Background: Pneumocystis jirovecii pneumonia (PJP) is an opportunistic interstitial fungal pneumonia. The incidence of PJP in HIV-positive populations is decreasing, while it is increasing in HIV-negative immunocompromised populations, such as neurosurgical patients treated with high-dose corticosteroids. Morbidity and mortality can be severe owing to acute respiratory failure. Methods: Two cases are described and a literature review performed to determine the incidence of PJP in the neurosurgery population. A standardized care pathway is proposed to reduce preventable harm. Results: Long-term, high-dose corticosteroid regimens (≥4 mg dexamethasone daily for ≥4 weeks) with taper are associated with increased risk of PJP infection. Additional risk factors for infection in HIV-negative patients include CNS malignancy and concurrent radiation therapy. TMP-SMX is the first-line agent for PJP prophylaxis. Conclusions: Clinicians should maintain a high index of suspicion of PJP and adopt a standardized protocol for prophylaxis in neurosurgical patients treated with high-dose corticosteroids.

Background: Previous studies have shown varied results with respect to the diagnostic utility of a positive nerve root sedimentation sign (SedSign) on MRI for symptomatic lumbar stenosis. The objective of this study was to analyze the clinical characteristics of SedSign utilizing a validated classification for low back and leg pain (Saskatchewan Spine Pathway classification; SSPc). Methods: This was a retrospective review of prospectively-collected data in 367 consecutive adult patients presenting to a spine surgeon with back and/or leg pain between January 1, 2012 and May 31, 2018. 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%) of patients. On the univariate analysis, a positive SedSign was correlated with age, male sex, several components of ODI, EQ5D mobility, cross-sectional area (CSA) of stenosis, and SSPc pattern 4 (intermitted leg dominant pain). On multivariate analysis, SedSign was associated with age, male sex, CSA stenosis and ODI sub-score for walking distance. The sensitivity and specificity of SedSign for neurogenic claudication was 50.3 and 82.9, respectively (positive predictive value 65.8%, negative predictive value 71.9%). Conclusions: The SedSign has high specificity for neurogenic claudication, but the sensitivity is poor.

Background: Due to increasingly limited access to cadavers and first-hand operative experience, there is an increasing need for innovative modalities in neurosurgical education. Recent developments in computer modelling, virtual/augmented reality, and video game technology have created new opportunities for novel teaching tools. We set out to develop a library of 3D models of normal anatomy and pathologic states for use in conjunction with an interactive simulated environment and 3D printing for teaching of neurosurgical residents. Methods: Anatomically accurate 3D models were developed using CT/MRI data from multiple patients using open source segmentation and 3D animation software. An interactive simulated environment was then created using a 3D game engine and used in conjunction with a virtual/augmented reality system. 3D models were also used to for 3D printing. Results: 3D models and an interactive simulated environment were used in conjunction with various viewing modalities, including 3D video, 360 video, and virtual reality headsets, as well as 3D printing. These teaching tools were successfully implemented in neurosurgery didactic teaching sessions and in the skull base lab. Additional benefits were seen with patient engagement and marketing. Conclusions: 3D modeling and animation show considerable promise for neurosurgical education, with additional benefits for patient engagement, marketing, and social media.

Background: In preparation for July 2019 rollout of competency-based design (CBD) in Canadian neurosurgery residency training, the University of Calgary launched a pilot-program of five representative EPAs using the One45 program. Our study objectives were to examine the uptake of CBD with residents and faculty and to quantify CBD implementation barriers. Methods: Phase one of the One45-based CBD pilot-program launched on November 1st, 2018 and ended on January 8th, 2019, after which a questionnaire was sent to each participating resident. The questionnaire examined number of EPAs initiated, measures of favourability, importance, ease of use, and barriers encountered. Results: Results obtained from the survey show 93.8% response rate (15/16 residents). 66.7% of residents feel that CBD is moderately important or higher to their education. Over the 10 study weeks, there were only 8 completed EPAs (expected was 50), five of which were completed by a single resident. Major expressed barriers of implementation of CBD were time involved (50.0%) and technical unfamiliarity with the platform itself (50.0%). Conclusions: This study demonstrates the critical importance of piloting a CBD program prior to official implementation as immediate buy-in was significantly slower than anticipated. Technical and time barriers exist which need to be rectified in advance of July 2019.

Background: People of aboriginal ancestry are more likely to suffer traumatic spinal cord injury (TSCI) compared to other Canadians; however, outcome studies are limited. This study aims to compare aboriginal and non-aboriginal populations with acute TSCI with respect to: pre-injury baseline, injury severity, treatment, outcomes, and length-of-stay characteristics. Methods: This was a retrospective analysis of 159 patients with TSCI prospectively enrolled in the prospective Rick Hansen Spinal Cord Injury Registry (RHSCIR), Saskatoon site between February 13, 2010 and December 17, 2016. Results: Sixty-two patients consented to the full dataset, which includes ethnic background: 21 ‘aboriginal’ (33.9%); 41 ‘non-aboriginal’ (66.1%). Aboriginal patients were younger, had fewer medical comorbidities and had similar severity of neurological injury and similar outcomes compared to non-aboriginal patients. However, the time to discharge to the community was significantly longer (median 104.0 days versus 38.5 days, p=0.021). While 35% of non-aboriginal patients were discharged home from the acute care site, no aboriginal patients were transferred home directly. Conclusions: This study suggests a need for better allocation of resources for transition to the community for First Nations patients with TSCI in Saskatchewan. We plan a further study to assess outcomes from TSCI for First Nations patients across Canada.

Background: Penetrating traumatic injuries to the clivus are rare. We describe the case of a 79-year-old man who presented to the emergency room with a butter knife protruding from his left cheek. Imaging showed the blade entering just beneath the left zygoma and transecting the clivus to terminate within the prepontine cistern. The tip of the knife abutted the right anterior inferior cerebellar artery and lower basilar artery. Methods: He was brought to the interventional neuroradiology OR with knife in place, by a combined surgical team of ENT, neurosurgery, and neuroradiology. Under local anaesthetic and intravenous sedation, vascular access to the distal left vertebral artery was obtained and a balloon positioned. Traction was applied to the knife and the knife was successfully removed avoiding any angular or rotational movements. An immediate angiogram showed no evidence of arterial injury. Results: The patient recovered uneventfully and was discharged home with no neurological deficit. Follow-up CT/CTA was performed a month later and confirmed no pseudoaneurysm or other complication. Conclusions: Management of penetrating skull base injuries by a multidisciplinary surgical team is advisable. Vascular imaging is crucial. Positioning of balloons within large vessels close to the penetrating object is recommended to control bleeding that may occur on removal.

Background: Pediatric craniocerebral gunshot wounds occur in the context of both accidental and intentional trauma. Unique physiologic factors merited research into prognostic factors and treatment priorities in the pediatric population. Methods: A systematic search of MEDLINE, EMBASE, Web of Science, LILACS, Cochrane Registered Trials and Systematic Reviews, ISRCTN, and ClinicalTrials.gov was conducted. Selection criteria included all studies published in any language since 2000 which described intracranial isolated gunshot wounds in a civilian individual or population of pediatric age. Post-mortem and epidemiological studies were excluded. Screening was conducted through Covidence. Results: Initial database search revealed 349 unique studies for abstract and title screening. Fifty studies were selected for full text screening. Nine studies were included in the final review. Study quality was assessed with the Newcastle-Ottawa Scale. Case series noted bullet migration, pituitary deficiency, neurovascular and neuropsychological concerns. Three single-center retrospective studies of 71, 30, and 48 pediatric patients suggested multiple negative prognostic signs on initial presentation. Early aggressive surgical treatment was recommended by some authors. Conclusions: This systematic review analyzed the best current understanding of evidence for prognostic factors and treatment considerations of intracranial gunshot wounds in the pediatric neurotrauma context. Areas for future research with larger multi-center studies were highlighted.

Background: Cellular prion protein (PrPC) is a lipid raft protein locallizing within CNS tissue. It is reguated by a disiintegrin and metaloproteinase domain containing protein 10 (ADAM10), which induces ectodomain shedding. PrPC has been previousy implicated as a ptentia lbiomarker for TBI, but no prior studies have examined the potential of ADAM10 as a biomarker. Methods: Serum samples from patients admitted for TBI were collected and patient data was recorded. Control serum was acquired from a commercial tissue bank. Patient GCS was recorded during admission. Serum was used for ELISA to assess PrPC and ADAM10 expression. GraphPad was used to conduct ANOVA and regressional analysis. Results: 37 control and 20 TBI samples were collected. Of the TBI patiients, 8 were mild, 3 were moderate, and 9 were severe cilnical grade. Both PrPC and ADAM10 were elevated in TBI patients compared with control (p<0.001). ADAM10 exhibited a dose response, with greter expression in patients with higher clinical grade. There was no significant association of either PrPC or ADAM10 with time after injury. Conclusions: Our results indicate that PrPC and ADAM10 may be useful tools for screening of TBI. ADAM10 is associated closely with clinlcal grade, and may in the future represent a promising prognostic tool.

Background: Micrographia is a rare neurological finding in isolation. Most cases of isolated micrographia have been found in association with focal ischemia of the left basal ganglia. Methods: We present a case of post-traumatic micrographia stemming from contusion to the left basal ganglia. We performed a detailed analysis of the patient’s writing at three-year follow-up. Results: A halthy 15 year old male was admitted following a BM accident. CT showed contusion to the left basall ganglia/external capsule. MRI was negative for underlying lesion. He had a short stay in the ICU and then was discharged. Two years later, he expressed concern regarding difficulty with sma, cramped writing at school. Writing analysis revealed micrographia with spontaneous printing as well as printing to dictation, but not with copied English nor Japanese writing. Conclusions: Isolated micrographia is a rare neurological finding. We present the incidence of this symptom folllowing gliding contusion to the et basal ganglia and external capsule.

Background: In aneurysms overall, a lower rate of recanalization in stent assisted coiling vs coiling alone has been observed without an increase in morbidity. This study aims to stratify and compare degree of occlusion outcome by treatment modalities. Secondarily, this study aims to stratify and compare postoperative adverse events. Methods: MEDLINE and EMBASE databases were searched. Study center were reviewed for inclusion. We performed meta-regressions, bias analysis and fail-safe N. We controlled for the quality of the studies. Results: 396 nonduplicated patients were separated into 4 groups: microsurgical, stent-assisted coiling, coiling, stent only. Stent-assisted coiling has lower rate of retreatment (17 vs 24%) and higher rehemorrhage (5% vs 3%) compared to coiling. Stent-assisted has higher rates of complete occlusion (55% vs 45%) and lower rate of residual aneurysm (15% vs 23%) compared to coiling. Comparative analyses were performed. Microsurgical remained the most morbid modality with the best rate of complete occlusion (93%) and lowest rehemorrhage (2%) and retreatment rate (5%). Conclusions: This is the first and largest meta-analysis focusing on patients treated for basilar apex aneurysm. To our knowledge, this is the first study to stratify and compare degree of occlusion per treatment modality. This study provides benchmark numbers to guide clinicians.

Background: Headaches are a major cause of disability and healthcare cost worldwide. When investigating headaches etiology, incidental unruptured intracranial aneurysms are often considered unrelated. We conducted a systematic review and meta-analysis to assess headaches outcomes (severity) after treatment of unruptured intracranial aneurysm. Methods: MEDLINE and EMBASE were systematically reviewed. Results: The data from eligible studies (n=7) was extracted and analyzed. 309 nonduplicated patients provided patient-level data for analysis. All studies used the 10-point numeric rating scale (NRS). 88% of patients were treated with endovascular technique. Overall, the observed effect estimate under a random effects model was found to be a standard mean difference in pre- and post-intervention headache severity of -0.448 (95% CI: -0.566 to -0.329). No significant heterogeneity was noted. No significant publication bias was demonstrated. Conclusions: This is the first and largest systematic review assessing postoperative headache outcomes after treatment of unruptured intracranial aneurysm. A significant reduction in headache intensity after treatment is observed in the current published literature. This study highlights an interesting clinical phenomenon that still warrants scientific effort before it can influence clinical practice. We encourage future study to stratify headache outcomes by aneurysm size, location and treatment modality.

Background: While recent clinical trials have demonstrated immense efficacy of mechanical thrombectomy (MT) in the setting of acute stroke, there remains debate over the safety in performing this procedure under general anesthesia (GA). In the Saskatchewan Acute Stroke Pathway, all patients presenting with LVO have endovascular thrombectomy performed under GA. Methods: Data was retrospectively reviewed on 108 consecutive LVO in 2016-2017. All MT were done under GA. Anatomical location of LVO, pre-MT ASPECTS score, post-MT TICI scores and 90-day NIHSS and mRS were recorded. Results: Of 108 LVO, 103 went on to have MT. 44 were right anterior circulation, 50 were left anterior circulation and 9 were posterior circulation. Of 94 anterior circulation strokes, 47 (50.0%), 43 (45.7%) and 4 (4.3%) had good, moderate and poor collateral circulation respectively, and the average pre-MT ASPECTS was 8.6. The average pre-MT NIHSS was 14.7. 81/90 (90.0%) achieved thrombolysis in cerebral infarction (TICI) perfusion scale grade of 2b/3 after recanalization. Average documented 90-day NIHSS was 2.4 and mRS was 2.5. Overall mortality was 21/103 (20.4%). Conclusions: In the Saskatchewan acute stroke pathway, general anesthesia is a safe modality for MT. This adds to the body of evidence supporting GA as a viable option for sedation in MT.

Background: Cerebral vasospasm is a leading cause of neurological disability following aneurysmal subarachnoid hemorrhage (aSAH). Clinical features associated with vasospasm development include blood burden on CT, neurological status, age and aneurysm location. Early cerebral CT perfusion (CTP) scanning in aSAH may be an independent predictor of vasospasm and/or delayed cerebral ischemia (DCI). Methods: Forty-one patients with aSAH were prospectively enrolled. Baseline data collected included WFNS grade, loss of consciousness at ictus, and modified Fisher grade. CTP was obtained at baseline and on day 6 post SAH. Cerebral blood volume, cerebral blood flow and mean transit time were measured. DCI was confirmed by a combination of clinical assessments, non-contrast CT and CTP. Radiological vasospasm was assessed with CT angiography. Results: Despite 80% of patients having a modified Fisher grade 3 or 4 aSAH, one-third presenting with ictal LOC and half having anterior communicating artery aneurysms, only one patient developed clinical evidence of vasospasm/DCI. Two others had asymptomatic radiological vasospasm. CTP parameters did not differ between groups defined by clinical predictors. Conclusions: In an unexpected finding, clinical and radiological vasospasm were very uncommon in this cohort. Clinical predictive variables correlated poorly with development of vasospasm. CTP may help refine the model but further work is needed.

Background: On February 6, 2015, the Supreme Court of Canada struck down the Criminal Code absolute prohibition on assisted dying, and in June 2016 the new law, Bill C-14, came into effect allowing for medical assistance in dying. We sought to determine the attitudes and opinions of Canadian neurosurgeons and orthopedic spine surgeons regarding MAID. Methods: A cross-sectional survey was sent out to members of the Canadian Spine Society (CSS), which included 21 questions pertaining to opinions regarding MAID. Responses were collected between May-June 2016. Results: A total of 51 surgeons responded to the survey, comprised of a mix of spine surgeons from across the country. The majority of surgeons supported MAID (62.8%), and right of physicians to participate (82.4%). Most surgeons supported the right to conscientious objection (90.1%), but also mandatory duty to refer (49.0%). The conditions most frequently felt to be appropriate for MAID included metastatic spine tumour (76.5%), malignant intramedullary tumour (64.7%), primary malignant spine tumour (54.9%), cervical spinal cord injury with tetraplegia (49.0%) and multiple myeloma (33.3%). Conclusions: This study highlights the complex landscape that exists when discussing MAID, but also the overall support of physicians, and need for ongoing conversations, particularly with issues not addressed by the current legislation.

Background: For robot-assisted telesurgery, the workstation, in particular the haptic handcontroller itself a robot, is paramount to the performance of surgery. Based on the requirements for microsurgery, a novel haptic handcontroller Excalibur has been developed. Methods: Thirty-two surgeons performed a peg-in-hole task (simulating micromanipulation) with Excalibur and two commercially available handcontrollers (Sigma 7 and PHANToM Premium 3.0). A modified Kuka endeffector with bipolar forceps, and Leica microscope completed the remote robotic site. Comparisons were made based on training time, task completion time and number of errors. All participants completed a questionnaire. Results: Repeated measures ANOVA demonstrated significance for task completion time (p=0.004), training time (p=0.021) and number of errors (p=0.004). Surgeons were faster with Excalibur (72s) than with Sigma (96s,p=0.005) and PHANToM (96s,p=0.036). Training time was shorter with Excalibur than with PHANToM (210s vs 310s,p=0.013), and users made fewer errors (0.7 vs 2.1,p=0.008). Training time required for Sigma (285s) and the number of errors (1.3) were not significant. The surgeons found Excalibur smoother, more comfortable, less tiring and easier to maneuver, with more realistic force feedback and superior movement fidelity. Conclusions: Surgical performance was superior with Excalibur compared to the other handcontrollers. This may reflect the microsurgical requirements and unique design architecture of Excalibur.

Background: The aim of this study is to assess factors impacting the postoperative length of stay (LOS) for patients undergoing microvascular decompression (MVD) surgery. Methods: A consecutive series of patients undergoing MVD at the Winnipeg Centre for Cranial Nerve Disorders were reviewed. All patients were monitored in a neurosurgical stepdown unit for at least 6 hours postoperatively and when medically stable discharged at their own discretion. The hospital LOS was measured in hours from midnight after day of surgery and categorized by days in hospital. Results: The 112 patients included 53 Manitobans (MB) and 59 from out of province (OOP). The overall LOS was 38±52 hours, and not significantly different between genders, diagnosis or age. LOS was significantly shorter for OOP versus MB patients (28±23/48±71 hours; p=0.02). OOP patients were also more often discharged on the first postoperative day (59% versus 32%; p=0.02) and 85% of them stayed at the hotel within the hospital complex prior to travelling home. Conclusions: Postoperative discharge to an adjacent hotel appears to have led to shorter LOS. These patients may have been reassured by the physical proximity to medical care. The utilization of discharge to an adjacent hotel or comparable faculty may reduce hospitalization days and associated costs.

Background: The aim of this study was to investigate intraoperative methods to generate patient-specific PMMA bone implants during a craniotomy. The proposed methods combine a cost-efficient, and non-invasive structured light scanner (SLS) as an imaging modality and a prototype printer for rapid generation of implant molds. Methods: This simulation study was performed using retrospective data from three craniotomy patients. The extracted bone flap and the cranial defect were scanned using a SLS, which generates a 3D surface model of an object by projecting a series of light-patterns on it. Prototype printed implant models were generated using two different techniques. The molds were then used to shape PMMA bone implants. These implants were evaluated regarding their accuracy to reconstruct the natural skull anatomy and compared to freehand formed implants. Results: The patient-specific bone implants reconstructed the preoperative anatomy with an average RMS error of 1.37mm (StDev 0.27), compared to an error of 1.5mm (StDev 0.43) for the freehand shaped implants. On average the intraoperative scanning time was 4.7min. The average time to generate and print the implant molds was 204 min. Conclusions: Results of this study have shown great promise for the proposed method to be used for patient-specific bone flap reconstruction during craniotomies.

Background: Idiopathic normal pressure hydrocephalus (iNPH) is a triad of impaired gait, cognition and urinary control in the setting of normal pressure ventriculomegaly. Various options for shunt implantation exist, but there is limited ability to predict outcome. Methods: This study is a retrospective chart review of 82 shunted patients for iNPH between 2007 and 2018. Factors examined included age, sex, lumbar puncture results, use of laparoscopic approach, type of shunt used, Charlson Comorbidity Index and imaging (callosal angle and DESH). Patient outcome was assessed via modified Rankin Scale (mRS). Results: 52 patients were male and 30 were female. Average age at surgery was 71.4 years. 58/62 (94%) improved following lumbar puncture. 41% of patients had VP shunt, and 59% of patients had LP shunt. 30/79 (38%) had laparoscopic placement of the distal catheter. 23/75 (31%) and 30/81 (36%) had a complication and required reoperation, respectively. Callosal angle showed statistically significant increase post-shunting (76 to 94 degrees, p<0.005). Presence of DESH did not change post-shunting. Average Charlson Comorbidity Index was 4.4. The mRS decreased from 3.84 to 2.66 post-operatively (p<0.005). Conclusions: In our centre, iNPH patients had clinicoradiologic improvement following shunting. We will perform regressional statistics to elucidate the factors influencing outcomes.

Background: Normal pressure hydrocephalus is a frequent cause of cognitive and functional impairment. Many symptoms are shared between Parkinson’s disease and normal pressure hydrocephalus. Only few studies examine extrapyramidal signs in NPH, and only one case report exists describing tremor improvement with shunting. Methods: We performed a retrospective chart review of our NPH database. We selected patients who had both NPH and question of Parkinsonism due to tremor. Results: Six patients with both NPH diagnosis and tremor were identified. Three patients were treated for Parkinson’s disease and followed by neurology. After shunting, all three improved and attempt was made to wean medications, which led to functional decline. The other three patients improved with shunting and after titration of the shunt had resolution of tremor. Conclusions: We provide evidence that NPH can result in tremor, treatable by shunting. We also emphasize that those patients do exist who have both diseases. This likely exists along a continuum. Careful consideration of NPH should be undertaken in those patients with suspected Parkinson’s disease and imaging findings reminiscent of NPH.

Background: Non-gunshot wound penetrating injury to the spinal canal have been known to have variable injury patterns with respect to trajectory and depth. Methods: We present a case of a penetrating glass fragment injury to the T11-12 level with a cerebrospinal fluid leak. Results: A T11-12 bilateral laminectomy and duraplasty with motor-evoked potential monitoring was performed to remove the foreign object and associated hematoma. The clinical presentation and surgical management are discussed with respect to other non-gunshot-related penetrating spine injuries in the literature. Conclusions: This case demonstrates a very rare injury pattern, as the vast majority of intradural penetrating injuries to the thoracic spine result in complete or incomplete spinal cord injury. This patient was neurologically intact, which is remarkable, given the 7cm glass fragment crossing the thoracic spinal canal transversely from the right to left.