data including modality, time, and distance were collected. Results Forty-seven patients were identified as having had a LVO diagnosed at a PSC, with subsequent transfer to the CSC for endovascular therapy. The average age was 70.6 years. Of these patients, 13 (28%) underwent EVT, while 34 patients did not: 7 (15%) had clinical improvement, 12 (25%) had vessel recanalization on repeat CTA, and 15 (32%) had ASPECTS decay leading to EVT ineligibility. Distance to the PSC and distance from PSC to CSC were the most significant contributors to ASPECTS decay. Conclusion Rates of ineligibility due to ASPECTS decay were similar to those found in other regional data, despite significantly greater distances. Since the large geographic area covered by the CSC leads to a significant cost burden associated with transfers, we aim to optimize transfer protocols to better serve the outlying areas. Disclosures S. Ahmed: None. E. Noyes: None. K. Whelan: None. B. Graham: None. G. Hunter: None. M. Kelly: None. L. Peeling: None.

A 69-year-old female patient presented with a ruptured small basilar apex aneurysm. Balloon-assisted coil embolization was performed, and the patient remained stable post-operatively. A CT-scan performed 12 days after the procedure showed coil migration from the aneurysm, and repeat angiography confirmed coil migration into the left proximal posterior cerebral artery segment. The patient gave consent for a revision procedure, where an LVIS Jr. stent and 7 micro-coils were placed into the aneurysm to re-secure the aneurysm. The patient suffered no further complications and was discharged home on dual antiplatelet therapy. Modified Rankin Score at 90-days was 1. We review the literature regarding delayed coil migration, and discuss management considerations. Disclosures S. Ahmed: None. J. Mann: None. L. Peeling: None. M. Kelly: None.

Background While recent clinical trials have demonstrated immense efficacy of mechanical thrombectomy in the setting of acute stroke; there remains debate over the relative safety in performing this procedure under general anesthesia (GA). Recent RCT and meta-analyses have not provided a definitive answer to this question. With the reorganization of stroke systems of care, as a result of the Saskatchewan Acute Stroke Pathway, all patients presenting with LVO are assessed and endovascular thrombectomy is performed routinely under GA. We reviewed data from our pathway to add to the data regarding safety of thrombectomy under GA. Methods Data was retrospectively reviewed on 154 consecutive LVO in 2016–2018 at the only Comprehensive stroke center in Saskatchewan. All patients undergoing MT were place under GA for the procedure. Pretreatment National Institutes of Health stroke scale (NIHSS), location of LVO and ASPECTS score were documented. Post-thrombectomy TICI scores, time to revascularization, and 90-day outcomes, both NIHSS and mRS, were recorded. Results Of 154 LVO, 147 went on to have mechanical thrombectomy (MT). 65 were right anterior circulation, 70 were left anterior circulation and 11 were posterior circulation. Of 135 anterior circulation strokes, 69 (51.1%), 58 (42.9%) and 8 (5.7%) had good, moderate and poor collateral circulation respectively, and the average pre-MT ASPECTS was 8.2. The average pre-MT NIHSS was 13.4. The average time from groin puncture to revascularization was 48.7 min. A total of 133/147 (90.4%) achieved thrombolysis in cerebral infarction (TICI) perfusion scale grade of 2b/3 after recanalization. On follow-up, 70/147 and 90/147 had documented 90-day National Institutes of Health stroke scale (NIHSS) (average = 2.4) and 90-day modified Rankin score (mRS) (average = 2.2). Overall mortality was 29/147 (19.7%). Conclusions In a high volume Comprehensive Stroke Center, general anesthesia is safe to always use mechanical thrombectomy. Outcomes of mechanical thrombectomy for LVO in are in keeping with published results for both conscious sedation and general anesthesia. This adds to the body of evidence supporting GA as a excellent option for sedation for mechanical thrombectomy. It is particularly useful in more complex cases and leads to high revascularization rates. Disclosures A. Persad: None. S. Ahmed: None. Z. Tymchak: None. R. Whelan: None. A. Gardner: None. G. Hunter: None. B. Graham: None. L. Peeling: 2; C; Medtronic. M. Kelly: 2; C; Medtronic.

Introduction: Endovascular therapy has revolutionized acute stroke management associated with large vessel occlusion (LVO). The province of Saskatchewan currently has 8 primary stroke centers (PSC) and 1 comprehensive stroke center (CSC) spread over a large geographical area. Seventy three percent of the population lives outside the Saskatoon metropolitan area, which houses the province’s single comprehensive stroke centre. Geography remains a significant barrier to providing endovascular therapy in a timely manner to eligible patients, knowing that the time to recanalization is a vital variable in clinical outcome. We aim to quantify the distance and time to transfer of patients to the CSC, and determine factors associated with clinically significant evolution of infarct during transfer. Methods: We completed a retrospective analysis of all acute stroke patients with LVOs who were transferred from PSCs to the CSC for possible endovascular therapy in Saskatchewan from July 2016 - July 2018. Along with patient, imaging, and outcome specific factors, detailed transfer data including modality, time, and distance were collected. Results: Sixty-nine LVO patients were transferred from PSCs to the CSC with intention to treat with mechanical thrombectomy. Upon reassessment at the CSC, 32 patients (46%) no longer qualified for thrombectomy, due to progression of stroke with ASPECTS score decay. Inter-facility deterioration risk factors were assessed using transfer metrics, patient characteristics, and initial imaging findings at the PSC to understand this patient population better. Distance to the PSC and distance from PSC to CSC were the most significant contributors to ASPECTS decay. Conclusions: Almost half of the patients transferred to the CSC with intention to treat with endovascular thrombectomy became ineligible during transfer. Since the large geographic area covered by the CSC leads to a significant cost burden associated with transfers, we aim to optimize transfer protocols to better serve the outlying areas.

Cranial dural arteriovenous fistulas (DAVFs) are abnormal dural-based connections between meningeal arteries and venous sinuses, meningeal veins, or cortical veins, without an intermediate capillary network or nidus. They account for 10–15% of aberrant intracranial arteriovenous connections. DAVFs are mostly acquired conditions that occur in middle-aged adults. Lesions in the pediatric population, although rare, are often much more complex and beyond the scope of this chapter. Exact etiology of adult DAVFs remains unknown. An association with venous sinus thrombosis has been found, and hypercoagulable states have therefore been implicated. Thrombosis has also been reported as a consequence of dural arteriovenous shunting. Other provocative factors have been reported, such as trauma, intracranial surgery, and radiation exposure. However, many DAVFs occur without an identifiable cause.

Introduction Endovascular treatment of intracranial aneurysms has evolved significantly, and includes coil occlusion, with or without stent-assistance, as well as parent-vessel reconstruction using flow-diverting stents. Treated aneurysms must be followed over time to ensure durable occlusion, as more than 20% of endovascularly treated aneurysms have recurrence, with up to 9% requiring re-treatment. While digital subtraction angiography (DSA) remains the gold standard, magnetic resonance angiography (MRA) has been utilized in the follow-up of endovascularly treated cerebral aneurysms as it is a non-invasive technique. Two different MRA techniques have traditionally been utilized: time-of-flight (TOF), and contrast-enhanced (CE) MRA. We systematically reviewed the literature comparing MRA techniques to DSA for the follow-up of aneurysms undergoing endovascular treatment. Methods Comprehensive searches utilizing the Embase, PubMed, and Cochrane databases were performed, and updated to December, 2017. Acquired studies were screened for appropriateness for inclusion in the meta-analysis. We included studies that compared an MRA technique with DSA for follow-up of aneurysms treated with endovascular means, and provided sufficient data for comparative evaluation of occlusion status. Studies were graded on methodological quality using the GRADE criteria. Data were analysed using the Meta-DiSc software. Pooled sensitivity and specificity, with 95% confidence intervals (CI) were calculated using aneurysm occlusion status as defined by the Raymond-Roy occlusion grading scale. Aneurysms were classified as either being occluded, having residual neck filling, or residual dome filling. Subgroup analyses for study design (prospective vs retrospective), study quality (GRADE assessment), type of treatment, DSA technique, and MRI magnet strength, were performed. Results The literature search yielded 1575 unique titles. Seventy-five titles were included in a full-text review, and after application of inclusion criteria, 40 studies were included in the meta-analysis. The GRADE assessment showed that the studies were of a good quality overall, with 22 studies (54%) scoring 4, 15 (37%) scoring 3, 3 (7%) scoring 2, while 1 (2%) study scored 1. For TOF-MRA, sensitivity and specificity of all aneurysms undergoing endovascular therapy were 0.89 (95% CI: 0.86–0.9) and 0.94 (0.93–0.95), respectively. For CE-MRA, the sensitivity and specificity were 0.91 (0.88–0.94) and 0.96 (0.94–0.97), respectively. Treatment modality subgroup analysis was performed using a coiling group and a group containing all studies with intracranial stent use. For aneurysms with intracranial stent placement, sensitivity and specificity were 0.92 and 0.98 respectively for TOF-MRA, and 0.94 and 0.99 for CE-MRA. Retrospective studies had higher sensitivity and specificity when compared to prospective studies (TOF: 0.93/0.97 vs 0.83/0.92; CE: 0.93/0.99 vs 0.87/0.92, respectively). Subgroup analyses did not reveal significant differences in the sensitivity and specificity of MRA techniques with respect to 2D vs 3D DSA, or MRA magnet strength. Conclusions MRA remains a reliable modality for the follow-up of aneurysms treated using endovascular means. Adjunctive use of intracranial stents does not significantly impede the diagnostic reliability of MRA techniques for detection of residual aneurysms. While most aneurysms can safely be followed using MRA techniques, patient and aneurysm-specific factors must be taken into account when planning follow-up for treated intracranial aneurysms. Disclosures S. Ahmed: None. X. Zheng: None. M. Kelly: 2; C; Penumbra, Medtronic. J. Mocco: 2; C; Rebound Medical, Endostream, Synchron, Cerebrotech. 4; C; Apama, The Stroke Project, Endostream, Synchron, Cerebrotech, NeurVana, NeuroTechnology Investors. R. De Leacy: 1; C; Asahi Intec, Medtronic. 2; C; Penumbra, Siemens.

The subaxial cervical spine has unique anatomical features that affect the clinical manifestations and treatment of metastatic tumors. In this chapter, we review the epidemiology, pathogenesis, clinical presentation, diagnosis, and management of this condition. The importance of understanding the histopathology prior to making treatment decisions is emphasized. A treatment decision-making framework called LMNOP is reviewed. The rationale and methods of anterior, posterior, and combined surgical approaches are outlined. Lastly, we touch on perioperative complication avoidance.

Background: Communicating with senior neurosurgical colleagues during residency necessitates a reliable and versatile smartphone. Smartphones and their apps are commonplace. They enhance communication with colleagues, provide the ability to access patient information and results, and allow access to medical reference applications. Patient data safety and compliance with the Personal Health Information Protection Act (PHIPA, 2004) in Canada remain a public concern that can significantly impact the way in which mobile smartphones are utilized by resident physicians Methods: Through the Canadian Neurosurgery Research Collaborative (CNRC), an online survey characterizing smartphone ownership and utilization of apps among Canadian neurosurgery residents and fellows was completed in April 2016. Results: Our study had a 47% response rate (80 surveys completed out of 171 eligible residents and fellows). Smartphone ownership was almost universal with a high rate of app utilization for learning and facilitating the care of patients. Utilization of smartphones to communicate and transfer urgent imaging with senior colleagues was common. Conclusions: Smartphone and app utilization is an essential part of neurosurgery resident workflow. In this study we characterize the smartphone and app usage within a specialized cohort of residents and suggest potential solutions to facilitate greater PHIPA adherence

Introduction: Carotid occlusion is a rare but serious complication of retropharyngeal abscess (RPA). Management questions that must be addressed include the choice between reconstruction and occlusion in the setting of an active infectious process. Case Report: A 4 year old female presented with hoarseness, shortness of breath, and a right-sided Horner’s syndrome. A CT scan confirmed the diagnosis of RPA, and contrast studies showed no filling in the right internal carotid artery (ICA). Surgical exploration of the abscess disrupted the occluded artery, causing deep, uncontrolled bleeding. Emergent angiographic evaluation was completed, and the decision was made to sacrifice the ICA. The patient recovered on antibiotics, but the Horner’s syndrome persisted. Discussion: The presence of a carotid artery occlusion must be ruled out in the setting of a RPA. When suspected, it should be investigated further. Therapeutic decisions regarding sacrifice or reconstruction of the carotid artery are burdened by risks associated with the setting of an infection, notably infection and systemic dissemination. Conclusion: The presence of a carotid occlusion is a serious complication resulting from a RPA that can lead to permanent neurological deficit. Endovascular vessel sacrifice is a viable treatment option for carotid occlusion in the setting of a retropharyngeal abscess, but must be considered on a case-by-case basis.