Background: Intracranial hemorrhage (ICH) in newborns poses a significant challenge to wellbeing and development. In preterm neonates, germinal matrix hemorrhage is most common. In term neonates, prevalence and type of ICH has not been well elucidated. This systematic review aims to assess prevalence, type, and risk factors of ICH in term neonates. Methods: A systematic review was conducted. Inclusion criteria was ICH in neonates born at 37+ weeks gestation. Exclusion criteria was one type of ICH, one risk factor, sample size <20, text not in English, full text not accessible. Eligible studies were evaluated by two authors, data was extracted and analyzed using a predesigned template and MetaXL. Results: A total of 1226 records were initially identified and 20 studies were included in the final analysis. The overall prevalence of ICH was 9.3%. This was subdivided into an asymptomatic subgroup (5.8%) and symptomatic subgroup (29.3%). Analysis showed CT detected ICH most commonly. Extra-axial hemorrhage was most commonly detected (~30%), with subdural more common than extradural hemorrhages. The odds of having an ICH was significantly higher with instrumental delivery (3.75%). Conclusions: This shows that prevalence of ICH is relatively high in symptomatic children. Measured prevalence varies according to the type of modality used for screening.

Background: Meningiomas are common brain neoplasms that can significantly influence health-related quality of life (HRQOL), yet the factors influencing HRQOL in adult patients remain unclear. We aimed to bridge this knowledge gap by determining these key factors. Methods: We conducted a systematic review, searching EMBASE, MEDLINE, CINAHL, Scopus, and PsycINFO up to March 2023. We included original, peer-reviewed studies focusing on adult patients (>18 years) with current or past meningioma at any stage of treatment that measured HRQOL or its proxies in relation to tumour-, treatment-, and patient-related factors. Two independent reviewers screened abstracts and full texts, selecting studies with acceptable risk of bias for data extraction and narrative synthesis. Results: Of N=2942 identified studies, N=30 were included. Key factors found to influence HRQOL in adult meningioma patients include surgery, radiotherapy, neurological function, functional status, comorbidities, sleep quality, psychological impairment, age, and employment. Factors related to tumour characteristics yielded inconsistent findings. Heterogeneity and inconsistencies in HRQOL measurement across studies hindered definitive conclusions about the impact of factors on HRQOL. Conclusions: Our review emphasizes the need for standardized, disease-specific HRQOL assessments in meningioma patients. More consistent, large-scale, prospective research is essential to comprehensively understand and improve HRQOL, and thereby ensure tailored care for this population.

Background: Surgical resection of vestibular schwannoma (VS) is often curative if gross total resection is achieved, however, it is a delicate procedure with high risk to the facial nerve. With retrosigmoid approach for resection, the head is positioned to maximize lateral head rotation and neck flexion in order to optimize the surgical field. However, this may inadvertently occlude cerebral venous drainage, elevating intracranial pressure (ICP) and increasing intraoperative bleeding. Methods: Here, we review relevant literature regarding the effects of head rotation and neck flexion on internal jugular vein (IJV) occlusion and ICP, and highlight the notion that head rotation and flexion may occlude the ipsilateral IJV, increasing ICP. Subsequently, we propose a novel technique using continuous, real-time monitoring of jugular bulb pressure (JBP) to detect obstructions in jugular venous flow and guide optimal head positioning prior to VS resection. Results: As proof of concept, we present a case in which JBP monitoring was employed to optimize head positioning prior to a VS resection, which shows a significant reduction in JBP compared to traditional positioning. Conclusions: This innovative approach offers promise in enhancing the safety and efficacy of intracranial surgery for VS and potentially other neurosurgical procedures.

Background: Patients with an acute ischemic stroke (AIS) are selected to receive reperfusion therapy using either computed tomography (CT-CTA) or magnetic brain imaging (MRI). The aim of this study was to compare CT and MRI as the primary imaging modality for AIS patients undergoing EVT. Methods: Data for AIS patients between January 2018 and January 2021 were extracted from two prospective multicenter EVT cohorts: the ETIS registry in France (MRI) and the OPTIMISE registry in Canada (CT). Demographics, procedural data and outcomes were collected. We assessed the association of qualifying imaging (CT vs. MRI) with time metrics and functional outcome. Results: From January 2018 to January 2021, 4059 patients selected by MRI and 1324 patients selected by CT were included in the study. Demographics were similar between the two groups. The median imaging-to-arterial puncture time was 37 minutes longer in the MRI group. Patients selected by CT had more favorable 90-day functional outcomes (mRS 0-2) as compared to patients selected by MRI (48.5% vs 44.4%; adjusted OR (aOR), 1.54, 95%CI 1.31 to 1.80, p<0.001). Conclusions: Patients with AIS undergoing EVT who were selected with MRI as opposed to CT had longer imaging-to-arterial-puncture delays and worse functional outcomes at 90 days.

Background: This study investigates the utility of low-density scalp electrical source imaging (LD-ESI) of the Ictal Onset Zone (IOZ) and interictal spike ripple high frequency oscillation (ISRHFO) networks using Source Coherence Maps (SCM) in the surgical evaluation of children with medically refractory epilepsy. Invasive intracranial monitoring, the gold standard for determining epileptogenic zones, has limited spatial sampling. SCM presents a promising new non-invasive diagnostic technique. Methods: This was a retrospective review of 11 patients who underwent focal resections. SCMs were generated using Standardized Low Resolution Electromagnetic Tomography (sLORETA). SCM concordance to resection margins was assessed, noting outcomes at 3 years. Results: For 7/11 cases, ictal SCMs included the resection, and 5/7 achieved seizure freedom, indicating inclusion of the epileptogenic zone. For the 2/7 not seizure-free, the IOZ networks on the SCMs extended beyond resection margins, suggesting the epileptogenic zone also extended beyond the resection. Interictal spike ripple ESI and ISRHFO SCM were performed for 7/11, with 3/7 included in the resection and all 3 seizure-free. Conclusions: These findings may support LD-ESI of the IOZ and ISRHFO network using SCM as promising methods complementary to ictal and interictal ESI in pediatric epilepsy surgical workup, guiding electrode placement for intracranial monitoring to identify the epileptogenic zone.

Background: Normal Pressure Hydrocephalus (NPH) is characterized by the clinical triad of dementia, gait disturbance, and urinary incontinence. An initial case series by Hakim and Adams highlighted that all patients exhibited this triad, with only one presenting with fecal incontinence. This study aims to examine the outcomes of individuals experiencing fecal incontinence who have undergone ventriculoperitoneal shunting (VPS). Methods: A systematic review and surgical case series was conducted, involving consecutive adults diagnosed with NPH and treated with VPS between September 2016 and September 2022. Results: In the cohort of 85 patients, the median duration of NPH symptoms was 3.2 years. Gait and balance symptoms were prevalent in all patients, while cognitive, bladder, and bowel symptoms were observed in 85.9%, 91.8%, and 23.5% of cases. No significant differences were noted in age, sex, neurologic diseases presence, or lower gastrointestinal or pelvic pathology. The prevalence of fecal incontinence pre-surgery, within less than 3 months, and 3 months post-surgery were 23.5%, 32.9%, and 17.6%. The systematic review search yielded 515 articles, and 18 included patients with fecal incontinence. Conclusions: The insights gained from the systematic review and cohort offer a comprehensive understanding of the outcomes observed in patients with NPH and fecal incontinence following VPS.

Background: Over the past decade, worldwide stroke incidence has been increasing among young adults (≤65years), which has implications during the most dynamic period of their life. There is a dearth of research exploring young adults stroke patients’ experiences, healthy lifestyle habits, preferences, and recommendations for brain care-related initiatives. The study aimed to gain knowledge and a deeper understanding of young adult stroke patients’ experiences, lifestyle habits, and support needs for brain care-related education and interventions. Methods: A descriptive qualitative study was used. Participants who took part in the quantitative phase of a larger mixed methods study (n=103 that expressed an interest in the qualitative phase, were invited to take part in semi-structured focus groups. Simultaneous data collection and analysis are being conducted. Data are being analyzed using inductive thematic analysis outlined by Braun and Clarke (2006). Results: Findings will be available by May 20, 2024. Conclusions: Study findings will be essential to 1) mobilize an understanding of young adult stroke patients’ lived experience; 2) reconceptualize the current model of stroke care and services that is traditionally geared towards older adults; and 3) inform the development of brain care-related education and interventions to meet the unique needs, priorities, and preferences of young adult stroke patients.

Background: Intraoperative testing for awake craniotomies requires a multidisciplinary team which may not be available in low-resource settings. We explored the creation of an AI tool for automated testing. Methods: We developed a NodeJS application, EloquentAid (https://www.eloquentaid.com/), for language testing automation. The workflow was as follows: users select an image-based naming task and verbally identify the image in English. Then, the application transcribes the response using OpenAI’s Whisper transcription service. Finally, the application evaluates response correctness. Feedback is provided through auditory and color signals. To assess its reliability, we tested the EloquentAid versus a human rater using a 57-item test based on the Boston Naming Test. Participants were neurosurgery and neurology residents from the Philippines. Qualitative surveys were obtained post-test. Results: A total of 798 observations were recorded (N=14). Human-application agreement was 60.52%. Cohen’s kappa was 0.31 (fair agreement). There were no false positive identifications by EloquentAid. Noun-type was felt to affect human error (i.e. “knocker,” “yolk,” “trellis”). Accent and pronunciation were felt to affect EloquentAid errors. Conclusions: EloquentAid is a promising tool to facilitate intraoperative testing and brain mapping using AI for speech recognition and response evaluation. Preliminary data shows fair human-app agreements. Improvements in test items and pronunciation recognition may be made.

Background: Medically refractory pediatric epilepsy is a disorder that can cause significant financial and physical burden. Although multiple treatments exist, cost-effectiveness remains unclear. We conducted a systematic review to assess cost-effectiveness of treatments for medically refractory pediatric epilepsy and to summarize key issues and areas for further inquiry. Methods: We searched MEDLINE and 6 other databases up to July 2022. We included partial and full economic evaluations (EEs) on treatments for medically refractory pediatric epilepsy. Pairs of reviewers independently screened the literature, extracted data, and assessed quality using the 24-item Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist. We extracted data on study characteristics, health outcomes, model design, costs, and treatment characteristics. Results: We identified 37 eligible studies for analysis, 19 of which were partial EEs and 18 were full EEs. Study quality, outcomes reported, treatment comparators, and factors included in cost calculations were common influential factors in study results. Vagus nerve stimulation and cannabinoid oil were the most consistently cost-effective, in 6 of 7 and 1 of 2 studies, respectively. Other treatments were inconsistently cost-effective. Conclusions: The cost-effectiveness of treatments for medically refractory pediatric epilepsy was not definitive. Consistency in study design and inputs is necessary for future comparison of epilepsy treatment.

Background: Canadian Emergency Departments (EDs) are overburdened. Understanding the drivers for postoperative patients to attend the ED allows for targeted interventions thereby reducing demand. We sought to identify “bounce back” patterns for subsequent QI initiatives. Methods: From April 1, 2016 to March 31, 2022, all provincial ED datasets (EDIS, STAR, Meditech) identified patients presenting within 90 days post-spine surgery. Using Canadian Classification of Health Interventions codes, laminectomies (1SC80) and discectomies (1SE87) demonstrated the highest ED visit rates. Comprehensive chart reviews were conducted identifying surgical and medical reasons for presentation within this timeframe. Results: Reviewing a cohort of 2165 post-decompression patients, 42.1% presented to the ED (n=912) with 62.8% of these directly related to surgery. Primary reasons included wound care (31.6%), pain management (31.6%), and bladder issues (retention or UTI, 11.0%). Simple wound evaluation constituted 49.7% of wound-related visits, with surgical site infection 37.6% and dehiscence 6.6% accounting for the remainder. Pain-related presentations resulted in 72.3% discharge with additional medications, and 27.7% necessitating hospital admission. New or worsening neurologic deficits were reported in 8.9% of ED visits. Conclusions: These findings illuminate crucial aspects of postoperative care and ED utilization patterns. Prioritizing patient education, pain management, and wound care could help alleviate the national ED crisis.

Background: Gender disparities endure in neurosurgery, impacting the experiences of female practitioners. Unveiling these challenges is crucial for promoting inclusivity and addressing the unique obstacles faced by women in the field. Methods: An international survey designed using a physician wellness framework was sent to neurosurgeons between June 2021 and November 2021. Univariate analysis (Kruskal-Wallis Test) was performed to assess feelings of inclusion and diversity as a function of gender. Results: Of the total 384 respondents (65% neurosurgeons, 6% fellows, and 29% residents), 71% identified as male, 27% as female, and 2% as other. Compared to their male colleagues, female neurosurgeons more strongly endorsed feeling that their career progression has been limited by their gender (p<0.05) and were less likely to feel entrusted in their surgical ability (p<0.05) or to have equal access to surgical resources (p<0.05). Furthermore, they were less likely to endorse feelings that leaders in their department were committed to creating an inclusive environment (p<0.05). Conclusions: Our survey sheds light on significant gender-related disparities in neurosurgery. Female neurosurgeons express heightened concerns about gender-limiting career progression, reduced trust in their surgical abilities, and disparities in resource access. These findings underscore the imperative to foster a more inclusive and supportive environment within the field.

Background: Cerebrospinal fluid (CSF) leak is a common complication of minimally invasive tubular microdiscectomy (MIM). However, it is not known whether patients with CSF leak can be safely discharged home the same day. Methods: This is a retrospective cohort study of patients with incidental durotomy after MIM from January, 2009 to August, 2023. Patient demographic information, surgery information, CSF leak management, and postoperative outcomes were recorded. Results: There were 16 patients (53%) who were admitted to hospital and 14 (47%) patients discharged home the same day post CSF leak. There were no differences in patient demographics between the two groups at baseline. Twenty-nine out of 30 (97%) of the patients had onlay duraplasty, and one (3%) patient was repaired using sutures. The hospitalized group was kept on bed rest overnight or 24 hours. The discharge group was kept on best rest for 2 hours or mobilized immediately after surgery. The average length of admission for the hospitalized group was 2.4 ± 4.0 days. No patients in either group required readmission or revision surgery for CSF leak. Conclusions: Patients with CSF leak post minimally invasive tubular microdiscectomy can be safely discharged home the same day provided that duraplasty or primary repair was performed intraoperatively.

Background: The Endoscopic Transphenoidal Approach to the Skull Base (ETSS) is now used internationally for a wide variety of pathologies ranging from CSF leaks to complex brain tumours. Methods: Case illustrations. Historical review of the evolution of ETSS with a focus on Canada’s contributions. Results: Canadians have been major contributors in the development and advancement of surgery of the skull base, particularly through endoscopic means. These will be highlighted with particular emphasis of those of Hardy, Cusimano, Kassam, Gentili, and others. Conclusions: Canada has been and continues to be an international leader in development and treatment of patients with skull base lesions, particularly those with lesions of the skull base amenable to ETSS.

The paper looks at the question of measuring the importance of shocks to cycles. We consider two types of cycles - oscillations and those summarized by the NBER that require a study of growth in activity to establish turning points in the level of activity. The latter demarcate expansions and contractions. We establish a connection between these two concepts of cycles that shows shocks may have very different effects on each. As an application we look at a question that has often been asked over how important technology shocks are to cycles in activity? Some recent research concludes that total factor productivity (TFP) shocks are not important for oscillations and therefore models should be designed to reflect that. Using the same data we show that TFP shocks are very important to both types of cycles.

Background: Cognitive flow has been linked with enhanced performance, career satisfaction, and decreased burnout. However, while elite sport has long trained athletes to enter flow states, the concept has not been adopted strongly in healthcare. Flow has primarily been explored from a unidimensional (cognitive) perspective. The present study sought to understand the experience of flow among surgeons through a multidimensional lens. Methods: Using a constructivist grounded theory methodology, semi-structured interviews were conducted with 19 staff surgeons at the University of Toronto, purposively sampled. Data were coded and analyzed iteratively by three researchers until theoretical saturation was achieved. Results: Although many surgeons had not previously heard of cognitive flow, the phenomenon deeply resonated with most. Participants described different physical, cognitive, emotional, sociocultural, and environmental components that interacted to shape the subjective experience of flow: “I think that there are many different facets of [flow] that don’t always come together all at the same time, you may feel different parts of it… depending on what the kind of case is, who your help is, if you recently had a complication.” (P4) Conclusions: Understanding flow in clinical practice may lead to new avenues for enhancing career satisfaction and promoting physician wellness.

Background: Intravenous Immunoglobulin (IVIg) use for Central Nervous System (CNS) conditions has increased over the last decade. In many CNS disorders, robust evidence for IVIg efficacy is still lacking. Building on the success of the British Columbia (BC) Neuromuscular IVIg utilization initiative, Guidelines for IVIg use in CNS conditions were developed. A provincial screening program was launched in 2023. Methods: For CNS IVIg, requests, diagnosis, dosing, consultation letters and treatment questionnaires were reviewed. Patient management was compared to provincial guidelines. A letter was sent to the ordering physician with the results of the review and treatment recommendations when management differed significantly from guidelines. Review of the first year’s cases was conducted. Results: Over the first 11 months of the program, 79 IVIg renewal requests were reviewed. The most common diagnoses were antibody mediated autoimmune encephalitis, severe drug resistant non-surgical epilepsy and Susac’s syndrome. Recommendations included dose reduction, discontinuation of IVIg, or initiation of alternative therapies for many of the requests. Conclusions: IVIg may be effective in the management of some CNS inflammatory conditions. A physician-led utilization program in BC with targeted education to ordering physicians promotes best practice. Review of year one data will inform a quality improvement cycle to optimize the guidelines.

Background: Near-infrared spectroscopy regional cerebral oxygen saturation (rSO2) has gained interest as a raw parameter and as a basis for measuring cerebrovascular reactivity (CVR). This study aimed to identify threshold values of rSO2 and rSO2 based CVR at which outcomes worsened following traumatic brain injury (TBI). Methods: A retrospective multi-institutional cohort study was performed. The cerebral oxygen indices, COx (using rSO2 and cerebral perfusion pressure) as well as COx_a (using rSO2 and arterial blood pressure) were calculated for each patient. 2x2 tables were created grouping patients by alive/dead and favorable/unfavorable outcomes at various thresholds of COx and COx_a as well as rSO2 itself. Chi-square values were calculated to identify the most discriminative significant threshold. Results: In the cohort of 129 patients rSO2 did not have any statistically significant threshold value. For COx and COx_a, an optimal threshold value of 0.2 was identified for both survival and favorable outcomes with values above this associated with worse outcomes. Conclusions: In this study, raw rSO2was found to contain no significant prognostic information. However, rSO2 based indices of CVR, were found to have a uniform threshold of 0.2, above which clinical outcomes worsened. This study lays the groundwork to transition to less invasive means of continuously measuring CVR.

Background: Sedation in PICU masks physical exam findings, leading to diagnostic challenges. In adult models, electroencephalography can evaluate the brain’s response to sedation using feedforward connectivity and anteriorization of alpha hubs, proving useful for prognostication. Feasibility of model translation into pediatric population was assessed, with the hypothesis that the same markers of adaptive reconfiguration would correlate with a higher potential for recovering consciousness. Methods: Electroencephalograms from children undergoing sedation were analyzed for strength and direction of functional connectivity using the weighted and directed phase lag index. Target population was refined with an iterative inclusion criteria. We examined relationships between hub location reconfiguration, directed phase lag index, baseline Glasgow Coma Scale, and 3-month post-treatment Glasgow Outcome Scale-Extended. Results: Evaluation of 14 subjects showed promise in children aged 5-18 undergoing sedation with midazolam, dexmedetomidine, and propofol. Further analysis of five subjects revealed a correlation between adaptive reconfiguration during anesthesia and both higher baseline Glasgow Coma Scale and Glasgow Outcome Scale-Extended scores post-treatment. Conclusions: The findings indicate that the functional brain network connectivity model may have diagnostic and prognostic potential regarding children’s consciousness levels. While the initial data is promising, further analysis of six additional cases is pending and deemed essential to thoroughly evaluate the model’s efficacy.

This article maps the shared legal anatomy of climate and environmental lawsuits, in which plaintiffs claim protection for future generations before domestic or international courts. By closely analyzing the litigation strategies of plaintiffs and the inquiry of courts, the article argues that these proceedings revolve around structurally similar legal standards across domestic and international jurisdictions, which correspond to five normative requirements flowing from the rule of law: namely, respect for human rights, certain quality of law requirements, prohibition of arbitrary exercise of governmental powers, non-discrimination, and access to justice. The cross-jurisdictional analysis shows that courts appear to be increasingly willing to protect future generations against arbitrary treatment by present-day decision makers. The article appraises whether such an intergenerationally sensitive reinterpretation of the rule of law could help to change the short-termist paradigm of environmental and climate law.