Background: Ischemic stroke is a major cause of morbidity and mortality in Canada. Since 2015, mechanical thrombectomy has been the standard of care for eligible large vessel occlusions (LVOs), though anesthetic strategies remain variable. Methods: We conducted a single-center retrospective review of patients undergoing mechanical thrombectomy for anterior circulation LVOs between 2021 and 2023. Patients were categorized by anesthetic strategy (general anesthesia vs. conscious sedation), and outcomes, including time to recanalization, angiographic results (mTICI), and 90-day functional status (mRS), were compared. Statistical analyses included Student’s t-test, Mann-Whitney U-test, and Fisher’s exact test. Results: Among 226 patients, 177 (78%) received general anesthesia and 49 (22%) underwent conscious sedation. Baseline characteristics including sex, age, NIHSS, ASPECTS, collaterals, and laterality were similar between groups. Conscious sedation was associated with a statistically significant shorter time from arrival to the angiography suite to groin puncture (p=0.007), but no differences in time to recanalization (p=0.893), angiographic outcomes (p=0.987), or 90-day functional status (p=0.795) were observed. Conclusions: Conscious sedation led to faster procedural initiation, though no difference in clinical or radiographic outcome was observed. Anesthetic choice should be individualized based on patient and physician factors in acute mechanical thrombectomy.

Background: This retrospective cohort study investigates radiographic factors linked to the success of Endoscopic Third Ventriculostomy (ETV) for hydrocephalus. Methods: We examined 48 patients who underwent ETV between August 2011 and March 2023. Radiographic factors analyzed included the basal skull angle, modified basal skull angle, interpeduncular cistern diameter, prepontine diameter, and approach angle to the third ventricle floor. Statistical analysis was performed using R studio. Results: The cohort had a median age of 41 years, with 22 females. Pathologies included aqueductal stenosis (21 cases), tectal tumors (7), and IVH (5). The mean ETV Success Score (ETVSS) was 76.7. Of the 21 failures, 16 required a shunt. A strong correlation was found between ETVSS and procedure success (p<0.001). Modified basal skull angle (p=0.028), interpeduncular cistern diameter (p<0.001), and approach angle (p<0.001) were all associated with ETV success. Decision tree analysis showed that the inclusion of approach angle to ETVSS improved sensitivity and specificity, reaching 1.0 for both. Conclusions: In conclusion, the study highlights that radiographic factors, particularly the modified basal skull angle, interpeduncular cistern diameter, and approach angle, are key predictors of ETV success. This information can assist neurosurgeons in planning cases more effectively.

Background: Infundibular lesions are rare entities with variable clinical manifestations. Their detection during workup for endocrinologic abnormalities represents a decision-making challenge. We present a patient with ACTH-dependent hypercortisolemia found to have a stalk lesion, which was treated surgically. Methods: Information was gathered from electronic medical records. Results: A 57F underwent workup for Cushing’s syndrome, demonstrating evidence of ACTH-dependent hypercortisolemia. Imaging demonstrated a 4.7mm infundibular nodule. We elected to proceed with endoscopic endonasal approach for resection of the infundibular lesion with goal of biochemical cure. A satisfactory technical and radiographic resection of the infundibular lesion was achieved. However, the patient’s hypercortisolemia failed to resolve. Histopathologic analysis identified the lesion as a granulocytoma. Inferior petrosal sinus sampling further demonstrated evidence of ACTH-dependent central hypercortisolemia. She then underwent bilateral adrenalectomy for management of her persistent hypercortisolemia. Conclusions: This demonstrates a complex clinical picture in which our patient presented with biochemical results suggesting central ACTH-dependent hypercortisolemia with no identifiable glandular lesion. The presence of an infundibular lesion led to surgical intervention which unfortunately did not result in biochemical cure despite adequate technical results. The authors believe this case illustrates a challenging clinical conundrum which emphasizes the uncertainty that should be associated with management of stalk lesions.

Background: Low back pain (LBP) is a common cause of disability and decreased quality of life. The Saskatchewan Spine Pathway classification (SSPc) is a method for triaging patients who are candidates for surgery. Methods: Consecutive patients who underwent lumbosacral instrumented fusion for degenerative spinal pathology from Jan 1, 2012, to Sept 20, 2018, by a single surgeon at our institution were retrospectively reviewed. Patients were stratified by SSPc into 4 groups based on pain pattern. Demographic and clinical data were collected. Outcomes were compared between cohorts both for absolute values and achieving MCID. Results: 169 consecutive patients were included in our study. After stratifying by SSPc grouping, there were 61 SSPc I patients, 45 SSPc III patients, and 63 SSPc IV patients. Patients in all groups had clinical improvement following surgery. Patients classified as SSPc III had superior outcomes in ODI, EQ-5D and EQ-VAS, and were more likely to achieve the MCID for ED-5D. Multivariate analysis demonstrated that SSPc grouping is an independent predictor of final VAS back, ODI, EQ-5D, and EQ-VAS as well as achieving the MCID for EQ-5D. Conclusions: The SSPc classification is associated with outcomes following lumbosacral fusion. In particular, patients with SSPc pattern 3 had better outcomes and improved QALY.

Background: Elevated BMI has been proposed as a risk factor for the development of meningioma. The relationship between body mass index (BMI) and disease control in high-grade meningioma has not yet been examined. A retrospective cohort study was performed to assess the relationship between high-grade meningioma recurrence and BMI. Methods: This is a retrospective cohort study of patients with Grade 2 or Grade 3 meningioma at a single tertiary care center between 2008 and 2017. We collected clinical data including age, sex, BMI, location, Simpson grade, brain invasion, and radiation treatments. Disease control was monitored on followup MRI scans. We stratified patients by BMI greater than or less than 25. Results: A total of 45 patients were included. Recurrence was observed in 15 patients (33.3%). There were 32 (71.1%) patients with BMI > 25, and 13 (28.9%) patients with normal BMI. Patients with elevated BMI had higher risk of recurrence (p=0.04). Multivariate analysis identified BMI as an independent predictor of recurrence. Conclusions: Our results suggest that overweight patients with a Grade 2 or Grade 3 meningioma are at higher risk of recurrence than patients with normal BMI. The explanation for this association unknown. Further research is suggested to confirm and better characterize this association.

Background: Chronic subdural hematoma (CSDH) is a common neurosurgical condition which can be treated with surgical evacuation. A significant percentage of CSDH patients are on antiplatelet or anticoagulation therapy at baseline which may influence risk of recurrence and postoperative thromboembolic events Methods: A search was conducted in MEDLINE (1946 to April 6, 2023), Embase (1974 to April 6, 2023), and PubMed (up to April 6, 2023) on preoperative use of antiplatelet or anticoagulation therapy and outcomes following surgical evacuation of CSDH. Results: Our literature includes 14,410 patients ifrom 42 studies, with 3218 (22%) in the antiplatelet (AP) group, 1731(12%) in the anticoagulation (AC) group, and 9537 (66%) in the no antithrombotics (NA) group. The AP group had significantly higher recurrence compared to NA (OR = 1.21, 95% CI = 1.04 to 1.40, p = 0.01). The AC group also had significantly high recurrence compared to NA (OR = 1.39. 95% CI = 1.15 to 1.68, p = 0.0007). However, being on any antithrombotic therapy is also associated with significantly higher thromboembolic events (OR 5.41, 95% CI 3.16 to 9.26, p < 0.00001). Conclusions: Patients on antithrombotic therapy have both higher recurrence and higher thromboembolic risk compared to patients not on antithrombotic therapy.

Background: The fragility index (FI) is the minimum number of patients whose status would have to change from a nonevent to an event to turn a statistically significant result to a non-significant result. We used this to measure the robustness of trials comparing carotid endarterectomy (CEA) to carotid artery stenting (CAS). Methods: A search was conducted in MEDLINE, Embase, and PubMed on RCTs comparing CEA to CAS. The trials need to have statistically significant results and dichotomous primary endpoints to be included. Results: Our literature search identified 10 RCTs which included 9382 patients (4734 CEA, 4648 CAS). The primary end points of all included trials favoured CEA over CAS. The median FI was 9.5 (interquartile range 2.25 - 21.25). All of the studies that reported lost-to-follow-up (LTFU) had LTFU greater than its fragility index, which raises concern that the missing data could change the results of the trial from statistically significant to statistically insignificant. Conclusions: A small number of events (FI, median 9.5) were required to render the results of carotid artery stenosis RCTs comparing CEA to CAS statistically insignificant. All of the studies that reported LTFU had LTFU greater than its fragility index.

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: Tethered cord syndrome, a condition in which the spinal cord stretches as a child grows, can cause various clinical symptoms. Occult TCS (OTCS) is a condition where a child displays some or many clinical symptoms of TCS, but no radiographic abnormality confirms the presence of a tethered cord (1-4). Diagnosis of OTCS in children is invasive and multi-factorial. The current diagnostic approach involves three main factors- clinical signs and symptoms, radiographic evidence, and motor evoked potentials (MEPs) tested under general anesthesia. Transcranial magnetic stimulation (TMS) is a non-invasive testing method for OTCS. It can replace MEPs, which are conducted under general anesthesia. Methods: We will conduct a case-control series of children at our center who have undergone TMS. We will characterize the children who have TCS and suspected OTCS and detail the children’s current diagnosis methods and outcomes in a technical note. We will then compare their pre-operative and post-operative data. Results: So far, we have conducted TMS on 10 children to help diagnose occult TCS. Conclusions: This approach is a novel and effective way to improve the accuracy of diagnosis in children, potentially preventing unnecessary surgery, or detecting patients who would otherwise suffer from the condition.

We established a surveillance program to evaluate persistence of C. auris colonization among hospitalized patients. Overall, 17 patients (34%) had ≥1 negative result followed by a positive test, and 7 (41%) of these patients had ≥2 consecutive negative tests.

In response to a crisis, policymakers face the decision of whether to enumerate specific actions the public must do or, instead, to aim at an overall outcome while leaving room open for choice. This essay evaluates the merits and demerits of crisis response that leaves room open for choice, with a particular focus on pandemic response. I evaluate two approaches: trades and offsets. Trades allow individuals or groups to exchange protection against harm or entitlement to engage in risky activity. Offsets allow the same actors to pay to mitigate the effects of decisions that increase risk for others. Choice-friendly approaches can free people to better align their actions with their values, harness local knowledge for better social outcomes, and act as natural experiments. However, they also are subject to objections, including negative externalities, agency problems, exploitation, and exacerbating inequality.

Background: Toxoplasma gondii is a protozoan parasite with the ability to infect any nucleated cell in humans. Most immunocompetent infected individuals are asymptomatic. Latent toxoplasma can become reactivated in immunocompromised individuals though this is exceptionally rare in HIV-negative individuals. Methods: We present the case of a 47-year-old male with chronic immunosuppression secondary to marginal zone lymphoma and steroid therapy. Results: The patient presented to hospital with a 1-week history of word-finding difficulties, intermittent right facial numbness and leg weakness, and tonic-clonic seizures. CT head showed a left temporal heterogenous mass measuring 2.8 × 2.8 × 3.5 cm. Biopsy of the lesion showed Multiple tachyzoites and rare bradyzoites with strong positivity for the toxoplasma specific immunostain. The patient was treated with trimethoprim/sulfamethoxazole which resulted in complete neurologic recovery. Conclusions: Our literature review included 32 cases of cerebral toxoplasmosis in HIV-negative patients with an overall mortality rate of 48%. Cerebral toxoplasmosis has a predilection for immunosuppressed patients with an underlying hematologic malignancy (74%, n= 23). Successful treatment requires early recognition of the disease and prompt treatment with sulfamethoxazole and trimethoprim, pyrimethamine, or sulfadiazine. Patients who recover from acute toxoplasmosis should remain on lifelong suppressive antibiotic therapy to prevent relapse.

Background: Neuromodulation unit placement can provide efficacious control of many neurological conditions. They are high risk for infection with a historic infection rate as high as 10%. Treatment of infection requires surgical removal and a long course of systemic antibiotics. <font size=”1”> </font>At our center, one surgeon uses antibacterial envelopes with all implanted neuromodulation devices. Methods: We conducted a retrospective cohort study of consecutive implantable pulse generator (IPG) and intrathecal pump unit implantation with an antibacterial envelope at our center. This cohort was then compared to a historical cohort of consecutive patients undergoing IPG or pump placement or revision prior to the use of the envelopes. Results: IPG: There were 18 (11.9%) class I infections in the pre-envelope cohort compared with 5 (2.1%) in the post-envelope cohort. The absolute risk reduction (ARR) with the use of antibacterial envelopes was 9.85% (95% confidence interval (CI) 4.3-15.4%, p<0.01).

Pump: There were 6 (14.6%) class I infections in the pre-envelope cohort compared with 1 (1.7%) in the post-envelope cohort. The ARR with the use of antibacterial envelopes was 12.9% (95% confidence interval 1.6-24.3, p<0.05). Conclusions: Based on our results, we recommend usage of antibacterial envelopes to reduce infection rates in neuromodulation surgery. Further study is needed.