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Background Risk of delayed cerebral ischemia (DCI) in patients with aneurysmal subarachnoid hemorrhage (aSAH) with asymptomatic angiographic vasospasm on admission is unclear in the literature. The goal of this study is to identify predictors of clinical DCI in this group of patients. Methods An exploratory subgroup analysis was conducted in the SAHIT (Subarachnoid Hemorrhage International Trialists) data repository to identify predictors of clinical DCI in patients with good-grade aSAH (World Federation of Neurological Surgeons grade I and II) with angiographic vasospasm on admission. Predictors considered include age, sex, systolic blood pressure at presentation, World Federation of Neurological Surgeon grade, Fisher grade, aneurysm size and location, treatment modality, hydrocephalus requiring external ventricular drain insertion, and severity of vasospasm. The predictors were ranked based on dominance analysis with R2 as fit statistics and assessed in a set of logistic regression analysis models. Results Four data sets out of 16 studies in the SAHIT database were analyzed, with a total of 4125 patients. One hundred and ninety-one patients (4.6%) had asymptomatic angiographic vasospasm at admission. Of those, 78 patients (40.8%) developed clinical DCI. Univariate analysis showed significant associations between severe vasospasm on admission and development of clinical DCI (odds ratio, 9.5, 95% confidence interval, 2.07–43.50; P = 0.004). None of the studied predictors was associated with the development of clinical DCI on multivariate analysis. Conclusions Asymptomatic angiographic vasospasm in patients with good-grade aSAH on admission is uncommon. Further studies are needed to identify high-risk patients for the development of DCI in the context of asymptomatic early vasospasm.

Background Subdural fluid collections (hygromas and effusions) in adults are usually seen following head trauma or overdrainage of cerebrospinal fluid (CSF) after CSF diversion procedures. We report an unusual case of subdural fluid collection that developed spontaneously 5 days after an aneurysmal subarachnoid hemorrhage (SAH). This patient neither had permanent CSF diversion procedure nor history of significant head trauma during her clinical course. Methods This study is a Case report of the patient suffering from an SAH. Results A 71-year-old woman suffered an SAH from a ruptured right-sided posterior communicating artery aneurysm. Computed tomography (CT) demonstrated diffuse SAH and signs of early hydrocephalus that did not require treatment. The aneurysm was treated with endovascular coil occlusion without any complications. Throughout her hospital course, she remained alert without neurological deficits. A large subdural fluid collection was discovered incidentally during a routine CT scan of the brain 5 days after the SAH. The patient remained asymptomatic; therefore, the collection was treated conservatively. It resolved spontaneously at five days after the initial diagnosis. Conclusion Subdural fluid collections following SAH can occur as a result of head trauma, external hydrocephalus, or as a treatment complication of CSF shunting and craniotomies. It is critical to differentiate simple hygromas from external hydrocephalus since their response to CSF diversion is entirely different.

Background Acquired Chiari malformations (ACM) and associated syringomyelia secondary to space-occupying lesions can cause neurologic deficits independent of or in combination with the offending mass. Although type I Chiari malformations are traditionally treated with posterior fossa decompression, optimal surgical management of ACM and associated syringomyelia remains unclear. The purpose of this study is to review the current literature surrounding the management of ACM. Methods A systematic review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Using the relevant keywords, articles were identified through multiple databases from inception to April 2016. Our primary outcome was postoperative resolution of tonsillar herniation, syringomyelia, and clinical symptoms and signs. Results Thirty studies (27 case reports and 3 case series), encompassing 44 patients, were included in the review. Meningiomas (36%) and arachnoid cysts (32%) were the lesions most commonly associated with ACM. Offending lesions were usually large (85%) and almost all were found in the posterior fossa (89%). Syringomyelia was present in 82% of cases. Overall, all but 1 patient had improvement or resolution of their syringomyelia after surgery and none required a syrinx shunt. Rates of tonsillar ascent, syrinx resolution, and neurologic recovery were similar in patients who underwent lesion removal alone versus those who underwent posterior fossa decompression and lesion removal. Conclusions Space-occupying lesions in the posterior fossa are a rare cause of ACM and syringomyelia. Surgical management of the underlying lesion improves ACM and associated syringomyelia without the need for syrinx shunting.

Background Endovascular thrombectomy is an effective procedure to treat selected ischemic strokes, as shown in recent randomized controlled trials (RCTs). The generalizability of these trial data to real-world settings, however, is unknown. The aim of this study was to examine our single-center experience with endovascular thrombectomy for acute ischemic strokes and perform a comparative outcome analysis to the most recent RCTs. Methods We performed a 5-year retrospective analysis, from April 2011 to March 2016, on 66 consecutive patients with acute ischemic stroke who received endovascular thrombectomy at our institution. The Alberta Stroke Program Early CT Score (ASPECTS) and the National Institutes of Health Stroke Scale were used to assess preoperative status. Our primary outcomes were the modified Rankin Score (mRS) at 90 days and recanalization grade measured by the 6-point thrombolysis in cerebral infarction (TICI) grading system. Results Sixty-six patients received endovascular treatment during the study period. Among the patients examined, 35 (53%) had a favorable outcome (mRS 0–2 at 90 days), 23 (35%) a poor outcome (mRS 3–5), and 8 (12%) died. Successful recanalization (TICI score 3–5) was achieved in 68% of cases. In univariate analysis, patients with good outcome at 90 days had significantly greater ASPECTS, lower National Institutes of Health Stroke Scale, and higher TICI scores. In a multiple logistic regression model, higher ASPECTS and TICI scores were significantly and independently associated with favorable outcome. Conclusions Excellent outcomes, as demonstrated by the recent RCTs, can be achieved in clinical practice and reproduced in dedicated tertiary centers.

There is a paucity of available strategies to increase visibility and engagement in social media (SM) within the neurosurgical community. The objective of this study was to investigate the possible factors for engagement and reach among SM users in neurosurgery.Data from Facebook and Twitter accounts of our institution were collected. We extracted data on demographics and attributes of our current users, including sex, country, age group, device used, and language. Attributes of SM posts were also collected, including time of post, type and content of post, impressions, and engagements. Nonparametric analyses were conducted to evaluate differences in metrics.Metrics were obtained on 192 Facebook and Twitter posts, published online between October 1, 2013, and March 13, 2016. On both platforms, there was a greater representation of male users relative to female users. Facebook users were predominantly in the 18-34 years age range (83%), with most users being from outside of North America. Conversely, users from Canada and the United States comprised the highest proportion of Twitter users. On both platforms, posts containing photos or videos scored significantly higher in engagements and impressions (P 0.05). Posts on weekdays and during work hours achieved higher visibility and engagements. Moreover, Facebook posts demonstrated higher SM metrics if they mentioned faculty with more than 16 years' experience (P0.05).The current study demonstrates that our SM users predominantly comprise a younger demographic and that content optimization with media materials may lead to higher visibility and engagement. The impact of high SM reach on academic neurosurgical programs remains to be determined.

Objective The aim of this study is to better understand perspectives of patients with persistent postoperative neuropathic pain (PPNP) and assess perceptions of the ethical issues surrounding their structural spinal surgeon also performing spinal cord stimulation (SCS). Methods Semistructured face-to-face interviews with 20 neurosurgical spine patients were conducted. Patients were recruited from the neurosurgery clinics at Toronto Western Hospital and were seen in consultation for PPNP. Interviews were transcribed and subjected to thematic analysis using open and axial coding. Results The range of the duration of participants' preoperative symptoms varied from one month to more than 20 years, and was primarily back dominant (13/20). The median time since patients most recently underwent spinal surgery was three years. The majority of patients (15/20) do not view their current condition of PPNP as a failure of their initial spine surgeon. The most commonly reported reason for this is that patients trusted their physician and clear communication between the physician and the patient, prior to their surgery, ensured an understanding of the goals of the procedure. Nearly unanimously (19/20), patients did not perceive an ethical problem with a surgeon performing a structurally corrective spinal surgery and subsequently also implanting a SCS device if the same patient that develops medically refractory PPNP. Conclusions This is the first clinical qualitative study of values and ethical perceptions of patients with medically refractory PPNP. Our findings provide a framework for understanding the values of patients with PPNP and demonstrate that a strong surgeon-patient relationship can ameliorate concerns surrounding PPNP and SCS implantation.

Inflammation may contribute to poor outcomes after aneurysmal subarachnoid hemorrhage (aSAH). Here, we compared outcomes among propensity score-matched cohorts who did and did not receive non-steroidal anti-inflammatory drug (NSAID) use after aSAH. Propensity score-matched analysis of 413 subjects enrolled in the Clazosentan to Overcome Neurological iSChemia and Infarction OccUring after Subarachnoid hemorrhage (CONSCIOUS-1) study. Propensity score matching was performed on the basis of age, sex, baseline National Institutes of Health Stroke Scale score, World Federation of Neurological Societies grade on admission, procedure used for securing aneurysm, and SAH clot burden. 178 patients were matched (89 received NSAIDs, 89 did not). Propensity score matching was considered acceptable. Patients who had received NSAIDs during their hospital stay had significantly lower mortality rate, and reduced duration of intensive care unit stay and total length of hospital stay (P = 0.035, P = 0.009, and P = 0.053, respectively). At 6 weeks, 80.9 % of patients treated with NSAIDs had good functional outcome compared to 68.5 % of matched controls (P = 0.083). There was no significant difference in the proportions of patients who developed delayed ischemic neurological deficits, angiographic vasospasm, or required rescue therapy. Inflammation may play a crucial role in the poor outcomes after SAH, and that NSAIDs may be a useful therapeutic option, once validated by larger prospective studies.

Intracranial arterial dissection usually leads to cerebral infarction or subarachnoid hemorrhage (SAH). It is rare to see both complications in one clinical scenario.Case report and review of the literature.A 48-year-old woman suffered a left middle cerebral infarct from a dissection of the left supraclinoid ICA. As she was recovering from the ischemic stroke 5 days later she suffered a SAH. The SAH was caused by rupture of a dissecting pseudoaneurysm, which only became evident on repeat catheter angiography. The dissecting pseudoaneurysm was treated with coil occlusion.Intracranial ICA dissections are typically associated with either ischemic or hemorrhagic presentation. We report an unusual case of a patient who suffered a SAH a few days after an ischemic stroke from the dissection. This case contradicts the long-held dogma that intracranial dissection can have either an ischemic or a hemorrhagic presentation, but not both.

Background: Spinal computer-assisted navigation (CAN) is proven to increase instrumentation accuracy. Adoption remains limited by workflow restrictions, learning curves and costs. Here, we assess spinal CAN usage among Ontario surgeons to identify gaps in application, and temporal trends of usage. Methods: A prospectively-collected database of provincial insurance billables and diagnostic codes was reviewed retrospectively, from 2002-2014. Patients undergoing instrumented spinal fusions or percutaneous vertebroplasty/kyphoplasty were identified. Fee and diagnostic codes were applied to distinguish surgical indication and approach. The use of intra-operative navigation was determined for each case. Results: We identified 4607 instrumented spinal fusions in our cohort. Most cases were performed by orthopedic surgeons (63.2%) and the remainder by neurosurgeons. Of 2239 cases with identifiable etiology, CAN was utilized in 8.8%, predominantly for trauma and degenerative pathologies rather than deformity. In univariate analyses, CAN was used more often by neurosurgeons (21.0% vs. 12.4%, pConclusions: Spinal CAN has proven benefit for instrumentation accuracy, but is used preferentially by academic neurosurgeons. Significant gains must be made in cost and usability to improve access across disciplines and institutions.

A 49-year-old man presented with 7 months of progressive ataxic gait. He had a minor head injury 4 years prior, with unremarkable imaging (figure 1A). There was no further head trauma, but a repeat study at presentation demonstrated a posterior fossa cyst with mass effect and early hydrocephalus (figure 1B). Intraoperative findings confirmed the lesion was an arachnoid cyst (figure 2). Symptoms improved postoperatively.

OBJECTIVE: Although surgery is the mainstay of treatment for most pituitary adenomas, post-operative radiotherapy has been shown to be beneficial in improving tumour control and recurrence-free survival. However, due to the potential complications of with radiotherapy, the role of adjuvant radiotherapy in the setting of pituitary adenomas remains unclear. To address this gap, we performed a systematic review and meta-analysis to determine the efficacy and safety of post-operative radiotherapy in the treatment of pituitary adenomas. METHODS: A systematic review was performed according to the Meta-analysis Of Observational Studies in Epidemiology (MOOSE) guidelines. We searched PubMed, MEDLINE and Cochrane databases with no language or publication date restrictions, and included studies where patients were treated post-operatively with any form of radiation therapy. Studies reporting on both functioning and non-functioning pituitary adenomas were included. Outcomes were reported as 5- and 10-year progression-free survival, as well as adverse events rates. Forest plots were generated to determine a pooled event rate and 95% confidence interval (CI) for each outcome using a random effect model analysis. RESULTS: A total of 86 studies from 1986–2017 met the inclusion criteria, with 7551 cumulative patients. Studies included patients with functioning adenomas only (n=12), non-functioning adenomas only (n=12) or both (n=20). The cumulative 5- and 10-year progression-free survival rates were 90.8% (95% CI 86–94%) and 88.6% (95% CI 81–93%), respectively. The overall adverse events rate was 8% (95% CI 5–12%). All outcomes were associated with significant heterogeneity (I2 70%). There were no differences in survival rates or adverse events in relation to study date, tumour pathology, radiosurgery system used or dose of radiation. CONCLUSIONS: Post-operative radiotherapy for pituitary adenomas is effective and safe. Because of the significant heterogeneity and lack of matched controls in the literature, optimum timing and dosage are still unclear. Further prospective studies are needed.

The variational iteration method (VIM) is applied to solve numerically the improved Korteweg-de Vries equation (IKdV). A correction function is constructed with a general Lagrange multiplier that can be identified optimally via the variational theory. This technique provides a sequence of functions with easily computable components that converge rapidly to the exact solution of the IKdV equation. Propagation of single, interaction of two, and three solitary waves, and also birth of solitons have been discussed. Three invariants of motion have been evaluated to determine the conservation properties of the problem. This procedure is promising for solving other nonlinear equations.

Background: Although surgery is the mainstay of treatment for most pituitary adenomas, post-operative radiotherapy has been shown to be of benefit in improving tumor control and recurrence-free survival. To understand potential side effects of radiotherapy we performed a systematic review and meta-analysis to determine the efficacy and safety of post-operative radiotherapy for pituitary adenoma. Methods: A systematic review was performed according to the Meta-analysis Of Observational Studies in Epidemiology (MOOSE) guidelines. We searched PubMed, MEDLINE and Cochrane databases with no language or publication date restrictions. Outcomes included 5- and 10-year progression-free survival and adverse events rates. Results: A total of 48 studies from 1986-2016 met the inclusion criteria, with 7551 cumulative patients. The cumulative 5- and 10-year s progression-free survival rates were 90.8% (95% CI 86-94%) and 88.6% (95% CI 81-93%), respectively. The overall adverse events rate was 8% (95% CI 5-12%). All outcomes were associated with significant heterogeneity (I2 ≥ 70%). No differences in survival rates or adverse events in relation to study date, tumor pathology, radiosurgery system used or dose of radiation. Conclusions: Post-operative radiotherapy for pituitary adenomas is effective and safe. Because of the significant heterogeneity and lack of matched controls in the literature, optimum timing and dosage are still unclear. Further prospective studies are needed.

Background:The Neurosurgical Atlas is a neurosurgical website with informative chapters and videos to promote excellence and safety in neurosurgical techniques. Here, we present our analysis of this website’s viewing data and describe how online neurosurgical resources are being utilized. We hope this will be a useful guide for neurosurgeons interested in online multimedia education. Methods: We analyzed Google Analytics data from The Neurosurgical Atlas between June 2016 and August 2017 which tracked user demographics, geographical location, and the videos watched. Views were also analyzed categorically by dividing videos into six neurosurgical topics and into basic and advanced levels as per their surgical complexity. Results: There were 246,259 website visits and 143,868 video plays. The most frequent age groups were 25-34 (44%) and 35-44 (24%). 71% of visitors were male. Most visitors were from the US (29.52%) and Brazil (6.43%). Website visits and video plays increased over time, with multiple peaks corresponding to promotional email updates. The six neurosurgical topics were all similarly popular. Conclusions: Our study presents the first piece of evidence demonstrating the feasibility and popularity of a free online resource in neurosurgical education. Our experience highlights the growing demand for free-access online chapters, anatomical illustrations, and operative videos.

Background:Clinical Inertia is defined as “failure of health care providers to initiate or intensify therapy according to current guidelines”. This phenomenon is gaining increasing attention as a major cause of clinicians’ failure to adequately manage hypertension, thus leading to an increas

Suboccipital decompressive craniectomy (SDC) for cerebellar infarction has been traditionally performed with minimal high-quality evidence. The aim of this systematic review and meta-analysis is to investigate the impact of SDC on functional outcomes, mortality, and adverse events in patients with cerebellar infarcts.A systematic review and meta-analysis in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Our primary outcome was the proportion of patients with moderate-severe disability after SDC. Secondary outcomes included mortality and adverse events. A sensitivity analysis was conducted to examine the roles of age, preoperative neurologic status, external ventricular drain insertion, and debridement of infarcted tissue on SDC outcomes.Eleven studies (with 283 patients) met our inclusion criteria. The pooled event rate for moderate-severe disability was 28% (95% confidence interval [CI], 20%-37%) and for mortality, it was 20% (95% CI, 12%-31%). The estimated overall rate of adverse events for SDC was 23% (95% CI, 14%-35%). Sensitivity analysis found less mortality with mean age60 years, higher rates of concomitant external ventricular drain insertion, and debridement of infarcted tissue. Several factors were identified for heterogeneity between studies, including follow-up time, outcomes scale, extent of infarction, and other neuroimaging features.The best available evidence for SDC is based on retrospective observational studies. SDC for cerebellar infarction is associated with better outcomes compared with decompressive surgery for hemispheric infarctions. Lack of standardized reporting methods for SDC is a considerable drawback to the development of a better understanding of the impact of this surgery on patient outcomes.

Adult males of the quail Coturnix coturnix were exposed to lead acetate trihydrate in drinking water (0.1, 0.25, 0.5, and 1% for one–six months) to investigate histological and histochemical alterations induced by lead intoxication in the liver. Chronic exposure to subtoxic concentrations of lead produced changes in hepatocytes, portal veins, Kupffer cells, and blood sinusoids. Alterations in hepatocytes mainly involved cytoplasmic vacuolation, necrosis, cytolysis, and glycogen accumulation. Kupffer cell hyperplasia, hemosiderosis, blood sinusoidal dilatation, portal vein congestion, and edema were also observed. No fibrosis or cirrhosis in the liver of any member of the dose groups over the entire period of the study was noted. The findings revealed that chronic exposure to lead produced mild histological and histochemical changes in the liver of the quail Coturnix coturnix.

Background There is an abundance of articles published on aneurysmal subarachnoid hemorrhage (aSAH). Bibliometric analyses are helpful in determining the most impactful studies within a field. Methods An aSAH-specific search using a publicly accessible software search engine that indexes raw citations from Google Scholar was performed in August 2015. References were organized by number of citations, and the full length-articles for the top 100 cited papers were reviewed. Articles were categorized based on the focus of the paper. Results The top 100 articles were cited on average 654 times per paper. The Journal of Neurosurgery published the greatest number of top cited articles (33 of 100). Authors from North America published the majority (64%) of the top-cited articles and most publications were from the 1990s onwards. The most popular categories were “surgical and endovascular treatment” and “reviews, meta-analyses, and consensus guidelines.” There has been a steady increase each decade in highly cited reviews and meta-analyses on aSAH since the 1960s. A total of 73 articles were cited more than 400 times and met the criteria to be considered a “citation classic.” Compared with studies of citation numbers in other subspecialties of neurosurgery such as epilepsy and Parkinson disease, the impact of work in aSAH appeared to accrue fewer citations. Conclusions The current report provides an analysis of the most influential works in aSAH to describe trends in highly cited research and to provide a comprehensive list of the most influential literature in the field.

We report a 46-year-old man who presented with a 2week history of worsening headaches and acute onset left sided hemiplegia. He had undergone a surgical resection of a sacral chordoma 13years prior, followed by adjuvant radiotherapy and chemotherapy. MRI revealed multiple enhancing lesions in the brain, and the two largest were resected. The histopathology was consistent with chordoma. Sacrococcygeal chordomas are locally invasive notochord-related sarcomas. They rarely metastasize to the brain, and only eight patients have been reported. While currently available adjuvant radiotherapy and systemic chemotherapeutic regimens can be implemented in the management of these rare patients, they have shown limited success. The newer strategies that are reported here have also been disappointing.

Elevated intracranial pressure (ICP) is a well-recognized phenomenon in aneurysmal subarachnoid hemorrhage (aSAH) that has been demonstrated to lead to poor outcomes. Despite significant advances in clinical research into aSAH, there are no consensus guidelines devoted specifically to the management of elevated ICP in the setting of aSAH. To treat high ICP in aSAH, most centers extrapolate their treatment algorithms from studies and published guidelines for traumatic brain injury. Herein, the authors review the current management strategies for treating raised ICP within the aSAH population, emphasize key differences from the traumatic brain injury population, and highlight potential directions for future research in this controversial topic.

Background Surgeon-dependent factors such as experience and volume are associated with patient outcomes. However, it is unknown whether a surgeon’s research productivity could be related to outcomes. The main aim of this study is to investigate the association between the surgeon’s academic productivity and clinical outcomes following neurosurgical clipping of ruptured aneurysms. Methods We performed a post-hoc analysis of 3567 patients who underwent clipping of ruptured intracranial aneurysms in the randomized trials of tirilazad mesylate from 1990 to 1997. These trials included 162 centers and 156 surgeons from 21 countries. Primary and secondary outcomes were: Glasgow outcome scale score and mortality, respectively. Total publications, H-index, and graduate degrees were used as academic indicators for each surgeon. The association between outcomes and academic factors were assessed using a hierarchical logistic regression analysis, adjusting for patient covariates. Results Academic profiles were available for 147 surgeons, treating a total of 3307 patients. Most surgeons were from the USA (62, 42%), Canada (18, 12%), and Germany (15, 10%). On univariate analysis, the H-index correlated with better functional outcomes and lower mortality rates. In the multivariate model, patients under the care of surgeons with higher H-indices demonstrated improved neurological outcomes (p = 0.01) compared to surgeons with lower H-indices, without any significant difference in mortality. None of the other academic indicators were significantly associated with outcomes. Conclusion Although prognostication following surgery for ruptured intracranial aneurysms primarily depends on clinical and radiological factors, the academic impact of the operating neurosurgeon may explain some heterogeneity in surgical outcomes.

Background: Web 2.0 technologies (e.g. blogs, social networks, and wikis) are increasingly being utilized by medical schools and postgraduate training programs as tools for information dissemination. These technologies offer the unique opportunity to track metrics of user engagement and interaction. Here, we employ Web 2.0 technologies to assess academic behaviors among neurosurgery residents. Methods: We performed a retrospective review of all educational lectures, part of the core Neurosurgery Residency curriculum at the University of Toronto, posted on our teaching blog (www.TheBrainSchool.net) from Sept 2013 - Nov 2016. We looked for associations with lecturer’s academic position, timing of examinations, and lecture/subspecialty topic. Results: The overall number of clicks on 123 lectures was 1079. Most of these clicks were occurring during the in-training exam month (43%). Click numbers were significantly higher on lectures presented by faculty (mean 18.6, SD ± 4.1) compared to residents-delivered lectures (mean 8.4, SD ± 2.1) (P= 0.031). Functional neurosurgery lectures were the most downloaded (47%), followed by pediatric neurosurgery (22%). Conclusions: The current study demonstrates the value of Web 2.0 analytic tools in examining residents study behavior. Residents tend to ‘cram’ downloading lectures in the same month of training exams and display a preference for faculty-delivered lectures.

To determine the prevalence of symptoms and risk of obstructive sleep apnea (OSA) among patients with ruptured cerebral aneurysms.In this case-control study, a validated Arabic version of the Berlin Questionnaire (BQ) was administered to patients admitted to King Fahd Medical City, Riyadh, Saudi Arabia with cerebral aneurysms between January 2006 and July 2011 (n=53). The same questionnaire was administered to a control group comprised of patients attending primary health care clinics who were matched for age, body mass index (BMI), and gender (n=212).The mean age of patients with ruptured cerebral aneurysms was 50.7 +/- 15.2 years, and the mean BMI was 27.9 +/- 4.8 kg/m2. In this group, 75.5% complained of snoring compared with 46.7% of the controls (p=0.000). Hypertension was present in 67.9% of cases compared with 30.2% of the controls (p=0.000). Based on the BQ scores, 60.4% of the cases were considered to be at high risk for OSA compared with 31.6% of the controls (p=0.000).The prevalence of OSA symptoms among patients with ruptured cerebral aneurysms is very high. Almost 60% of patients with ruptured cerebral aneurysms are at risk for OSA.

Social media plays an increasingly important role in dissemination of knowledge and raising awareness of selected topics among the general public and the academic community.To investigate the relationship between social media metrics and academic indices of neurosurgical programs and journals.A 2-step online search was performed to identify official social media accounts of neurosurgical departments that were accredited by the Accreditation Council for Graduate Medical Education and the Royal College of Physicians and Surgeons of Canada. Dedicated neurosurgery and spine journals' social media accounts also were identified through an online search on SCImago Journal and Country Rank portal. Nonparametric tests were performed with bootstrapping to compare groups and to look for correlations between social media and academic metrics.We identified 36 social media accounts officially affiliated with academic neurosurgical institutions. These accounts represented 22 of 119 neurosurgical programs in North America (18.4%). The presence of a social media account for neurosurgical departments was associated with statistically significant higher values of academic impact metrics (P0.05). Specific social media metrics for neurosurgical department accounts, however, did not correlate with any values of academic indices. For journals, there were 11 journals present on social media and had greater academic metrics compared with journals without social media presence (P0.05).Social media presence is associated with stronger academic bibliometrics profiles for both neurosurgical departments and journals. The impact of social media metrics on indices of scientific impact in neurosurgery is not known.

Objective To measure the presence and popularity of neurosurgical departments, journals, and nonprofit organizations on 3 major social networks. Methods A systematic 2-pronged search strategy was used in June 2015 to identify all accounts on Facebook, Twitter, and YouTube that were relevant to neurosurgery. Online search was conducted by 2 independent authors. All accounts were ranked according to their popularity data. Results Our search yielded 158 social media accounts (86 Facebook, 59 Twitter, and 13 YouTube) of neurosurgical private and academic practice departments. Of the 158 accounts we retrieved, 117 were for private practice centers (74%). Accounts of academic and private departments had a similar median number of “likes” and “followers” on Facebook and Twitter, respectively. Seven neurosurgical journals only had active Facebook and Twitter accounts (of 20 screened journals). When compared with studies of social media in other medical subspecialties, the use of these networks in neurosurgery followed a similar pattern in their presence and popularity. Conclusions The current study shows different uses of social media platforms and numbers of users of the online neurosurgical community. Content optimization, advanced metrics of user engagement, and their subsequent effects on academic impact remain unanswered queries and require further prospective study.

Objective To perform a systematic review of the literature of cases of vasospasm following tumor resection and to discuss possible etiologies, diagnosis and management of this complication. Methods A literature search was performed using relevant search key words to identify cases of ‘cerebral vasospasm’ as a complication following tumor resection. Articles were identified by searching MEDLINE and PubMed databases. Relevant cross references were added by manually searching the references of all retrieved articles. Results There were a total of 56 patients in our initial search but only 40 cases matched our inclusion criteria. Pituitary tumors and sellar area were the most common pathologies and location associated with this complication. Average time interval to development of symptomatic vasospasm was 8 days and mortality was high (30%). The most common encountered causative factors were vascular factors (vessel encasement, displacement and narrowing) and presence of blood in the basal cisterns in postoperative scans. Conclusions ‘Cerebral vasospasm’ after tumor resection is a rare but challenging complication with very high morbidity and mortality in reported cases. Vasospasm following brain tumor surgery shares some of the same clinical variables (time interval, causative factors, morbidity and death rates) of vasospasm after aneurysmal subarachnoid hemorrhage. A high index of suspicion is required for early diagnosis and prompt management which are key elements of final outcome.

0967-5868/$ see front matter 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.jocn.2013.08.024 doi of answer: http://dx.doi.org/10.1016/j.jocn.2013.11.001 ⇑ Corresponding author. Tel.: +1 416 603 5800x5503. E-mail address: alireza.mansouri@utoronto.ca (A. Mansouri). 1 These authors have contributed equally to the manuscript. Naif M. Alotaibi , Alireza Mansouri a,⇑, Michael D. Staudt , Felipe G. Carvalho , Fred Gentili a