Intravenous tissue plasminogen activator (IV tPA) has been studied primarily in patients over age 50. We sought to describe baseline differences in adult patients ≤50 years-old taken from a large prospective cohort of acute stroke patients treated with intravenous tPA (IV tPA) and to determine whether outcomes differed for this population.

Data (n = 1120) prospectively collected from the Canadian Alteplase for Stroke Effectiveness Study (CASES) were reviewed and patients aged ≤50 years-old (n=99) were compared with those aged >50 years (n=1021) with regards to baseline characteristics, symptomatic intracerebral haemorrhage (sICH), functional outcome at 90 days and death.

Nine percent of patients were ≤50 years-old. Among patients aged ≤50 years, 40.4% were women and median age was 42 ± 6.1 years (range 20 to 50). They had significantly more current cigarette use but fewer other vascular risk factors than older patients (p<0.05) and their baseline median NIHSS score was lower (13 versus 15, P=0.001). Although this group was more likely to have a favourable 90-day outcome, multivariable regression confirmed that age ≤50 years, while independently associated with a decreased risk of death (RR 0.36, 95% CI 0.14 to 0.95), was not itself predictive of favourable 90-day outcome or decreased risk of sICH.

Adult patients ≤50 years-old had fewer medical co-morbidities and a modestly lower baseline median NIHSS score than their older counterparts. Age ≤50 years was independently associated with a decreased risk of death but not with favourable outcome or risk of sICH.

To present our experience with the endovascular management of intracranial dural arteriovenous fistulas with direct cortical venous drainage by trans-arterial embolisation using Onyx.

Between January 2004 and April 2008, 12 consecutive high grade intracranial dural arteriovenous fistulas (Cognard type III (eight patients) or IV (three patients)) were treated by trans-arterial embolisation with Onyx. The majority of cases were treated by Onyx embolisation alone. One case had additional embolisation with n-butyl-2-cyanoacrylate at the same session. Imaging follow-up was obtained in all but one patient (mean 3.6 months).

Nine patients had a technical success at the end of the embolisation procedure with complete angiographic exclusion of the fistula. Two patients had a small residual fistula at the end of embolisation, one of which had residual mild cortical venous drainage. Both were stable at follow-up angiography. One patient had a residual fistula supplied by the ophthalmic artery, which was thought to be unsafe to embolise and was sent for surgery, which was curative. In one patient the microcatheter ruptured, with a fragment of the distal microcatheter left in the occipital artery. No clinical complications were observed in this series at clinical follow-up (mean 3.3 months). Two patients were noted to have significant radiation dose.

Endovascular management of intracranial dural arteriovenous fistulas with direct venous cortical drainage by trans-arterial Onyx embolisation is a safe and effective treatment according to our experience. Fluoroscopy times and radiation dose may be a concern.

To compare the efficacy of computed tomographic angiography (CTA) to that of digital subtraction angiography (DSA) in the detection of secondary causes of intracerebral hemorrhage (ICH).

Between January 2001 and February 2007 there were 286 patients that had both CTA and DSA for intracranial hemorrhage of all types. Those with primarily subarachnoid hemorrhage or recent trauma were excluded. Fifty-five patients formed the study cohort. Three reviewers independently analyzed the CTAs in a blinded protocol and classified them based on presence or absence of a secondary etiology. Results were compared with the reference standard DSA and kappa values determined for interobserver variability.

The overall sensitivity, specificity, positive predictive value, negative predictive value and accuracy of CTA were 89%, 92%, 91%, 91% and 91%, respectively. Kappa value for interobserver agreement ranged from 0.78 to 0.89. Two of four dural arteriovenous fistulas (dAVF) were missed on CTA by all three reviewers.

CTA is nearly as effective as DSA at determining the cause of secondary intracerebral hemorrhage, but with a lower sensitivity for dAVFs. This supports the use of CTA as the first screening test in patients presenting with spontaneous ICH.

There are no studies from Pakistan that describe stroke presentation rates or factors associated with early or delayed presentation. This is important to know because current clinical protocols limit the use of recombinant tissue plasminogen activator (rtPA), the only available therapy for acute ischemic stroke, to a three-hour window from symptom onset.

All patients aged 14 years or above with acute ischemic stroke of ≤ 48 hours duration were prospectively identified from the Aga Khan University Stroke Data Bank over a 22-month period ending May 2001.

269 ischemic stroke patients presented within 48 hours of stroke onset. 55 out of 269 (21%) presented within first three hours and 110 out of 269 (41%) within first six hours. Unawareness of treatment options (p <0.001) and inappropriate diagnosis and field triage (p=0.005) were associated with delayed presentation. Small vessel occlusion or lacunar stroke in the TOAST (Trial of ORG 10172 in Acute Stroke Treatment) ischemic stroke subtype was associated with delayed presentation (p=0.047) and cardioembolic stroke was associated with earlier presentation (p=0.048). Stroke severity assessed with the National Institutes of Health Stroke Scale at a cut off score of ≥ 15 was not associated with earlier time to presentation at three hours (p=0.114) but there was some tendency at six hours (p=0.097).

The rate of early stroke presentation in a Pakistani tertiary care facility is comparable to certain developed countries. To increase the proportion of patients who can benefit from thrombolytic therapy, programs need to be instituted to increase public awareness of treatment options for stroke and expedited referral by the primary care provider.

To ascertain neurosurgical practices in the surgical management of one-level lumbar discectomies in the Canadian adult population.

One page questionnaire faxed to each Neurosurgeon in Canada with questions relating to their practice in the management of this common neurosurgical procedure. All data analyzed using Chi-square statistics.

112 completed surveys were returned hence, giving a 64% response rate with the respondents being predominantly adult neurosurgeons. Of the respondents, 88% perform lumbar discectomy in adults. Only 15% of respondents had a Spine Fellowship. For preoperative imaging, 44% use BOTH CT and MRI whereas 28% use only MRI and 15% use only CT. Prior to initial skin incision, 57% use a localization X-ray image. Preoperative antibiotics are prescribed by 92% of respondents. Majority of respondents (60%) use a pre-incision local anesthetic, whereas only a minority (44%) of respondents employ pre-closure intramuscular injection. With respect to magnification, 70% use microscope, 19% loupes, and 8% neither. Only 12% use minimally invasive tubular retractors. 68% remove “as much disc as possible”, while 31% remove “ONLY herniated part”. In the case of dural tears, 77% of respondents use fibrin glue (Tisseel®). Prior to skin closure, majority of neurosurgeons do NOT use a fat graft (72%), whereas 61% of respondents use epidural steroids. With respect to discharge from the hospital, 58% are discharged on the next day, 18% on the same day, and 23% in two days. Return to work is not recommended until at least six weeks post-op (96%). Most neurosurgeons (93%) would not operate on an individual with a chief complaint of low back pain.

Our survey has identified variations in practice patterns amongst Canadian Neurosurgeons with respect to performing one-level lumbar discectomies. This survey is expected to form a basis for the design of a randomized controlled trial in the evaluation of the best management approach for this common neurosurgical procedure.

In the present study we review our experience with 900 consecutive percutaneous muscle biopsies over the period 1993 to 2007. We examined the advantages and limitations of the procedure, biopsy site preferences, diagnostic range, frequency of diagnoses and quality of histopathology. Demographics, referral patterns and patients' perceptions of the procedure were also assessed.

Cases were identified through the London Health Sciences Centre Department of Pathology database. Standard biopsy procedures were followed using a manual trocar style instrument. With a neuropathology technologist in attendance at all biopsies, biopsies were oriented in the fresh state and snap frozen.

Most referrals for muscle biopsy were from neuromuscular neurologists. The procedure was found to be efficient, well-tolerated and produced high quality specimens in all diagnostic categories. No major complications occurred. Failure to obtain an adequate tissue sample, although uncommon (<2%), was usually due to marked obesity, edema or muscle wasting. Bleeding at the site was rarely problematic and no wound infections were reported.

Needle muscle biopsies represent an efficient alternative to open biopsies when peripheral nerve sampling is not required and when large tissue samples are not needed for extensive biochemical analyses.

To determine the compliance rate among hockey players with concussion or other head injuries who were advised by a physician about return to play. To assess compliance of hockey players with return to play advice and to assess the incidence of long-term post-concussion symptoms.

A retrospective chart review, telephone questionnaire and follow-up analysis of income, level of education and professional aspirations. The study examined 40 hockey players with concussion or other head injury treated at a neurosurgical ambulatory clinic, who had initial visits between 1995 and 2003, and had been seen at least two years prior to completing the questionnaire.

There was a 58% (23 of 40) participation rate in the study. Fifteen (65%) of the 23 participants were advised to never return to play, and 5 (33%) were non-compliant and returned to play. Four (80%) of the five non-compliant players continued to suffer from post concussion symptoms. Overall, 15 (65%) of the 23 players participating in the study continued to suffer post concussion symptoms at least two years after the clinic visit.

Five (33%) of 15 hockey players advised to never return to play were non-compliant and returned to play, and four continued to suffer from post concussion symptoms two or more years later. After repeated concussions, 65% of hockey players had long-term sequelae that prevented return to play and produced long-term post-concussion symptoms.

Glucocorticoid treatment improves the speed of functional recovery of acute multiple sclerosis (MS) relapses but has not been shown to provide any long-term functional benefit. There is currently no convincing evidence that the clinical benefit is influenced by the route of administration or the dosage of glucocorticoid, or the particular glucocorticoid prescribed. Recent studies support similarities in the bioequivalence and in the clinical effect of high dose oral corticosteroids for MS relapses.

This survey aimed to determine the relapse treatment preferences of clinicians in Canadian MS clinics.

Members of the Canadian Network of MS Clinics are linked by an email server. A one page survey was distributed to the group to determine and report use of corticosteroids to manage MS relapses amongst Canadian MS specialists.

Fifty-one clinicians from 17 MS clinics were surveyed. 32 (63%) surveys were returned representing 16 clinics. Five doses are most commonly prescribed, usually without a taper. Three or four doses and the use of a corticosteroid taper, however, are not uncommon. Gastric cytoprotection and sedatives are often prescribed for use as needed.

This survey illustrates that when Canadian clinicians with expertise in managing MS treat MS relapses they choose high dose corticosteroids, either oral or IV. The results therefore represent Canadian practice as these clinicians provide direct patient care and influence care by community neurologists. Until evidence clearly identifies a superior practice all options should be available to clinicians and their patients.

Studies on migraine in Nigeria are scanty while the disability associated with the disease has not been determined. We aimed at determining the lifetime prevalence of migraine and its associated disability among the students of a Nigerian university.

Using a multi-stage sampling method, undergraduates of Ambrose Alli University, Nigeria were screened with the International Headache Society (IHS) criteria. Those who satisfied the criteria for migraine were then assessed with the Migraine Disability Assessment questionnaire to ascertain the level of disability resulting from migraine in the three months preceding the study. Information was also obtained on the use of preventive and abortive medications.

Out of the 1513 respondents screened, 145 satisfied the IHS criteria for the diagnosis of migraine giving an overall lifetime prevalence of 9.6% (females 10.3%, males 8.9%, p>0.05). Migraine associated disability was little or none in 53.1% (males 55.2%, females 51.3%, p>0.05), mild in 10.3% (males 11.9%, females 9.0%, p>0.05), moderate in 20.7% (males 20.9%, females 20.5%, p>0.05) and severe in 15.9% (males 11.9%, females 19.2%, p>0.05). In spite of the fact that 53 (36.6%) of the migraineurs had moderate-severe disability, only 19/53 (35.8%) reported being on preventive treatment while none had ever used a triptan.

Prevalence of migraine among our respondents falls within the range reported from similar studies among university students outside Africa. In spite of the high disability associated with the disease, use of effective preventive and abortive therapies is very poor.

Cervical dystonia (CD) may be classified according to the underlying cause into primary or secondary CD. Previous exposure to neuroleptics is one of the main causes of adult-onset secondary dystonia. There are few reports that characterize the clinical features of primary CD and secondary neuroleptic-induced CD. Herein our aim was to investigate a series of patients with neuroleptic induced tardive CD and to describe their clinical and demographic features.

We retrospectively evaluated 20 patients with neuroleptic-induced tardive CD and compared clinical, demographic and therapeutic characteristics to another 77 patients with primary CD. All patients underwent Botulinum toxin type-A therapy.

We did not identify any relevant clinical and demographic characteristics in our group of patients that could be used to distinguish tardive and primary CD.

Patients with tardive CD presented demographic characteristics and disease course similar to those with primary CD.

Cortical mapping during awake surgery assesses intraoperative neurological change in response to electrical stimulation to provide direct information regarding the anatomical localization of the primary motor area (M1). The goal of the present study was to analyze the reliability of the identification of the precentral knob in the axial image of magnetic resonance imaging or functional MRI (fMRI) for the detection of M1.

Among patients with brain tumors within or near M1 in whom awake surgery was employed from April 2004 through March 2007, 14 cases were analyzed in which either the M1 or premotor area (PMA) was successfully detected by mapping during awake surgery.

The precentral knob was localized to the PMA in 4 cases and to M1 in 10 cases. By contrast, the gyrus activated by hand clenching in fMRI on the affected side at least partially corresponded to M1 in all cases, while those on the unaffected side corresponded to M1 in 12 of 12 cases.

These results indicate that the precentral knob corresponds to PMA as well as to M1, whereas the gyrus activated in fMRI corresponds to M1 on the affected and unaffected side.

Resiniferatoxin, the most potent agonist of inflammatory pain/vanilloid receptor/cation channel (TRPV1) can be used for neuron subtype specific ablation of pain generating cells at the level of the peripheral nervous system by Ca2+-excytotoxicity. Molecular neurosurgery is an emerging technology either to alleviate severe pain in cancer or treat/prevent different local neuropathies. Our aim was determining sensory modalities that may be lost after resiniferatoxin treatment.

Newborn or adult mice were treated with resiniferatoxin, then changes in chemical and heat sensitivity were correlated with alterations of the cell composition of sensory ganglions.

Only mice treated at adult age became less sensitive to heat stimuli, while both treatment groups lost sensitivity to specific vanilloid agonists of TRPV1 and, interestingly, to allyl-isothiocyanate, a selective agonist of TRPA1. Our in vivo and post mortem analytical results confirmed that TRPV1 and TRPA1 function together and resiniferatoxin-mediated neurosurgery removes both sensor molecules

In adult mice resiniferatoxin causes: i) desensitization to heat and ii) sensitization to cold. Cold hyperalgesia, an imbalance in thermosensation, might be conferred by a prominent cold receptor that is expressed in surviving resiniferatoxin-resistant sensory neurons and compensates for pain signals lost with TRPA1 and TRPV1 double positive cells in the peripheral nervous system.