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Neuromodulation unit placement carries a historic infection rate as high as 12%. Treatment of such requires surgical removal and a long course of systemic antibiotics. Antibiotic-impregnated envelopes have been effective in preventing infection in implantable cardiac devices. At our center, 1 surgeon uses these envelopes with all implanted neuromodulation units.To assess the efficacy of antibacterial envelopes in prevention of infection in neuromodulation device placement.We conducted a retrospective cohort study of consecutive implantable pulse generator (IPG) unit implantation with an antibacterial envelope at a single center between October 2014 and December 2019. We collected demographic data, including postoperative infections, reoperations, and complications, associated with the IPGs. This cohort was then compared with a historical cohort of consecutive patients undergoing surgery before envelope usage (October 2007-April 2014).In the pre-envelope cohort of 151 IPGs placed in 116 patients, there were 18 culture-confirmed infections (11.9%). In the antibacterial envelope cohort of 233 IPGs placed in 185 patients, there were 5 culture-confirmed infections (2.1%). The absolute risk reduction of the antibacterial envelope was 9.85% (95% CI 4.3%-15.4%, Plt; .01). The number needed to treat was 10.1 (95% CI 6.5-23.1, Plt; .01) envelopes to prevent 1 IPG infection.We saw a reduced rate of infections in the antibacterial envelope cohort. Although this is likely multifactorial, our results suggest a benefit of antibacterial envelopes on infection after neuromodulation surgery.

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.

The advent of endovascular therapy for acute large vessel occlusion has revolutionized stroke treatment. Timely access to endovascular therapy, and the ability to restore intracranial flow in a safe, efficient, and efficacious manner has been critical to the success of the thrombectomy procedure. The stentriever has been a mainstay of endovascular stroke therapy, and current guidelines recommend the usage of stentrievers in the treatment of large vessel occlusion stroke. Despite the success of existing stentrievers, there continues to be significant development in the field, with newer stentrievers attempting to improve on each of the three key aspects of the thrombectomy procedure. Here, we elucidate the technical requirements that a stentriever must fulfill. We then review the basic variables of stent design, including the raw material and its form, fabrication method, geometric configuration, and further additions. Lastly, a selection of stentrievers from successive generations are reviewed using these engineering parameters, and clinical data is presented. Further avenues of stentriever development and testing are also presented.

A pediatric patient presented after a gunshot injury to the right shoulder and thorax region, with injuries requiring a thoracotomy, tracheal repair, axillary artery repair, and external fixation of the humerus. A CT scan of the brain showed a metal fragment in the interpeduncular cistern. CT angiography confirmed a pellet occluding the basilar apex. Successful endovascular retrieval resulted in mobilizing the pellet from the basilar apex to the left vertebral artery proximal to the posterior inferior cerebellar artery. This vertebral artery was then sacrificed proximally to prevent re-embolization. We present our technique and discuss endovascular options for management of intracranial arterial embolization of bullet fragments.

Introduction: Moyamoya Disease (MMD) is a progressive steno-occlusive vasculopathy of the large intracranial vessels precipitating ischemic and hemorrhagic events. Cerebral revascularization is the mainstay of treatment in MMD. Intraoperative measurements of cerebral blood flow following direct intracranial bypass may be performed to quantitatively assess the anastomosis. Objectives: To correlate intraoperative flow parameters in direct cerebral bypass for moyamoya disease to postoperative angiographic and clinical outcomes. Methods: Consecutive patients undergoing direct superficial temporal artery (STA) to middle cerebral artery (MCA) bypass were retrospectively analyzed. Preoperative and 6-month postoperative patient data was collected including presenting symptoms, MRI and angiographic findings, neurological complications, and functional outcome. Intraoperative cerebral blood flow was measured from the donor and recipient arteries using a micro flow probe pre- and post-anastomosis. Results: A total of 50 direct revascularization procedures in 39 patients were analyzed, of which 40 were in females (80%). The mean flow prior to anastomosis in the M4 MCA was +2.2 ± 6.1 ml/minute and +26.8 ± 19.0 ml/min in the STA. Post-anastomosis, the mean flow was -10.9 ± 14.8 ml/min (towards the Sylvian Fissure) in the proximal M4 and +7.9 ± 9.2 ml/min in the distal M4. At 6-month follow-up angiography, the graft was patent in all cases, with 98% demonstrating direct supply. A component of indirect supply was observed in 56% of grafts. Matsushima grade A, B, and C revascularization were obtained in 64%, 20%, and 16% of cases, respectively. Amongst Matsushima grade A patients, low flow was observed in the M4 (mean 1.7 ± 4.8 ml/min) prior to bypass, which became retrograde following bypass, measuring -13.5 ± 16.0 ml/min. Lower post bypass flow was observed in grade B and C patients, with -6.8 ± 13.1 ml/min and -5.6 ± 10.3 ml/min, respectively. Postoperative stroke occurred in one patient, who had a Matsushima grade C. Conclusions: Greater intraoperative retrograde flow in the recipient MCA immediately following anastomosis was observed in patients achieving a higher Matsushima grade.

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.

Backgrounds: Types of anesthesia provision and perioperative patient cares are the main determinants of neonatal outcome in mothers undergo caesarean section. Body of evidence didn't clearly reveal which types of Anesthesia technique is associated with better neonatal outcomes in mothers who gave birth under spinal anesthesia than general anesthesia. The aim of this systemic review and meta-analysis was to compare neonatal outcomes in mothers who undergo caesarean section under general anesthesia and regional anesthesia. Methods: We carried out a systemic search of the electronic databases of central, Medline, Embase, LILACS, AOLJ and others with PICO strategy for controlled clinical trials comparing neonatal outcomes under general and regional anesthesia. Twenty trials were identified for eligibility assessment, ten trials were selected for data extraction, and nine trials were finally included in the meta-analysis. All controlled clinical trials using regional and general anesthesia for ASA I-II term pregnant women coming for cesarean section in elective and semi-urgent condition were selected. Eligibility assessment was performed independently by the two review authors using a customized form, while discrepancies were resolved by consensus. The Data from individual trial were extracted and entered Review Manager for synthesis. Results: Ten studies (782 participants) were included in this review. The Apgar score at one minute less than seven was better in spinal anesthesia as compared to General Anesthesia (OR=0.24, 95% confidence interval (CI) 0.14 to 0.42, 5 trials, 548 participants). There was no significant association at 5^(th) minute Apgar score less than seven (OR= -0.02, 95% CI -0.09 to 0.05, 3 trials, 260 participants). There was significant mean difference between spinal and general anesthesia on neonatal mean Apgar score at 5^(th) minute (MD=0.51, 95% CI 0.14 to 0.88, 5 trials, 671 participants). There was a significant mean difference on Umbilical artery and Venous PH when general anesthesia is compared with spinal anesthesia (MD= -0.01, 95% CI -0.002 top -0.00, one trial, 40 participants) and (MD= -0.98, 95% CI -1.66 to -0.30, one trial, 40 participants). Conclusion: Regional Anesthesia is superior over general Anesthesia in certain neonatal outcomes as depicted by the pooled analysis of individual trials. However, there should be further review with individual trials having high power and similar dosage and techniques as most of the individual trials in this review are low powered and different types of outcome assessment techniques.

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

Background Currently, the literature lacks reliable data regarding operative case volumes at Canadian neurosurgery residency programs. Our objective was to provide a snapshot of the operative landscape in Canadian neurosurgical training using the trainee-led Canadian Neurosurgery Research Collaborative. Methods: Anonymized administrative operative data were gathered from each neurosurgery residency program from January 1, 2014, to December 31, 2014. Procedures were broadly classified into cranial, spine, peripheral nerve, and miscellaneous procedures. A number of prespecified subspecialty procedures were recorded. We defined the resident case index as the ratio of the total number of operations to the total number of neurosurgery residents in that program. Resident number included both Canadian medical and international medical graduates, and included residents on the neurosurgery service, off-service, or on leave for research or other personal reasons. Results: Overall, there was an average of 1845 operative cases per neurosurgery residency program. The mean numbers of cranial, spine, peripheral nerve, and miscellaneous procedures were 725, 466, 48, and 193, respectively. The nationwide mean resident case indices for cranial, spine, peripheral nerve, and total procedures were 90, 58, 5, and 196, respectively. There was some variation in the resident case indices for specific subspecialty procedures, with some training programs not performing carotid endarterectomy or endoscopic transsphenoidal procedures. Conclusions: This study presents the breadth of neurosurgical training within Canadian neurosurgery residency programs. These results may help inform the implementation of neurosurgery training as the Royal College of Physicians and Surgeons residency training transitions to a competence-by-design curriculum.

Background: External ventricular drain (EVD) insertion is a common neurosurgical procedure performed in patients with life-threatening conditions, but can be associated with complications. The objectives of this study are to evaluate data on national practice patterns and complications rates in order to optimize clinical care Methods: The Canadian Neurosurgery Research Collaborative conducted a prospective multi-centre registry of patients undergoing EVD insertions at Canadian residency programs Results: In this interim analysis, 4 sites had recruited 46 patients (mean age: 53.9 years, male:female 2:1). Most EVD insertions occurred outside of the operating theatre, using free-hand technique, and performed by junior neurosurgery residents (R1-R3). The catheter tip was in the ipsilateral frontal horn or body of the lateral ventricle in 76% of cases. Suboptimally placed catheters did not have higher rates of short-term occlusion. EVD-related hemorrhage occurred in 6.5% (3/45) with only 1 symptomatic patient. EVD-related infection occurred in 13% (6/46) at a mean of 6 days and was associated with longer duration of CSF drainage (P=0.039; OR: 1.13) Conclusions: Interim results indicate rates of EVD-related complications may be higher than previously thought. This study will continue to recruit patients to confirm these findings and determine specific risk factors associated with them

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

Background: Spontaneous hemorrhage from angiographically occult vascular malformations is not a rare occurrence. We present a case of in-hospital cavernous malformation rupture after initial normal CT. Methods: A 55-year-old female presented with severe headache with onset during activity, and normal neurological examination. Rapid neurological deterioration occurred 60 minutes following the CT scan. The patient was intubated, and repeat CT scan showed significant parafalcine ICH and intrahemispheric SAH. ICU transfer and expectant management led to neurological recovery and discharge to rehabilitation. Results: The patient underwent angiography on initial admission which was negative. A delayed MRI showed the presence of a cavernous malformation. This was followed conservatively with repeat imaging. The malformation remained stable. Conclusions: Our unique case highlights the sudden onset of hemorrhage occurring almost immediately following normal brain imaging. A cavernous malformation was discovered to be the cause, and was observed.

Background: The Canadian Neurosurgery Research Collaborative (CNRC) was founded in November 2015 as a resident-led national network for multicentre research. We present an annual report of our activities. Methods: CNRC meetings and publications were reviewed and summarized. The status of ongoing and future studies was collected from project leaders. Results: In its first year, the CNRC produced two papers accepted for publication in the Canadian Journal of Neurological Sciences: A CNRC launch letter and a study of operative volume at Canadian neurosurgery residency programs. Three manuscripts are in preparation: 1) a study of the demographics of Canadian neurosurgery residents, 2) an assessment of mobile devices usage patterns and 3) a validation study of the most utilized neurosurgery mobile apps. In addition, protocols for two multi-centre studies are currently undergoing national Research Ethics Board review: A retrospective study of the incidence and predictors of cerebellar mutism and a prospective registry of external ventricular drain procedures and complications. The network is now a registered not-for-profit organization endorsed by the Canadian Neurosurgical Society. Conclusions: The CNRC is a feasibile, relevant and productive resident-led national research network. As the CNRC matures, we look forward to expanding the scope and impact of its projects.

The efficient design of lighting in buildings is very important for comfort and energy saving. It is vital to determine the overall comfort level for the personnel occupying the rooms. This chapter is an attempt for providing high efficient lighting system and low electrical energy consumption in a residential building. For this purpose, a faculty residential house situated in the campus of Sultan Qaboos University was selected as a case study. This chapter has two aims. The first aim was to study the existing lighting systems used in the house. The second aim was to redesign the existing lighting system of the house in an efficient way to provide higher efficient lighting system and lower energy consumption. The current LEED codes and ASHRAE green tips for the green building codes were used as benchmark and as guide. The proposed lighting design is a model engineering design. The design of the lighting system for each space of the house was carried out with the support of the DIALux lighting program version 4.5. A thorough study of lighting requirements was undertaken. The existing lighting practice was compared with present green design through isolux maps. The results showed significant savings of up to 34% of thermal load from better and reliable design. A reduction in electrical load was also achieved through efficient luminaires selection.

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.