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Geographic, social, political, and economic factors shape access to advanced neurotechnologies, yet little previous research has explored the barriers, enablers, and areas of opportunity for equitable and meaningful access for diverse patient communities across Canada. We applied a mixed-mode approach involving semi-structured interviews and rating scale questions to consult with 24 medical experts who are involved in the care of patients who undergo functional neurosurgery targeting the brain. Seven major themes emerged from the qualitative analysis: Health care system, Neurotechnology features, Patient demographics, Target condition features, Ethics, Upstream barriers and enablers, and Areas of opportunity. Descriptive statistics of the Likert-scale responses suggest that interviewees perceive a disparity between the imperative of access to advanced neurotechnologies for people living in rural and remote areas and the likelihood of achieving such access. The results depict a complex picture of access to functional neurosurgery in Canada with pockets of excellence and a motivation to improve the availability of care for vulnerable populations through the expansion of distributed care models, improved health care system efficiencies, increasing funding and support for patient travel, and increasing awareness about and advocacy for advanced neurotechnologies.

ObjectiveNovel and minimally invasive neurotechnologies offer the potential to reduce the burden of epilepsy while avoiding the risks of conventional resective surgery. Few neurotechnologies have been tested in randomized controlled trials with pediatric populations, leaving clinicians to face decisions about whether to recommend these treatments with insufficient evidence about the relevant risks and benefits. This study specifically explores the preferences of clinicians for treating pediatric drug-resistant epilepsy (DRE) with novel neurotechnologies.MethodsA discrete-choice experiment (DCE) was designed to elicit the preferences of clinicians with experience in treating children with DRE using novel neurotechnological interventions. The preferences for six key attributes used when making treatment decisions (chances of clinically significant improvement in seizures, major and minor risks from intervention, availability of evidence, financial burden for the family, and access to the intervention) were estimated using a conditional logit model. The estimates from this model were then used to predict the adoption of existing novel neurotechnological interventions.ResultsSixty-eight clinicians completed the survey: 33 neurosurgeons, 28 neurologists, and 7 other clinicians. Most clinicians were working in the United States (74%), and the remainder (26%) in Canada. All attributes, apart from the nearest location with access to the intervention, influenced preferences significantly. The chance of clinically significant improvement in seizures was the most positive influence on clinician preferences, but low-quality evidence and a higher risk of major complications could offset these preferences. Of the existing neurotechnological interventions, vagus nerve stimulation was predicted to have the highest likelihood of adoption; deep brain stimulation had the lowest likelihood of adoption.SignificanceThe preferences of clinicians are drive primarily by the likelihood of achieving seizure freedom for their patients, but preferences for an intervention are largely eradicated if only low quality of evidence supporting the intervention is available. Until better evidence supporting the use of potentially effective, novel neurotechnologies becomes available, clinicians are likely to prefer more established treatments.

This qualitative study investigated factors that guide caregiver decision making and ethical trade-offs for advanced neurotechnologies used to treat children with drug-resistant epilepsy. Caregivers with affected children were recruited to semi-structured focus groups or interviews at one of 4 major epilepsy centers in Eastern and Western Canada and the USA (n = 22). Discussions were transcribed and qualitative analytic methods applied to examine values and priorities (eg, risks, benefits, adherence, invasiveness, reversibility) of caregivers pertaining to novel technologies to treat drug-resistant epilepsy. Discussions revealed 3 major thematic branches for decision making: (1) features of the intervention—risks and benefits, with an emphasis on an aversion to perceived invasiveness; (2) decision drivers—trust in the clinical team, treatment costs; and (3) quality of available information about neurotechnological options. Overall, caregivers’ definition of treatment success is more expansive than seizure freedom. The full involvement of their values and priorities must be considered in the decision-making process.

Background: Epilepsy affects over 500,000 children in North America of whom 30% have drug-resistant epilepsy. Advancements with neurotechnologies show promising benefits, but the perceptions of these procedures by youth is unknown. Methods: We conducted semistructured interviews with 10 youth in British Columbia, Canada who underwent procedures for drug-resistant epilepsy involving different forms of neurotechnology (subdural grids, vagus nerve stimulation, responsive neurostimulation). Interviews were analyzed using the constant comparative qualitative method. Results: Four major thematic categories emerged from the interviews. Treatment values, impact of the disorder, personal context, and impact of neurotechnology. Conclusions: Besides the predictable goal of seizure reduction, a desire for autonomy and the importance of trust in the medical team emerged as dominant values within the 4 thematic categories that were explicit to the use of new neurotechnologies for the management of drug-resistant epilepsy.

Optimal management of the bone flap after craniotomy for intracranial infection has not been well defined in the pediatric population. This study reviewed the outcomes of a single Canadian center where immediate replacement of the bone flap was standard practice. This is a retrospective study of all patients who underwent craniotomies for evacuation of epidural or subdural empyema at a single center from 1982 to 2018. Patients were identified using the prospective surgical database maintained by the Division of Pediatric Neurosurgery at BC Children’s Hospital. Primary outcome was treatment failure, defined as reoperation at the site of initial surgery for removal of an infected bone flap or repeat drainage of empyema under the replaced bone flap. Secondary outcome was any reoperation for recurrent infection at any site. Twenty-four patients met the inclusion criteria with a minimum of 3-month follow-up from the index intervention. Treatment failure occurred in four patients (17%), all of whom required repeat surgery for further drainage of pus underlying the bone flap. Mean time to repeat surgery was 13 days. Any reoperation for recurrent infection at any site occurred in three patients. Seven out of 24 patients required a second surgery to evacuate empyema (29.2%). Age, sex, epidural or subdural location, osteomyelitis, and bone flap wash were not associated with the primary outcome of treatment failure. Immediate replacement of the bone flap in the surgical management of pediatric subdural or epidural empyema is reasonable. Replacing the flap at the time of first surgery avoids the morbidity and costs of a subsequent reconstructive operation.

Objective: To characterize the clinical research landscape of pediatric drug-resistant epilepsy (DRE) with a focus on neurotechnology. Method: We searched the ClinicalTrials.gov registry using the terms “epilepsy” and “drug resistant” for studies including participants age 0-17 years. Returns were grouped by intervention (eg, neurotechnological, drug). Key trial features such as age range, trial status and outcomes were compared across interventions. Results: We identified 101 registered trials with pediatric DRE patients. Thirty-two (32%) investigate neurotechnological interventions, devices, or diagnostic procedures; 13 (41%) are currently active. Among neurotechnology trials, 15 (46%) investigate vagus nerve stimulation, transcranial direct current stimulation, or deep brain stimulation; few are specific to children. Of the remaining 69 trials, 37 investigate a drug, 17 investigate a dietary therapy, and 15 investigate another intervention. Seizure frequency is the most frequent primary outcome measured in the trials identified. Significance: The landscape of registered trials pertaining to pediatric DRE reflects a lag between clinical research and clinical practice, and highlights the need for timely evidence before novel neurotechnological interventions are widely adopted into clinical practice.

To examine the prevalence of cervical spine injuries among children and adolescents referred with suspected and diagnosed sports-related concussion (SRC); and evaluate the effect of cervical spine dysfunction (CSD) on physician-documented clinical recovery following SRC.A multidisciplinary pediatric concussion program.A total of 266 patients (6-19 years) referred with suspected SRC.A retrospective cohort study.CSD defined as neurological symptoms localized to the cervical spine or the presence of neck pain, headache, or dizziness and abnormal cervical spine examination findings; physician-documented clinical recovery.One patient was diagnosed with a T1 compression fracture. Of the 246 patients diagnosed with SRC, 80 (32.5%) met the clinical criteria for CSD including 4 patients with central cord neuropraxia and 1 with a spinal cord injury without radiographic abnormality (SCIWORA). Excluding patients with central cord neuropraxia OR SCIWORA, patients with SRC with CSD took longer to achieve physician-documented clinical recovery (28.5 days vs 17 days, P.0001) and were 3.95 times more likely to experience delayed physician-documented clinical recovery (4 weeks postinjury) compared with those without CSD.Patients with suspected and diagnosed SRC can present with a wide spectrum of coincident cervical spine injuries. Cervical spine dysfunction may be a risk factor for delayed clinical recovery.

OBJECTIVE Hydrocephalus may be seen in patients with multisuture craniosynostosis and, less commonly, single-suture craniosynostosis. The optimal treatment for hydrocephalus in this population is unknown. In this study, the authors aimed to evaluate the success rate of ventriculoperitoneal shunt (VPS) treatment and endoscopic third ventriculostomy (ETV) both with and without choroid plexus cauterization (CPC) in patients with craniosynostosis. METHODS Utilizing the Hydrocephalus Clinical Research Network (HCRN) Core Data Project (Registry), the authors identified all patients who underwent treatment for hydrocephalus associated with craniosynostosis. Descriptive statistics, demographics, and surgical outcomes were evaluated. RESULTS In total, 42 patients underwent treatment for hydrocephalus associated with craniosynostosis. The median gestational age at birth was 39.0 weeks (IQR 38.0, 40.0); 55% were female and 60% were White. The median age at first craniosynostosis surgery was 0.6 years (IQR 0.3, 1.7), and at the first permanent hydrocephalus surgery it was 1.2 years (IQR 0.5, 2.5). Thirty-three patients (79%) had multiple different sutures fused, and 9 had a single suture: 3 unicoronal (7%), 3 sagittal (7%), 2 lambdoidal (5%), and 1 unknown (2%). Syndromes were identified in 38 patients (90%), with Crouzon syndrome being the most common (n = 16, 42%). Ten patients (28%) received permanent hydrocephalus surgery before the first craniosynostosis surgery. Twenty-eight patients (67%) underwent VPS treatment, with the remaining 14 (33%) undergoing ETV with or without CPC (ETV ± CPC). Within 12 months after initial hydrocephalus intervention, 14 patients (34%) required revision (8 VPS and 6 ETV ± CPC). At the most recent follow-up, 21 patients (50%) required a revision. The revision rate decreased as age increased. The overall infection rate was 5% (VPS 7%, 0% ETV ± CPC). CONCLUSIONS This is the largest prospective study reported on children with craniosynostosis and hydrocephalus. Hydrocephalus in children with craniosynostosis most commonly occurs in syndromic patients and multisuture fusion. It is treated at varying ages; however, most patients undergo surgery for craniosynostosis prior to hydrocephalus treatment. While VPS treatment is performed more frequently, VPS and ETV are both reasonable options, with decreasing revision rates with increasing age, for the treatment of hydrocephalus associated with craniosynostosis.

This qualitative study investigated factors that guide physicians’ choices for minimally invasive and neuromodulatory interventions as alternatives to conventional surgery or medical management for pediatric drug-resistant epilepsy. North American physicians were recruited to one of 4 focus groups at national conferences. Discussions were analyzed using qualitative content analysis. A pragmatic neuroethics framework was applied to interpret results. Discussions revealed 2 major thematic branches: (1) clinical decision making and (2) ethical considerations. Under clinical decision making, physicians emphasized scientific evidence and patient candidacy when assessing neurotechnologies for patients. Ongoing seizures without intervention was important for safety and neurodevelopment. Under ethical considerations, resource allocation, among other financial considerations for technology adoption, were considerable sources of pressure on decision making. Access to neurotechnology was a salient theme differentiating Canadian and American contexts. When assessing novel neurotechnological interventions for pediatric drug-resistant epilepsy, physicians balance clinical and ethical factors to guide decision making and best practice.

Objective Media coverage of disorders and medical advancements can impact public perception regarding the riskiness, effectiveness, and accessibility of treatment options. We studied that coverage for epilepsy with a focus on surgical interventions and emerging neurotechnologies. Methods Epilepsy-related English language articles published through 2019 were retrieved from online International news media with a circulation of 80,000 or above. We used directed content analysis of news articles to code content into a priori categories both to identify salient themes and to characterize their valence. Results One hundred forty-six unique articles matched our search terms. Overall, there was a steady increase in epilepsy reporting over time, with a majority of articles published with a positive tone. Neuromodulation was the focus of over 50% of all the articles in the time points analyzed. Vagus nerve stimulation (VNS) and deep-brain stimulation (DBS) were discussed more prominently than other types of neurotechnological interventions; VNS was the neurotechnological focus in 39% of the pediatric articles; resective surgery was the focus in 34% of adult articles. Access, support, and epilepsy literacy were the central themes in the context of ethical, legal, and social issues. Significance News media can influence the trust that the public places in science and medicine, and by extension, influences health policy. As innovations in neurotechnology for epilepsy emerge, understanding of individual and societal values is essential to their beneficial evolution and translation to care.

The 2013 Physician Payments Sunshine Act mandates that all U.S. drug and device manufacturers disclose payments to physicians. All payments are made available annually in the Open Payments Database (OPD). Our aim was to determine prevalence, magnitude, and nature of these payments to physicians performing neurologic surgery in 2015 and to discuss the role that financial conflicts of interest play in neurosurgery.All records of industry financial relationships with physicians identified by the neurological surgery taxonomy code in 2015 were accessed via the OPD. Data were analyzed in terms of type and amounts of payments, companies making payments, and comparison with previous studies.In 2015, 83,690 payments (totaling $99,048,607) were made to 7613 physicians by 330 companies. Of these, 0.01% were$1 million, and 73.2% were$100. The mean payment ($13,010) was substantially greater than the median ($114). Royalties and licensing accounted for the largest monetary value of payments (74.2%) but only 1.7% of the total number. Food and beverage payments were the most commonly reported transaction (75%) but accounted for only 2.5% of total reported monetary value. Neurologic surgery had the second highest average total payment per physician of any specialty.The neurological surgery specialty receives substantial annual payments from industry in the United States. The overall value is driven by a small number of payments of high monetary value. The OPD provides a unique opportunity for increased transparency in industry-physician relationships facilitating disclosure of financial conflicts of interest.

Background Blunt cerebrovascular injury is an important cause of morbidity and mortality following head trauma. Intracranial vessel dissections, carotid-cavernous fistulae, and pseudo-aneurysms are uncommon traumatic vascular lesions with limited evidence to guide endovascular management. Case description We describe the case of a sixteen year old male patient suffering a traumatic paraclinoidal internal carotid artery (ICA) dissection with carotid-cavernous fistula and ophthalmic artery pseudo-aneurysm. Repeat angiography demonstrated worsening dissection prompting an endovascular parent vessel sacrifice following a passed balloon test occlusion. Relevant imaging is included. Conclusions Amongst new and developing stenting technologies as well as complex surgical solutions, utilizing a modern endovascular adaptation of simple Hunterian ligation to treat a complex multi-pronged pathology may in some cases represent the best available option. Given the limited published literature, our diagnostic and treatment approach may be informative to clinicians as well as inform an evidence based management approach in similar complex intracranial vascular injuries.

An interhypothalamic adhesion (IHA) is a gray mater–like band of tissue traversing across the third ventricle anterior to the mammillary bodies and is similar but distinct from an interthalamic adhesion. These rare anatomic anomalies can be detected with magnetic resonance imaging or, incidentally, during endoscopic ventricular surgery. All cases of interhypothalamic adhesions visualized during endoscopic third ventriculotomy (ETV), outside of the myelomeningocele setting, were identified from two institutions. Retrospective chart and imaging reviews were conducted and compared to intraoperative videos and photos for all cases. IHA variables collected included the following size, location, multiplicity, and associated anatomic anomalies. Four cases of interhypothalamic adhesions were identified during ETV—all of which, either partially or completely, obscured access to the third ventricular floor. The IHAs in our cohort were duplicated in two patients, large (> 3 mm and severely obstructing access to the third ventricular floor) in three patients, and adherent to the floor of the third ventricle in three patients. All four patients had primary absence of the septum pellucidum. Previous reports found associations of IHAs with other congenital, particularly midline, abnormalities. The IHAs in our cohort affected the surgery in three of four cases including misdirecting the ventriculostomy and requiring retraction or division of the IHA. In no case was postoperative pituitary or hypothalamic dysfunction observed. Although interhypothalamic adhesions are rare, these anomalies must be recognized as they may hinder access to the third ventricular floor. IHAs may be large, multiple, or adherent to adjacent ventricular structures, they can misdirect or occlude the ventriculostomy or impart risk of bleeding and hypothalamic injury. Techniques for management of IHA include aborting the attempt, re-siting the ventriculostomy, or retracting or dividing the IHA, which enabled technically successful ETV in three of four patients in this series.

Thalamic gliomas are rare. The natural history is unpredictable, and the optimal management of these tumors in children is poorly defined. The aim was to identify outcomes, prognostic factors, and response to various modalities of treatment in a relatively large population of pediatric thalamic tumors from many centers within a fairly homogeneous health care system. We performed a Canadian multicenter retrospective review of pediatric thalamic tumors presenting during the MRI era (1989–2012). Radiology and pathology were reviewed by central independent reviewers. Paraffin shavings for RNA extraction were taken and tested for fusion events involving KIAA1549:BRAF. Tumors were classified as unilateral or bithalamic based on their origin on imaging. Univariate and multivariate analyses on factors influencing survival were performed. Seventy-two thalamic tumors were identified from 11 institutions. Females represented 53 % of the study population, and the mean age at presentation was 8.9 years. Sixty-two tumors were unilateral and 10 bithalamic. Unilateral tumors had a greater propensity to grow inferiorly towards the brainstem. These tumors were predominantly low grade in comparison to bithalamic tumors which were high-grade astrocytomas. The 5-year overall survival was 61 ± 13 % for unithalamic tumors compared to 37 ± 32 % for bithalamic tumors (p = 0.097). Multivariate analysis indicated tumor grade as the only significant prognostic factor for unithalamic tumors. Six unilateral tumors, all low grade, were BRAF fusion positive. Unilateral and bilateral thalamic tumors behave differently. Surgical resection is an appropriate treatment option in unilateral tumors, most of which are low grade, but outcome is not related to extent of resection (EOR). Bilateral thalamic tumors have a poorer prognosis, but the occasional patient does remarkably well. The efficacy of chemotherapy and radiotherapy has not been clearly demonstrated. Novel therapeutic approaches are required to improve the prognosis for malignant unilateral thalamic tumors and bilateral thalamic tumors.

Background: Preliminary studies suggest sports-related concussion (SRC) is associated with alterations in cerebral blood flow (CBF) regulation. Here, we use advanced magnetic resonance imaging (MRI) techniques to measure CBF and cerebrovascular responsiveness (CVR) in individual SRC patients and healthy control subjects. Methods: Fifteen SRC patients (mean age=16.3, range 14-20 years) and 27 healthy control subjects (mean age=17.6, range 13-21 years) underwent anatomical MRI, pseudo-continuous arterial spin labeling (pCASL) MRI and model-based prospective end-tidal targeting (MPET) of CO2 during blood oxygenation level-dependent (BOLD) MRI. Group differences in global mean resting cerebral blood flow (CBF) were examined. Voxel-by-voxel group and individual differences in regional CVR were examined using statistical parametric mapping (SPM). Leave-one-out receiver operating characteristic curve analysis was used to evaluate the utility of brain MRI CO2 stress testing biomarkers to correctly discriminate between SRC patients and healthy control subjects. Results: All studies were tolerated with no complications. Traumatic structural findings were identified in one SRC patient. No significant group differences in global mean resting CBF were observed. There were no significant differences in the CO2 stimulus and O2 targeting during BOLD MRI. Significant group and patient-specific differences in CVR were observed with SRC patients demonstrating a predominant pattern of increased CVR. Leave-one-out ROC analysis for voxels demonstrating a significant increase in CVR was found to reliably discriminate between SRC patients and healthy control subjects (AUC of 0.879, p=0.0001). The optimal cut-off for increased CVR declarative for SRC was 1899 voxels resulting in a sensitivity of 0.867 and a specificity of 0.778 for this specific ROC analysis. There was no correlation between abnormal voxel counts and PCSS scores among SRC patients. Conclusions: Acute and sub-acute sports-related concussion is associated with alterations in CVR that can be reliably detected by brain MRI CO2 stress testing in individual patients.

Our goal is to describe a case of hydrocephalus in the setting of a Yasargil Type IV-C secondary vein of Galen malformation (VGM), treated with a combined endscopic and endovascular approach. We retrospectively reviewed the records of a patient admitted to the neurosurgical department hydrocephalus related to a secondary VGM. A 47 year old male, presents with 8 months of progressive headaches and gait ataxia. Imaging displays a triventricular hydrocephalus, a tectal AVM, and an aneurysmal dilation of the great vein of Galen. Angiography displays a tectal AVM supplied by bilateral posterior choroidals with drainage into the vein of Galen. In addition there were direct high-flow arteriovenous fistulas into the vein of Galen via meningeal feeders. The diagnosis of a Yasargil Type IV-C secondary VGM was made. The patient was treated via a combined endoscopic and endovascular approach. An endoscopic third ventriculostomy (ETV) was conducted for his hydrocephalus. He subsequently underwent a partial endovascular embolization of the left tentorial arterial feeder 1.5 months after his ETV. Post-operatively his hydrocephalus resolved, and his complex secondary VGM completely obliterated after a single partial embolization. Secondary VGMs with associated high-flow arteriovenous fistulas are rare. Our case provides a nice example a combined endoscopic and endovascular approach aimed at achieving cure of the hydrocephalus and the Yasargil Type IV-C secondary VGM. We were able to avoid the placement of shunt hardware via ETV treatment of the patient's hydrocephalus. Furthermore, our case displays the impact of partial embolization on control and potential cure of these complex vascular malformations.

Background:Gamma Knife (GK) radiosurgery for pediatric arteriovenous malformations (AVM) of the brain presents a non-invasive treatment option. We report our institutional experience with GK for pediatric AVMs.Methods:We performed a retrospective review of all pediatric patients treated with GK for cerebral AVMs at our institution from November 2003 up to and including September 2014. Patient demographics, AVM characteristics, treatment parameters and AVM responses were recorded.Results:Nineteen patients were treated, with 4 lost to follow-up. The mean age was 14.2 years (range. 7-18 years), with 10 being males (52.6%). The mean AVM diameter and volume were 2.68 cm and 3.10 cm3respectively. The mean Spetzler-Martin (SM) and Pollock grades of the treated AVMs were 2.4 and 0.99 respectively. The mean follow-up was 62 months. All AVMs treated demonstrated a response on follow-up imaging. Nine of 15 (60.0%) patients displayed obliteration of their AVMs. Nine of 11 patients with a minimum of 3 years follow-up (81.8%) displayed obliteration, with SM and Pollock grades correlating to the chance of obliteration in this group. Two patients developed post-GK edema requiring short course dexamethasone therapy. No other major complications occurred. No permanent complications occurred.Conclusions:GK radiosurgery for pediatric AVMs offers a safe and effective treatment option, with low permanent complication rates during early follow-up.

Background: Despite the critical role played by neurosurgeons in performing radiosurgery, neurosurgery residents in Canada have limited exposure to radiosurgery during their training. A survey of neurosurgery residents and faculty along with radiation oncology faculty was conducted to analyze perspectives regarding incorporating formal radiosurgery training into the neurosurgery residency curriculum Methods: An online survey platform was employed. Descriptive statistics were used to summarize center and respondent characteristics. Categorical variables were compared using odds ratios and corresponding 95% confidence intervals. The chi-squared test was utilized to assess statistical significance. A value of pResults: The response rate was 31% (119/381); 87% (102/119) of respondents were from the neurosurgical specialty and 13% (17/119) from radiation oncology. Some 46% of residents (18/40) were “very uncomfortable” with radiosurgery techniques, and 57% of faculty (42/73) believed that dedicated radiosurgery training would be beneficial though impractical. No respondents felt that “no training” would be beneficial. A total of 46% of residents (19/41) felt that this training would be beneficial and that time should be taken away from other rotations, if needed, while 58% of faculty (42/73) and 75% (28/41) of residents believed that either 1 or 1-3 months of time dedicated to training in radiosurgery would suffice Conclusions: Canadian neurosurgeons are actively involved in radiosurgery. Despite residents anticipating a greater role for radiosurgery in their future, they are uncomfortable with the practice. With the indications for radiosurgery expanding, this training gap can have serious adverse consequences for patients. Considerations regarding the incorporation and optimal duration of dedicated radiosurgery training into the Canadian neurosurgery residency curriculum are necessary.

Background: The 2013 Physician Payments Sunshine Act mandates that all US drug and device manufacturers disclose payments to physicians annually in the Open Payments Database (OPD). We aimed to determine the prevalence, magnitude and nature of these payments to neurological surgery in 2015. Methods: Records of payments to physicians identified by the ‘neurological surgery’ taxonomy code in 2015 were accessed via the OPD. The data were analyzed in terms of the type and amounts of payments, companies making payments, and in comparison to previous studies. Results: In 2015, 330 companies made 83,690 payments ($99,048,607) to 7,613 physicians. The mean payment ($13,010) was substantially greater than the median ($114). Royalties and licensing accounted for the largest proportion of total payment value (74.2%), but only 1.7% of the total number. Food and beverage payments were the most commonly reported transaction (75%), but only 2.5% of the total value. Neurological surgery had the second highest average total payment per physician of any specialty. Conclusions: The overall value of payments to the neurological surgery specialty is driven by a small number of payments that may represent appropriate compensation for novel device development. The OPD provides an opportunity for increased transparency and for the interpretation of research in light of potential conflicts of interest.

Object:To review our institutional experience with Gamma Knife (GK) stereotactic radiosurgery in treating large vestibular schwannomas (VS) of 3 to 4 cm diameter.Methods:We conducted a retrospective cohort review of all patients treated with GK for VS at our institution between November 2003 and March 2012. Data on age, sex, VS volume, location and maximal diameter, House-Brackmann (HB) facial nerve scores pre and post-GK, Gardner-Robertson (GR) hearing score pre and post-GK, GK treatment parameters, VS response time, complications and clinical outcome was recorded.Results:A total of 28 patients during the defined time period were identified. Three patients were lost to follow-up. Mean follow-up was 34.5 months. Tumor control occurred in 92%, and was maintained in 85.7% at two years. Facial nerve or hearing preservation occurred in all treated compared to pre-GK status, as per HB and GR grading. Transient complications occurred in 80%. Temporary vestibular dysfunction occurred in seven patients (28%). One patient (4%) had the permanent complication of worsening pre-GK hemifacial spasm. Four patients (16%) developed hydrocephalus post-GK.Conclusion:GK stereotactic radiosurgery as a primary treatment modality for large VS can provide acceptable tumor control rates with good facial nerve and hearing preservation, and low complication rates.

Objectives: To summarize the clinical characteristics and outcomes of pediatric sports-related concussion (SRC) patients who were evaluated and managed at a multidisciplinary pediatric concussion program and examine the healthcare resources and personnel required to meet the needs of this patient population. Methods: We conducted a retrospective review of all pediatric SRC patients referred to the Pan Am Concussion Program from September 1st, 2013 to May 25th, 2015. Initial assessments and diagnoses were carried out by a single neurosurgeon. Return-to-Play decision-making was carried out by the multidisciplinary team. Results: 604 patients, including 423 pediatric SRC patients were evaluated at the Pan Am Concussion Program during the study period. The mean age of study patients was 14.30 years (SD: 2.32, range 7-19 years); 252 (59.57%) were males. Hockey (182; 43.03%) and soccer (60; 14.18%) were the most commonly played sports at the time of injury. Overall, 294 (69.50%) of SRC patients met the clinical criteria for concussion recovery, while 75 (17.73%) were lost to follow-up, and 53 (12.53%) remained in active treatment at the end of the study period. The median duration of symptoms among the 261 acute SRC patients with complete follow-up was 23 days (IQR: 15, 36). Overall, 25.30% of pediatric SRC patients underwent at least one diagnostic imaging test and 32.62% received referral to another member of our multidisciplinary clinical team. Conclusion: Comprehensive care of pediatric SRC patients requires access to appropriate diagnostic resources and the multidisciplinary collaboration of experts with national and provincially-recognized training in TBI.

AT-22. ALISERTIB MONOTHERAPY IN THE TREATMENT OF RELAPSED ATYPICAL TERATOID RHABDOID TUMOR (ATRT) Magimairajan Issai Vanan1, Patrick McDonald2, Colin Kazina3, Junliang Liu1, Sherry Krawitz4, Martin Bunge5, Annie Ong1, and Brent Orr6; CancerCare Manitoba/Winnipeg Children’s Hospital, Winnipeg, MB, Canada; Pediatric Neuro-surgery/BC Children’s Hospital, Vancouver, BC, Canada; Pediatric Neuro-Surgery/University of Manitoba, Winnipeg, MB, Canada; Neuropathology/University of Manitoba, Winnipeg, MB, Canada; Radiology/University of Manitoba, Winnipeg, MB, Canada; Pathology/ St Jude Children’s Research Hospital, Memphis, TN, USA Atypical teratoid rhabdoid tumors (ATRTs) account for up to 20% of brain tumors in children less than 3yrs of age. The overall prognosis of ATRTs is extremely poor with median survival in the range of 10-18mths from the time of diagnosis. Aurora A Kinase (AURKA) encodes a protein that regulates the formationandstabilityof themitotic spindleand ishighlyactive inATRTthrough loss of the INI1 tumor suppressor gene. Alisertib (MLN8237) is a selective small molecule inhibitor of AURKA. We report a case of recurrent ATRT treated with alisertib monotherapy producing sustained and durable disease remission. Our patient underwent gross total resection (GTR) of the Posterior fossa tumor at diagnosis and was initially treated as per ACNS0333 protocol. She remained in remission for 15 months after completion of chemotherapy when she relapsed in the right frontal lobe. She underwent sub-total resection (STR) followed by focal IMRT (54Gy/30 fractions) followed by chemotherapy (DFCI-IRS-III, modified protocol) with Doxorubicin / Etoposide alternating with Actinomycin-D and triple intrathecal chemotherapy. After 7 months of treatment, she relapsed again in the right frontal region, presenting with focal seizures. She received 10 cycles of alisertib (60mg/m2 by mouth once daily for 7 days of a 21 day treatment cycle) monotherapyand is clinically stablewith her imaging showingsustained regression of disease. Somnolescence and neutropenia were the most common side effects seen in our patient. Neuro-Oncology 18:iii1–iii6, 2016. doi:10.1093/neuonc/now065.21 #The Author(s) 2016. Published by Oxford University Press on behalf of the Society for Neuro-Oncology. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

Background: Despite being mandatory for accreditation by the RCPSC and ACGME, little is known about how ethics education is undertaken during neurosurgery training. This study assessed the current state of ethics education in North American neurosurgery training programs. Methods: A web-based survey was developed based on ethics competencies outlined by the RCPSC and the ACGME and emailed to North American neurosurgery residency program directors(PD’s). Responses were analyzed using descriptive statistics. Results: 47/119 (40%) PD’s completed the survey. Most(74%) spent Conclusions: This study provides a snapshot of ethics education in neurosurgery training. Time constraints and a lack of expert faculty were seen as barriers to ethics education. Most program directors felt residents were well prepared to deal with ethical issues. Identified ethical topics of importance should be incorporated into training curricula.

Background: Industry funding of neurosurgery research is on the rise and this creates a conflict of interest (COI) with the potential to bias results. The reporting and handling of COI is impacted by the variation in policies and definitions between journals. In this study we sought to evaluate the prevalence and comprehensiveness of COI policies amongst leading neurosurgical journals. Methods: We conducted a cross-sectional study of publicly available online disclosure policies in the 20 highest-ranking neurosurgical journals, as determined by Google Scholar Metrics, in July of 2016. Results: Eighteen (89.5%) of the top neurosurgical journals included COI policy statements. Ten journals requested declaration of non-financial conflicts, while two journals defined a time period of interest for conflicts. Sixteen journals required declaration from the corresponding author, 13 from all authors, six from reviewers and five from editors. Five journals included COI declaration verification, management or enforcement. Journals with more comprehensive COI policies were significantly more likely to have higher h5-indices (p=0.003) and higher impact factors (p=0.01). Conclusions: In 2016, the majority of high-impact neurosurgical journals had publicly available COI disclosure policies. Policies varied substantially across neurosurgical journals; but COI comprehensiveness was associated with impact factor and h5-index. More comprehensive and consistent COI policies will facilitate increased transparency in neurosurgery research.

Winter sports are often associated with high speed, which carries with it the potential for collision. As such, head injuries are among the more commonly encountered injuries in winter-related sporting activities. This article focuses on popular winter sports such as downhill skiing and snowboarding, sledding, snowmobiling, ice skating, and hockey. In virtually all of these activities, the incidence and severity of head injuries can be reduced by the use of appropriate protective headgear.

Background: Transitioning from medical school to residency is difficult and stressful, necessitating innovation in easing this transition. In response, a Canadian neurosurgical Rookie Camp was designed and implemented to foster acquisition of technical, cognitive and behavioral skills among incoming Canadian post graduate year one (PGY-1) neurosurgery residents. Methods: The inaugural Rookie Camp was held in July 2012 in Halifax. The curriculum was developed based on a national needs-assessment and consisted of a pre-course manual, 7 case-based stations, 4 procedural skills stations and 2 group discussions. The content was clinically focused, used a variety of teaching methods, and addressed multiple CanMEDS competencies. Evaluation included participant and faculty surveys and a pre-course, post-course, and 3-month retention knowledge test. Results: 17 of 23 PGY-1 Canadian neurosurgical residents participated in the Camp. All agreed the course content was relevant for PGY-1 training and the experience prepared them for residency. All participants would recommend the course to future neurosurgical residents. A statistically significant improvement was observed in knowledge related to course content (F(2,32) = 7.572, pConclusion: The inaugural Canadian Neurosurgery Rookie Camp for PGY-1 residents was successfully delivered, with engagement from participants, training programs, the Canadian Neurosurgical Society, and the Royal College. In addition to providing fundamental knowledge, which was shown to be retained, the course eased junior residents’ transition to residency by fostering camaraderie and socialization within the specialty.

Hypothalamic hamartomas (HH) are rare lesions of ectopic neural tissue arising from the wall of the hypothalamus. Patients with HH can present with gelastic seizures, precocious puberty or both 1 . Seizures are usually progressive and accompanied by worsening behavioral problems and developmental delay 1 . Stereotactic radiosurgery (SRS) has been shown to be safe and effective, resulting in improvement in s eizures and halting tumor progression. Gamma Knife (GK) radiosurgery in the treatment of hypothalamic hamartoma has reported Engel Class 1 seizure status of up to 60%, with improvement in behavioral status in some cases 2 . Post-treatment magnetic resonance (MR) imaging as reported in the literature has not demonstrated significant changes within the treated areas of a HH. The authors report the case of a four year-old boy with a symptomatic hypothalamic hamartoma treated with GK radiosurgery. Serial MR imaging after treatment revealed significant and progressive edema and swelling at the treatment site, with increased T2 signal change and gadolinium uptake lasting one year after treatment and eventually resolving spontaneously. Although not accompanied by clinical worsening, these changes have not been p reviously reported in SRS for HH.

Aim: To examine the online personnel and practice profiles of concussion healthcare providers in the USA. Methods: We conducted independent, blinded, Google Internet searches for concussion healthcare providers using the terms ‘concussion clinic’ and ‘concussion program’ and each American state and completed a critical appraisal of healthcare personnel and services at these websites. Results: A total of 184 concussion healthcare providers were identified. Despite offering care to traumatic brain injury (TBI) patients, access to professionals with expertise in TBI including neuropsychologists (40.8%), neurologists (33.7%) and neurosurgeons (21.7%) was variable across sites. Conclusion: Concussion healthcare in the USA is presently delivered by a range of healthcare professionals with varying levels of training in TBI offering a variety of services.

A 28-month female with a clinical diagnosis of neurocutaneous melanosis and numerous intracranial abnormalities (including a right choroid plexus tumor and left hemimegalencephaly) presented with a rapidly expanding tumor in the left occipital cerebrum. Microscopic examination of the resected specimen revealed a myxoid mesenchymal neoplasm consisting of fusiform cells that were immunoreactive for vimentin, CD34, and P53 but no melanocyte markers. Focused amplicon deep sequencing on DNA extracted from the brain tumor and a cutaneous nevus revealed a heterozygous (c.37G > C; p.G13R) substitution in the NRAS gene. DNA sequencing of “normal” skin and buccal swab showed the identical NRAS change albeit at lower allelic frequency. Her parents did not harbor the NRAS mutation. The skin lesion, but not the brain tumor, had a BRAF mutation (c.1397G > T; p.G466V). A germline single nucleotide polymorphism in MET was found in the child and her father (c.3209C > T; p.T1010I). The findings suggest NRAS mosaicism that occurred sometime after conception and imply an oncogenic role of the activating NRAS mutation in both the brain and skin lesions in this child.

The skull may be a site of metastasis in malignancies such as carcinoma of the breast, prostate, lung, and multiple myeloma. The majority of patients with skull metastases are asymptomatic or present with localized swelling which is often painless. While subdural hematoma has been commonly associated with metastatic disease involving the dura, hemorrhage from a skull metastasis remains a rare occurrence. We present the case of acute epidural hematoma resulting from metastatic esophageal carcinoma to the skull.

Arachnoid cysts are relatively common lesions encountered in neurosurgical practice. While arachnoid cysts are most commonly observed to remain of fixed volume over time, little is actually known about their natural history and optimal method of treatment. We present 2 young children with middle fossa arachnoid cysts. In 1 child, the cyst enlarged over time, prompting neurosurgical intervention. However, in the other child, the cyst resolved spontaneously without intervention. The child whose cyst enlarged underwent cyst wall fenestration and cyst-peritoneal shunting. For the child whose arachnoid cyst disappeared without treatment, there was no history of trauma or antecedent headache. These 2 cases serve to illustrate in a single report that middle fossa arachnoid cysts can be dynamic in nature, with some growing in size while others spontaneously resolving. In both cases presented, the temporal lobe on the affected side was compressed by the large cyst. Following treatment or spontaneous resolution of the cyst, the temporal lobe reexpanded, suggesting a normal volume of temporal lobe, and not temporal lobe agenesis. In asymptomatic patients with moderate-sized arachnoid cysts such as the ones demonstrated in these case reports, we suggest close follow-up with serial imaging before deciding on a final treatment plan.

Primary intracranial sarcomas are rare tumors of mesenchymalorigin in the central nervous system (CNS). Spontaneoushemorrhage, while not an uncommon presentation of braintumors, has not been described in primary cerebral sarcoma.We report the case of a 43 yearold woman presenting with spontaneous hemorrhage into aprimary cerebral fibrosarcoma, and discuss this case inthe context of the diagnostic criterions of theserare tumors, previous reports of intracranial sarcomas andmechanisms of intratumoral hemorrhage.

Introduction:Stereotactic radiosurgery offers a unique and effective means of controlling cavernous sinus meningiomas with a low rate of complications.Methods:We retrospectively reviewed all cavernous sinus meningiomas treated with Gamma Knife (GK) radiosurgery between November 2003 and April 2011 at our institution.Results:Thirty patients were treated, four were lost to follow- up. Presenting symptoms included: headache (9), trigeminal nerve dysesthesias/paresthesias (13), abducens nerve palsy (11), oculomotor nerve palsy (8), Horner's syndrome (2), blurred vision (9), and relative afferent pupillary defect (1). One patient was asymptomatic with documented tumor growth. Treatment planning consisted of MRI and CT in 17 of 30 patients (56.7%), the remainder were planned with MRI alone (44.3%). There were 8 males (26.7%) and 22 females (73.3%). Twelve patients had previous surgical debulking prior to radiosurgery. Average diameter and volume at time of radiosurgery was 3.4 cm and 7.9 cm3 respectively. Average dose at the 50% isodose line was 13.5 Gy. Follow-up was available in 26 patients. Average follow-up was 36.1 months. Mean age 55.1 years. Tumor size post GK decreased in 9 patients (34.6%), remained stable in 15 patients (57.7%), and continued to grow in 2 (7.7%). Minor transient complications occurred in 12 patients, all resolving. Serious permanent complications occurred in 5 patients: new onset trigeminal neuropathic pain (2), frame related occipital neuralgia (1), worsening of pre-GK seizures (1), and panhypopituitarism (1).Conclusion:GK offers an effective treatment method for halting meningioma progression in the cavernous sinus, with an acceptable permanent complication rate.

A 69-year-old female presented to the emergency department after becoming unresponsive at home following a progressive decrease in her level of consciousness (LOC) (See Figure 1). An urgent computerized tomography (CT) scan of the head demonstrated large bilateral chronic subdural hematomas (SDH’s). Due to the resulting mass effect she was brought urgently to the operating room where the SDH’s were evacuated via anterior and posterior burr holes placed bilaterally. No complications were encountered during the procedure. Prior to skin closure bilateral subdural catheters were placed in the posterior burr hole sites and left under closed suction.

Object:To review our institutional experience with Gamma Knife (GK) stereotactic radiosurgery in treating focally recurrent high grade glial neoplasms of World Health Organization (WHO) grade III or IV.Methods:We conducted a retrospective cohort review of all patients treated with GK for focally recurrent high grade gliomas at our institution between November 2003 and April 2013. Data on age, sex, tumor volume, location and maximal diameter, presenting clinical status, complications and clinical outcome was recorded.Results:A total of 33 patients were identified. Four were lost to follow-up. Average post-GK and overall survival was 20.4 months (range: 3 – 72) and 63.3 months (range: 10 – 214) respectively. For WHO grade IV gliomas, the average post-GK and overall survival was 15.8 months (range: 3 – 77) and 40.1 months (range: 13 – 148) respectively. Similarily, for WHO grade III gliomas, the average post-GK and overall survival was 34.9 months (range: 6 – 72) and 136.4 months (range: 22 – 214) respectively. Twenty-two patients (75.9%) had post-GK edema, with 14 requiring dexamethasone and eight being asymptomatic. Four patients (13.8%) had imaging defined radiation necrosis.Conclusions:Gamma Knife SRS affords an extension of local tumor control, acceptable morbidity, and potentially prolonged survival, for highly selected patients with focally recurrent high grade glial neoplasms.

Introduction:Gamma Knife (GK) radiosurgery for pituitary adenomas can offer a means of tumor and biologic control with acceptable risk and low complication rates.Methods:Retrospective review of all the patients treated at our center with GK for pituitary adenomas from Nov 2003 to June 2011.Results:We treated a total of 86 patients. Ten were lost to follow-up. Mean follow was 32.8 months. There were 21 (24.4%) growth hormone secreting adenomas (GH), 8 (9.3%) prolactinomas (PRL), 8 (9.3%) adrenocorticotropic hormone secreting (ACTH) adenomas, 2 (2.3%) follicle stimulating hormone/luteinizing hormone secreting (FSH/LH) adenomas, and 47 (54.7%) null cell pituitary adenomas that were treated. Average maximum tumor diameter and volume was 2.21cm and 5.41cm3, respectively. The average dose to the 50% isodose line was 14.2 Gy and 23.6 Gy for secreting and non-secreting adenomas respectively. Mean maximal optic nerve dose was 8.87 Gy. Local control rate was 75 of 76 (98.7%), for those with followup. Thirty-three (43.4%) patients experienced arrest of tumor growth, while 42 (55.2%) patients experienced tumor regression. Of the 39 patients with secreting pituitary tumors, 6 were lost to follow-up. Improved endocrine status occurred in 16 (50.0%), while 14 (43.8%) demonstrated stability of hormone status on continued pre-operative medical management. Permanent complications included: panhypopituitarism (4), hypothyroidism (4), hypocortisolemia (1), diabetes insipidus (1), apoplexy (1), visual field defect (2), and diplopia (1).Conclusions:Gamma Knife radiosurgery is a safe and effective means of achieving tumor growth control and endocrine remission/stability in pituitary adenomas.

Background:We report the results of a consecutive series of patients treated with Gamma Knife (GK) Surgery for cerebral arteriovenous malformations (AVMs).Methods:We retrospectively reviewed 69 patients treated with GK for cerebral AVMs between November 2003 and April 2009, recording clinical data, treatment parameters, and AVM obliteration rates in order to assess our effectiveness with GK in treating these lesions.Results:Ten patients were lost to follow-up. Presentations included: seizure (24), hemorrhage (18), persistent headache (12), progressing neurological signs (10), and incidental (9). In 24 patients (34.8%) treatment planning consisted of digital subtraction angiography (DSA), magnetic resonance imaging (MRI), and computed tomogram (CT) angiography (CTA). Currently we rely predominantly on CTA and/or MRI scanning only. Fourty-one patients have been followed for a minimum of 3 years; average age 40.9yr., 58.5% males. Average dose at the 50% isodose line was 20.3 Gy (range 16 to 26.4 Gy). Obliteration was observed in 87.8% by MRI, CT, or DSA. Not all obliteration was confirmed by DSA. Complications occurred in 12 of 59 (20.3%) patients, and in 11 of 41 (26.8%) with 3 year follow-up. Major (temporary) complications for the 59 included symptomatic cerebral edema (7), seizure (2), and hemorrhage (1). Major permanent complications occurred in one patient suffering a cranial nerve V deafferentation, and in two patients suffering a hemorrhage.Conclusion:GKS for cerebral AVM's offers an effective and safe method of treatment, with low permanent complication rate.