Background: Faster administration of tissue plasminogen activator (tPA) for patients with acute ischaemic stroke yields greater clinical benefits. We implemented door-to-needle (DTN) time reduction strategies at our centre and evaluated their short- and long-term effects on in-hospital treatment delays and clinical outcomes. Methods: Stroke team pre-notification, direct computed tomography (CT) transfer, not routinely waiting for labs and tPA delivery on CT table were implemented in June 2013. We included all thrombolysed patients admitted directly to our hospital between January 2012 and March 2015. In-hospital delays and clinical outcomes (Modified Rankin scale, mRS) at 3 months were compared between patients pre- and post-modification, and the latter period was divided into early and late phases to assess the durability of our modifications. Results: Forty-eight individuals were treated pre-modification, compared to 58 post-modification. The median DTN time was reduced from 75 (interquartile range: 60-93) minutes to 46 (33-59) minutes (p<0.0001). The median DTN time in the early and late post-modification phases was not different (41 versus 46 minutes, p=0.4085). Functional outcome at 3 months was not different in the two groups (proportion of mRS≤1: 34% versus 28%, p=0.882). Conclusions: We were able to decrease our DTN time for treatment of acute stroke by implementing simple modifications and these improvements persisted over time.

Background: The Canadian Stroke Best Practice recommends admission of patients to a specialised stroke unit within three hours. We aimed at assessing delays in our emergency department (ED) and correlating these with medical complications and clinical outcomes. Methods: Predictors and outcomes This is a retrospective review of patients (n=353) admitted with ischemic strokes (January 2011-March 2014). We assessed the length of stay in ED, medical complications in ED and in the stroke unit, functional status (modified Rankin Scale) at discharge and survival. Results: The median delay in ED was 13.8 hours. The rate of medical complications in the ED was 14% (most common being delirium), compared to the stroke unit with 46.7% (most common being pneumonia). Worse functional outcome was correlated with diagnosis of pneumonia (standardised β coefficient=0.2, p=0.001) and presence of brain oedema in the stroke unit (standardised β coefficient=0.2, p<0.01). Increased risk of death was correlated with brain oedema (OR=649.2, 95%CI=19-2184, p<0.01) and sepsis in the stroke unit (OR=26.8, 95%CI=2.1-339, p<0.01). Conclusions: We found a significant delay in the admission of our patients from the ED to the stroke unit, which is not in keeping with the present guidelines. Medical complications were correlated with worse outcomes. Future analyses will correlate ED delays with clinical outcomes.

Background: Approximately, one-third of TIA clinics use the ABCD2 score to triage referrals. However, the usefulness of the score is limited because of its low specificity for non-cerebrovascular/mimic conditions. Timely access of referred patients to specialized TIA clinics may reduce recurrent stroke. Methods: The SpecTRA project implemented a novel electronic triage system in the TIA clinic that services Vancouver Island (BC), which replaced the existing ABCD2 triage model. A clinical classifier generating an ACVS probability score was calculated on the basis of the clinic referral form information. Next, a time-varying ABCD2-based risk score derived from Johnston et al. (2007) was calculated, which is then weighted by the ACVS probability score to produce a finalized triage score. Time-to-care was compared pre- (2013/14) and post- (2014/15) implementation. Results: One year results show a statistically significant improvement in that time-to-care for ACVS patients (ABCD2 4/5) was one day earlier with the new triage system (median= 4days since symptom onset; N=250) compared to the previous year (median=5days; N=255) (Mann-Whitney U=38130, p< 0.001). No difference in unit arrival times (median= 5days) for non-cerebrovascular patients was observed (Mann-Whitney U=5563, p= 0.15). Conclusions: The performance of our ACVS triage system highlights quality improvement potential in time-to-care for outpatient TIA clinics.

Background: Bedside dysphagia screening is recommended for all patients with acute ischemic stroke, in order to detect swallowing impairment early and prevent complications. However, limited data are available on outcomes associated with failing a dysphagia screen. Methods: We used the Ontario Stroke Registry to identify patients who were admitted to Regional Stroke Centres from 2010-2013 and received a dysphagia screen within 72 hours. We used multivariable regression to determine outcomes of patients who failed the dysphagia screen. Results: Among 5145 patients who underwent dysphagia screening, 2458 (47.8%) failed and 2687 (52.2%) passed. Patients who failed had more co-morbidities and presented with more severe strokes (mean NIHSS 11.0 vs. 5.4). Among those who failed, 9% required permanent feeding tubes, versus 0.1% among those who passed. After controlling for age, co-morbidities, and stroke severity, failing a bedside swallowing screen remained highly predictive of poor outcomes, including decubitus ulcer (adjusted odds ratio aOR 10.5), pneumonia (aOR 4.6), discharge to long-term care (aOR 4.1) and 30-day mortality (aOR 4.5; 16.6% vs. 2.2%). *All p <0.0001 Conclusions: Patients who failed a dysphagia screen on admission had dramatically worse outcomes after controlling for baseline factors. A bedside dysphagia screen provides immediate risk stratification for acute stroke patients and can be used to guide appropriate care.

Background: Stroke alerts are used to triage patients with acute neurologic change for rapid imaging evaluation. CTA has been advocated to rapidly triage stroke patients for endovascular therapy. However, the yield of this approach is not well established. We evaluated the stroke alert yield in a non-teaching hospital system. Methods: A retrospective review of radiology reports for stroke alerts using PACS archive. Cases were then followed for 72 hours to determine the types of advanced imaging obtained and the findings of those studies. Results: From January to March 2014, 269 stroke alert head CTs were performed. Subsequent imaging included 128 MRIs (48%), 25 CTAs (9%) and 2 angiograms (0.7%). There were 58 (22%) tissue-defined strokes and 16 were non-lacunar (6% stroke alerts). 61% of stroke alert head CTs were negative or reported microvascular change. Other findings included large vessel occlusion (5%), intracranial stenosis (1.5%), extracranial stenosis(1.5 %), intracranial hemorrhage (9%) and masses (13%). Conclusions: Most stroke alerts were negative for tissue-defined stroke. Based on this data, universal use of CTA in the ER to triage patients with acute neurologic symptoms may not be appropriate. An updated triage system to facilitate endovascular rescue is being analyzed for changes to advanced imaging utilization and yield.

Background: Electroencephalogram (EEG) is used in evaluating thalamocortical function in comatose patients. EEG reactivity is increasingly being recognized as a potentially important predictor of outcome in comatose patients. There are no existing guidelines or standardized testing for EEG reactivity assessment. We will report the use of a clinically implemented standardized reactivity testing protocol in comatose patients to determine accurate prognosis. Methods: In this retrospective study we report results from standardized reactivity testing from January 2016 to May 2016. Five stimuli (Calling name, clapping, nasal tickle, noxious stimulus, tracheal suctioning) were applied at one minute intervals in comatose patients of all etiologies. The EEG background reactivity will be analyzed by two independent electroencephalographers ad correlated to clinical outcome. Results: The methods for establishing EEG reactivity and the inter-rater reliability in determining EEG reactivity will be reported. Conclusions: EEG background reactivity is likely beneficial in determining prognosis. However, reliable methods for eliciting and determining EEG reactivity in comatose patients are necessary.

Background: Psychiatrists commonly use electroencephalogram (EEG) to rule out epilepsy as a cause of psychiatric symptoms. A large number of these studies are normal. Our study aims to identify the predictive factors of an EEG with epileptiform activity in these patients. Methods: We performed a retrospective study of the EEG results and chart reviews of the 208 psychiatric patients at Royal University Hospital in Saskatoon, Saskatchewan from 2013-2015. The EEG results were correlated with several factors known to increase the probability of an abnormal recording including history of seizures, previously abnormal EEGs, imaging abnormalities, medications known to cause epileptiform discharges, electroconvulsive therapy, prematurity, brain infection, childhood febrile seizures, head trauma, and family history. Results: Of the 208 EEGs performed, 176 (84%) were normal (77%) or essentially normal (7%). Epileptiform activity was found in 13 EEGs (6.3%), of which 9 (4.3%) had a previous EEG with epileptiform activity. Focal slowing appeared in 12 EEGs (5.8%), two of which had previous abnormal EEGs. Generalized slowing was found in 7 EEGs (3.4%). Conclusions: We conclude that the majority of EEGs in patients with psychiatric manifestations are normal. The most predictive factor for epileptiform activity in this population is a previous EEG with epileptiform discharges. Other predictive factors are under review.

Background: Donation after circulatory death (DCD) is a recently accepted source for solid organ donation in Canada. Standards for circulatory death vary within and between countries and little is known about neurologic function at the time of circulatory death. This pilot study will explore the electrical physiology of the brain during the dying process following withdrawal of life support and at the time of declaration of circulatory death. Methods: This single-centre pilot study will build on preliminary data from the DDePICt (Death Determination Practices in Intensive Care) research program. With institutional approval and signed consent from the substitute decision maker, participants will undergo continuous 10-20 EEG (cEEG) monitoring in addition to monitoring vital signs during the dying process and for 30 minutes after the declaration of death. Results: Preliminary results including cEEG, blood pressure with arterial wave forms, EKG activity and oxygen saturations are currently under analysis and will be presented. Conclusions: It is feasible to study neurologic function during withdrawal of life support and these results will allow us to further understand the electrical activity of the brain during the dying process.

Background: NMDA receptor encephalitis (NMDA-RE) is an autoimmune disorder caused by antibodies to the NR1-NR2B heterodimer of the NMDA receptor. Currently, disease status is tracked primarily by the presence of auto-antibodies in the cerebrospinal fluid (CSF) and serum. Using serological and CSF markers along with clinical parameters to track disease progress can be challenging since patient symptoms and disease progress can vary widely. Methods: EEGs were reviewed in a 31 year old male patient with proven NMDA-RE. EEG data were sampled from various times before and after diagnosis, as well as during various stages of treatment. All analyses were performed using Matlab (Mathworks). Results: We showed that using a simple 1/f model of spectral behaviour (Buzsaki and Draguhn, 2004), we could fit the power spectra of the raw data at various instances during routine EEGs. We have demonstrated that the values of specific fitting parameters vary in relationship to the patient’s clinical status across various stages of illness. Conclusions: The aim of this project was to explore the potential utility of EEG as a complement to the usual clinical metrics used in monitoring NMDA-RE. The analysis techniques presented here highlight the use of EEG as a practical, minimaly-invasive tool to monitor progress and potentially aid in clinical decision making.

Background: Transient osteoporosis is an infrequent musculoskeletal condition most often seen in middle-aged males, but can rarely present during late pregnancy in females. Patients present with sudden onset of severe joint pain. MRI typically shows T2 hypersignals and bone marrow edema. Abnormal neurophysiological findings have only rarely been described in the literature. Methods: Case report Results: A 35-year old patient presented at 34 weeks of pregnancy with acute onset of right hip and leg pain. MRI showed marked T2 hypersignals in the head of the femur with distal extension and bone marrow edema pathognomonic of transient osteoporosis. Neurophysiological studies showed normal nerve conductions of the lower extremities, but fibrillation potentials and positive sharp waves were found acutely in proximal muscles of the affected extremity and not limited to a single nerve territory. Inflammatory markers were unremarkable. Treatment was conservative with rest and reduction of weight bearing and pain resolved in the hip, but recurred in the ipsilateral knee several months after delivery suggesting evolution toward regional migratory osteoporosis. Conclusions: Transient osteoporosis of the hip may be associated with EMG signs of denervation that could suggest a contributing neurogenic mechanism. Their prevalence may be underestimated and we suggest considering serial EMG studies in its investigation.

Background: Postoperative infection is a significant cause of morbidity and mortality in traumatic brain injury (TBI) patients who undergo craniotomy and/or craniectomy. Data on the rates of infections associated with these procedures are limited. We present a single-center retrospective study on the rates of infection in post-traumatic craniotomies, craniectomies and cranioplasties. Methods: Data on 100 TBI adult patients who underwent a craniotomy, craniectomy and/or cranioplasty from 2011-2015 will be analyzed. Demographic and perioperative data including open/closed TBI, peri/postoperative infections, duration of procedure, type and mode of bone flap preservation will be retrieved. Results: Following our data collection (to be completed by the end of February), we expect infection rates of 3-20% in our study. Upon instituting a protocol similar to the Hydrocephalus Clinical Research Network’s (HCRN) ventriculoperitoneal shunt (VP) protocol, we hope to reduce our post-TBI craniotomy/craniectomy/cranioplasty infections rates to less than 10%. Our projection is based on the HCRN protocol’s 3.15% absolute risk reduction of VP shunt infections. Conclusions: The results of this study will emphasize the need for instituting robust perioperative protocols to reduce infections. Further research will be pursued following this study to establish a protocol similar to the VP shunt protocol from the HCRN, in an attempt to reduce perioperative rates of infection.

Background: Characteristics of traumatic spinal cord injury (tSCI) patients admitted to the Saint John Regional Hospital and the Stan Cassidy Center for Rehabilitation from 2011 to 2014 were examined. Methods: Demographic, neurological and functional outcome data for 18 patients, who had consented to participate in a database for tSCI in Canada, was obtained. Results: The majority of patients were male (88.9%), with a mean age of 41. 33 (SD=17.17). The most common causes of tSCI were motor vehicle accidents (41.2%) and falls (29.4%). Cervical spine injuries (70.6%) and an ASIA impairment scale classification of D (38.9%) predominated. The median latency from injury to surgery was 22.67 hours. Functional independence Measure scores (M=64.17, SD=25.84) indicated that motor/functional independence was impaired (M=32.44, SD=19.15) relative to cognitive independence (M=31.83, SD=4.07). Conclusions: The results suggest that characteristics of tSCI patients in New Brunswick are similar to the Canadian tSCI patient population. Emergency care appears to be delivered in a timely fashion. Both centers participate in research registries focused on collecting data related to tSCI, surgical interventions, and patient outcomes. Registries are valuable research tools that allow for an alternative way to examine the quality of care their patients receive.

Background: Research has suggested that female athletes have a higher incidence of concussion compared to their male counterparts. As such, programs designed to improve knowledge and attitudes of concussion should target this high-risk population. Previous work demonstrated the effect of a novel Concussion-U educational presentation on knowledge and attitudes of concussion amongst male Bantam and Midget AAA hockey players. The objective of this study was to determine if the same presentation was effective in improving the knowledge and attitudes of concussion in a cohort of elite female hockey players. Methods: 26 elite female high-school aged (14-17) hockey players from the province of New Brunswick consented to participate in the study. Each participant completed a modified version of Rosenbaum and Arnett’s Concussion Knowledge and Attitudes Survey questionnaire immediately before and after a Concussion-U educational presentation. Results were compared across the two time-points to assess the effectiveness of the presentation. Results: Concussion knowledge and attitude scores significantly (p<.001) increased from pre-presentation to post-presentation by 12.5% and 13.4%, respectively. Conclusions: A Concussion-U educational presentation resulted in increased knowledge and improved attitudes towards concussion in elite female hockey players. Future research should examine the long-term retention of these improvements.

Background: Indigenous populations are disproportionately affected by traumatic brain injury (TBI). These populations rely on large jurisdiction surveillance efforts to inform their prevention strategies, which may not address their needs. This study describes the TBI determinants of a Quebec indigenous population, the Cree served by the Terres-Cries-de-la-Baie-James health region, and compares them to the determinants of two neighbouring health regions and the entire Province of Quebec. Methods: We conducted a retrospective population-based cohort study of incident TBI hospitalizations, stratified by the aforementioned health regions, in Quebec from 2000-2012. MED-éCHO administrative data were used for case finding. A sub-analysis of the Terres-Cries-de-la-Baie-James adults was completed to assess for determinants of TBI severity and outcomes. Regression models, multiple imputations and a sensitivity analysis were used to account for biased associations. Results: 172 incident TBI hospitalizations occurred in the Terres-Cries-de-la-Baie-James region from 2000-2012. The incidence rate was 92.1 per 100,000 person-years and the adjusted IRR was 1.86 (95% CI 1.56-2.17) when compared to the entire province. Determinants of TBI for the Terres-Cries-de-la-Baie-James were significantly different from those of neighboring populations and the entire province. Conclusions: TBI surveillance information from large jurisdiction initiatives can be misleading for indigenous communities. Community-based surveillance provides evidence that these populations should use to prioritize prevention strategies.

Background: Penetrating brain injury is a rare entity. Furthermore, clinical presentation can be highly variable and management difficult, especially when the foreign body is retain in the skull Methods: We present a serie of three recent cases of penetrating brain injury that happened at our institutionm including clinical and radiological data. We discuss management of those challenging cases and present a brief review of the literature. Results: Our cases (3) encompassed different mechanisms: bilateral nail gun injury, knife and aircraft propeller. All patients were male, with a median age of 37 years old. Work-up was negative for intracranial vascular injury. All patients were treated with initial craniectomy (bilateral in one case) and a course of antibiotics. Cranioplasty was later performed. All patients survived and evolved in favorable fashion. Conclusions: Penetrating brain injury is a rare injury, requiring individualized surgical and medical management. A few recommendations may be found in the literature but are often based on literature from blunt traumatic brain injury or war-related injuries.

Background: There is currently little data on the incidence, clinical outcome and management of traumatic interhemispheric subdural hematomas (IHSDHs). Methods: All patients admitted with an acute subdural hematoma (SDH) over a 5-year period at a Level I trauma center were included. A detailed review of all cases of large IHSDH (≥7 mm) was performed to document clinical presentation, management and outcomes. Results: Of 1182 patients with acute subdural hematomas (SDHs), 420 had IHSDHs (24%), and 50 were large IHSDHs. For patients with large IHSDH, the average age was 76 years (±11) and 44% were female. The average GCS was 12 on presentation (±4), and the average GOSE was 4 (±2). 66% of patients had associated cranial/ intracranial injuries (fracture, subarachnoid/epidural/SDH) and 26% required operations for acute convexity SDH. Three patients required operations for their IHSDH by inter hemispheric approach. By 10 weeks, 82% had a complete resolution of the IHSDHs. Conclusions: IHSDHs are often referred to as rare entities. Our results show they are common. Conservative management is often appropriate to manage even large IHSDHs, as most resolve spontaneously. This study will help document the occurrence of falx syndrome, as well as the management and outcomes of larger IHSDHs.

Background: Trigeminal neuralgia (TGN) is usually caused by arterial compression of the trigeminal nerve. There are very few cases caused by intra-axial brainstem masses. Little information is therefore available regarding the response to incomplete resection of offending lesions. We present one such case, and systematically review the published in the literature. Methods: Case report and systematic review of MEDLINE and EMBASE Results: Case report: A seven year-old girl is referred with typical TGN pain. MRI revealed a cervicomedullary tumor with no abnormalities of the pons or trigeminal nerve. Subtotal resection under neurophysiologic monitoring was achieved, leaving a small residual attached near the expected location of the trigeminal spinal nucleus and tract.Patient recovered well with resolution of her TGN pain. She is asymptomatic seven years post-operatively. Literature Review: We found no other published cases in children or secondary to gliomas. Among reviewed cases, only two underwent surgery. Both were adults with brainstem cavernomas and both reported substantial improvement despite incomplete resection. Conclusions: Our case as well as literature review both show that surgical resection is beneficial in such cases and, even if subtotal, can result in substantial pain relief. This suggests intra-axial compression of the trigeminal spinal nucleus and tract as the possible cause of TGN pain in such cases.

Background: A diagnosis of trigeminal neuralgia (TN) may be broadly applied to many neuralgic facial pains, while more stringent criteria are required for management decisions, outcome assessment, and pathophysiological correlations. Our aim was to evaluate existing classification systems of facial pain. Methods: The study population was comprised of 534 Manitobans referred to neurosurgery for facial pain from 2001 to 2013. A retrospective chart review identified presenting features; pain distribution, nature, and duration. The recorded diagnoses (rDx) were then re-classified according to the International Classification of Headache Disorders (ICHD-3) and Burchiel System of TN1 and TN2. Results: There was complete correlation between rDx and ICHD-3 for typical TN (tTN) in 266(49.8%) patients, atypical TN (aTN) in 39(7.3%), and idiopathic facial pain (IFP) in 59(11%). Idiopathic trigeminal neuropathy (iTn) in 35(6.6%) was not classified in ICHD-3. Burchiel-TN1 included heterogeneous diagnoses including tTN (266), aTN (27), iTn (2) and IFP (8); Burchiel-TN2 included aTN (10), iTn (23), and IFP (15). Another 135(25.5%) had other facial pain diagnoses. Conclusions: Classification of TN is especially important when selecting and evaluating surgical treatments. Diagnostic criteria should clearly differentiate between unique conditions and ideally have basis on underlying etiology. The ICHD-3 nomenclature best satisfies these aims although should be expanded to include iTn.

Background: Advances in surgical leads have been thought to potentially enable improved low-back pain relief using SCS. A recently introduced 32-contact surgical lead, which couples multiple independent current control and anatomically-based neural targeting stimulation algorithms, allows for patient-specific programming optimization. We present a real world study of this surgical lead. Methods: A multi-center, consecutive, observational study of a new 32-contact surgical lead was carried out, using the Precision Spectra SCS System (Boston Scientific) in 100 subjects out to 12 months post-implant. We examined procedural information, programming parameters, and clinical outcomes including pain reduction (NRS), activities of daily living, and change in pain medications. Results: Surgical lead placement distribution was between T7 and L2, with most at top of T9 (26%). A mean reduction of 5.1 points (SD 2.15, p<0.001) from 7.8 (baseline) to 2.6 in overall pain was observed. A subset of subjects reporting low-back pain only exhibited a mean decrease of 6.0 points (SD 2.12, p<0.001) from 8.3 (baseline) to 2.2. Of these, 83.1% of subjects showed ≥50% back pain reduction. Increases in activities of daily living and reduction in pain medication usage were also observed in majority of subjects. Conclusions: Subjects implanted with a 32-contact surgical lead using a neural targeting algorithm demonstrated significant low-back pain reduction.

Background: Patients with pituitary disorders may be placed on steroid replacement for secondary adrenal insufficiency (SAI), generally after pituitary surgery; however, data regarding recovery of long-term SAI are lacking. We conducted a study to assess the longer term recovery rate of SAI in patients with pituitary disorders. Methods: We identified all SAI patients from prospectively entered data in the Halifax Neuropituitary Database from November 1, 2005 to September 30, 2014, who had required glucocorticoid therapy for >3 months, and a minimum follow-up of 6 months. Exclusion: ACTH-secreting adenomas; peri-operative glucocorticoid treatment only; glucocorticoids for non-pituitary conditions. Results: 55 patients fulfilled the criteria, 41 (75%) of which had transsphenoidal surgery. Nine (16.4%) patients had complete recovery of SAI over a median of 20 months (range: 8–51). Smaller tumour size and initial cortisol >175 nmol/L had increased likelihood of recovery; those with secondary hypogonadism or growth hormone deficiency were less likely to recover. Conclusions: This is the first study to examine long-term recover of SAI in patients with pituitary disorders: approximately 1 in 6 patients recover adrenal function, up to 5 years after diagnosis. Consequently, patients with SAI should undergo regular testing to prevent unnecessary chronic glucocorticoid therapy.