An effective strategy for salvage therapy in refractory or relapsed childhood brain tumours is yet to be established. A national retrospective review of 135 children diagnosed with treatment refractory or recurrent MB from 2000 to 2021 at 5 academic Canadian pediatric neurosurgical centers was performed. The mean age at diagnosis was 7.09 years (SD 4.37) with a male predominance (64.4

We sought to assess the prognostic value of incorporating daily inpatient physiological biomarker trajectories to the International Mission for Prognosis and Analysis of Clinical Trials in TBI (IMPACT) model for mortality and morbidity six months after severe traumatic brain injury (TBI). Patients with severe TBI (presenting Glasgow Coma Scale ≤ 8) were prospectively collected in a single-center database (n = 598). Morbidity (yes/no) was defined as Glasgow Outcome Scale Extended of 1–4. Daily blood labs (e.g., glucose, sodium, platelets, hemoglobin, neutrophils, lymphocytes, creatinine, blood urea nitrogen) were extracted for the first 14 days after injury. IMPACT was compared with IMPACT-extended (IMPACT + daily lab trajectories) for area under the curve (AUC). Net reclassification index (NRI) assessed the number of correctly reclassified cases for IMPACT-extended compared with IMPACT. IMPACT-extended had a better AUC than IMPACT for mortality (AUC 0.93 vs. 0.84, P < 0.001) and morbidity (AUC 0.84 vs. 0.80, P < 0.001). NRI analyses revealed IMPACT-extended improved correct classifications of patients who survived to 6 months by 41

Fundamentals of acute care for patients with traumatic spinal cord injury include initial evaluation, cervical collar clearance, diagnostic imaging, spinal injury classification systems, closed reduction of fracture-dislocation injuries, corticosteroid therapy, hemodynamic management, timing of decompressive surgery, spinal cord perfusion pressure monitoring, lumbar intrathecal cerebrospinal fluid drainage, and venous thromboembolism prophylaxis. In this review, modern management paradigms are highlighted in the context of published clinical practice guidelines from the American Association of Neurologic Surgeons/Congress of Neurologic Surgeons, AO Spine-Praxis, the American College of Surgeons Trauma Quality Programs, and the National Association of Emergency Medical Services Physicians.

BACKGROUND AND OBJECTIVES:Stereotactic intracavitary irradiation of cystic sellar masses (CSMs) with 90-Yttrium colloid ( 90 Y) may mitigate significant morbidity and/or recurrence rates associated with traditional microsurgical resection. In this study, we aimed to prospectively assess the long-term effect of 90 Y on tumor-cyst volume, endocrine, and vision outcomes after treatment of CSMs. METHODS:We conducted a Health Canada-approved, phase II, open label, prospective clinical trial. The primary indication for treatment was clinical evidence of mass effect on initial presentation or subsequent cyst enlargement. Patients underwent right frontal stereotactic insertion of 90 Y (200 Gy to the cyst wall). Cyst volumes were measured using serial MRI. Visual field (VF) assessment and hypothalamic-pituitary hormone panel were obtained. Outcomes were collected postoperatively at 3, 9, and 24 months, then annually up to 5 years. RESULTS:Twenty-two patients (55% women, mean age = 63.6 years [SD 15.4]) received 90 Y. The mean follow-up was 52 months (5-113). Primary diagnoses were the following: craniopharyngioma (86%), Rathke cleft cyst (9%), and cystic prolactinoma (5%). Preoperative clinical features included VF deficit (41%), VF deficit plus headache (36%), or headache alone (13%). For the aggregate cohort, statistically significant reduction in mean tumor-cyst volume for the cohort was observed at all follow-up visits beyond 3 months (all P < .01). At 5-year follow-up, cyst volume reduction was sustained in 82% of cases. The mean percent reduction in tumor-cyst volume was 77.2% (SD 16.8). Ninety-one percent of patients had stable or improved vision postoperatively. The overall proportion of patients with endocrine dysfunction preoperatively (59%) and postoperatively (68%) remained stable ( P > .05). Treatment failure requiring conventional surgery occurred in 3 patients who received 90 Y for cyst recurrence. CONCLUSION:Stereotactic treatment of CSMs with intracavitary 90 Y is associated with sustained reduction in tumor-cyst volume, improved visual function, and stable endocrine function at 5-year follow-up.

BACKGROUND CONTEXT Significant variability in the management of Adult Spinal Deformity (ASD) has been observed among spine surgeons worldwide. The variability among Canadian spine surgeons, a country with universal public healthcare, remains unknown. PURPOSE The study aims to evaluate areas of variability in the perioperative optimization and surgical management of ASD among Canadian spine surgeons. STUDY DESIGN/SETTING In this cross-sectional study, 25 Canadian spine surgeons, predominantly orthopedic surgeons (20) and neurosurgeons (5) with varying experience, participated in an online survey focused on Adult Spinal Deformity (ASD). SAMPLE The study involved 25 Canadian spine surgeons with varying level of experience, representing both orthopedic and neurosurgical specialities. OUTCOME Measure The study aimed to evaluate the variability in surgical decision-making and perioperative optimization strategies among Canadian spine surgeons when faced with simulated scenarios of ASD pathologies. METHODS The online survey presented 4 vignettes with simulated scenarios of the most common ASD pathologies, including High Grade Spondylolisthesis (HGS), Neglected Adolescent Idiopathic Scoliosis (NAIS), Degenerative Scoliosis (DS), and Flat Back Syndrome (FBS). Questions in the vignettes explored ASD surgical decision-making, while additional questions focused on perioperative optimization. Descriptive statistics were used to analyze multiple-choice responses, and open-text responses were categorized into themes. RESULTS Variability was observed in the duration conservative treatment across the 4 ASD cases. Surgeons exhibited variability in the use of preoperative osteoporosis treatment. There was varied use of a dedicated anesthesiology team. Surgical goals varied in HGS and NAIS. The primary surgical method was variable in DS and HGS, the type of osteotomy varied in DS and FBS, and level of fixation varied in HGS and NAIS. Consensus was observed in the use of intraoperative monitoring across of all 4 ASD pathologies, the implementation of a team-based approach, and the selection of the primary surgical goal in DS and FBS. CONCLUSION Our cross-sectional study revealed variability among Canadian spine surgeons in the management of ASD, potentially influenced by the uncertain ASD progression, the need for evidence-based nonsurgical guidelines, and insufficient evidence on optimal surgical approaches. These findings will help guide future research to ultimately reduce variability and improve ASD patient management and outcomes.

BACKGROUND:Patients undergoing craniotomy experience a higher risk of seizures in the ensuing months. Consensus is lacking regarding the appropriate timeframe for safe return to driving following craniotomy in patients not otherwise limited by neurological deficits or a history of epilepsy. METHODS:We performed a systematic literature review on driving recommendations post-craniotomy. We then performed a scoping review on the risk of seizure post-craniotomy and used risk calculations and accepted risk thresholds from the epilepsy literature to develop an evidence-based approach to driving recommendations post-craniotomy. RESULTS:The systematic review of driving recommendations revealed national guidelines (the United Kingdom, New Zealand, Australia). We transposed risk calculations and accepted risk thresholds from the epilepsy literature (accident risk ratio [ARR] < 2; chance of occurrence of a seizure in the next year < 20%) to patients who undergo a craniotomy. Using data from a large meta-analysis of seizure risk post-craniotomy, we calculated ARRs for various underlying pathologies at different postoperative timepoints and compared them with accepted risk thresholds from the epilepsy literature. We determine that patients who undergo a craniotomy for a higher-risk condition (like high-grade glioma) may resume driving after at least 1 month without seizure, whereas those patients undergoing a craniotomy for lower-risk conditions (like infratentorial pathology) may resume driving without consideration for the risk of seizure. CONCLUSION:This systematic review of the literature and evidence-based approach to risk threshold calculations derived from the epilepsy literature provides a preliminary framework to guide clinicians regarding recommendations for return to driving following craniotomy.

Study Design Systematic review and clinimetric analysis. Objectives Frailty and sarcopenia predict worse surgical outcomes among spinal degenerative and deformity-related populations; this association is less clear in the context of spinal oncology. Here, we sought to identify frailty and sarcopenia tools applied in spinal oncology and appraise their clinimetric properties. Methods A systematic review was conducted from January 1st, 2000, until June 2022. Study characteristics, frailty tools, and measures of sarcopenia were recorded. Component domains, individual items, cut-off values, and measurement techniques were collected. Clinimetric assessment was performed according to Consensus-based Standards for Health Measurement Instruments. Results Twenty-two studies were included (42 514 patients). Seventeen studies utilized 6 frailty tools; the three most employed were the Metastatic Spine tumor Frailty Index (MSTFI), Modified Frailty Index-11 (mFI-11), and the mFI-5. Eight studies utilized measures of sarcopenia; the three most common were the L3-Total Psoas Area (TPA)/Vertebral Body Area (VBA), L3-TPA/Height2, and L3-Spinal Muscle Index (L3-Cross-Sectional Muscle Area/Height2). Frailty and sarcopenia measures lacked or had uncertain content and construct validity. Frailty measures were objective except the Johns-Hopkins Adjusted Clinical Groups. All tools were feasible except the Hospital Frailty Risk Score (HFRS). Positive predictive validity was observed for the HFRS and in select studies employing the mFI-5, MSTFI, and L3-TPA/VBA. All frailty tools had floor or ceiling effects. Conclusions Existing tools for evaluating frailty and sarcopenia among patients undergoing surgery for spinal tumors have poor clinimetric properties. Here, we provide a pragmatic approach to utilizing existing frailty and sarcopenia tools, until more clinimetrically robust instruments are developed.

The objective of this study was to evaluate whether paroxysmal slow wave events (PSWEs) identified in early electroencephalography (EEG) predict posttraumatic epilepsy (PTE) and disability outcomes following severe traumatic brain injury (sTBI). A retrospective case–control study included 45 patients with sTBI (17 with PTE and 28 without PTE) matched by age and Glasgow coma scale. Clinical and EEG data were analyzed. Logistic regression and leave-one-out cross-validation (LOOCV) assessed PTE risk and disability. The area under the curve (AUC) measured accuracy. Patients with PTE had longer time in PSWEs (P = 0.04) and lower median power frequency (MPF) of PSWEs (P = 0.02) on initial EEGs, along with increased time in PSWEs between initial and follow-up EEGs (P = 0.03). Lower MPF was associated with increased PTE risk (odds ratio 5.88; P = 0.04). Multivariate regression identified hemicraniectomy, time in PSWEs, and MPF as PTE predictors (AUC 0.87; P < 0.0001), maintaining strong LOOCV performance (AUC 0.83; P < 0.0001, accuracy 80

INTRODUCTION:Traumatic brain injury (TBI) is a leading cause of long-term disability. N-methyl-D-aspartate receptor (NMDAR) signaling constitutes an important target for pharmacological treatment options. METHODS:The authors have systematically reviewed primary clinical literature reporting on FDA-approved NMDAR antagonist treatment in TBI, based on a set of pre-defined eligibility criteria. Risk of bias assessment was performed using Scottish Intercollegiate Guidelines Network (SIGN) recommendations. Patient characteristics, treatment conditions, and outcomes were reported according to PRISMA guidelines. RESULTS:This review of five clinical literature databases identified 32 eligible studies. Of 1,827 included patients, the majority (74.8%) experienced severe TBI (weighted mean baseline GCS 6.35). Amantadine (24 studies) variably influenced functional recovery and was linked to adverse effects. Ketamine (five studies) variably lowered intracranial pressure and suppressed spreading depolarization. Memantine and dextromethorphan (2 and 1 studies, respectively) showed favorable safety profiles, though data were limited. Across controlled studies, there was a 0.46 (95% CI: 0.16-0.76) weighted mean difference between control and intervention, favoring NMDAR antagonist treatment. CONCLUSIONS:Future trials should incorporate mechanism-driven biomarkers and must expand research on safe, well-tolerated drugs to improve efficacy and mitigate adverse effects.PROSPERO registration number: CRD42024539051.

BACKGROUND:Cerebrospinal fluid diversion via ventriculoperitoneal (VP) shunting is the mainstay treatment for hydrocephalus. Traditionally, neurosurgeons place the abdominal catheter through abdominal incision, which has become an efficient and standardized technique. This approach carries a 10-30% complication rate, including infection, catheter obstruction, misplacement, hemorrhage and post-operative pain. Laparoscopic assistance (LA) is an emerging alternative to mini-laparotomy, with potential benefits including reduced distal catheter malplacement and shorter operative times. Most investigations on LA are limited to single centers, with no data from Canada. This study aims to identify practice patterns in VP shunting within a Canadian context. METHODS:Practicing Canadian neurosurgeons were surveyed using a modified Delphi methodology. The survey was distributed to practicing neurosurgeons via the Canadian Neurosurgical Society and the Canadian Neurosurgery Research Collaborative. RESULTS:Across two rounds, 36 neurosurgeons participated, representing all provinces with academic neurosurgical centers. Consensus was reached on five out of eight topics. Findings revealed that 65.5% of respondents had experience with LA, and 93% believed it reduced distal catheter malposition. Infection (77.8%), distal catheter obstruction (82.9%) and proximal obstruction (69.4%) were identified as the most common complications, each occurring in up to 10% of cases. In total, 71% anticipated eventual reduced operative times with increased LA experience. CONCLUSION:Canadian neurosurgeons did not identify major barriers to LA beyond personal preference. LA is expected to improve distal catheter placement, though its broader benefits remain uncertain. Patient comorbidities were considered a greater risk factor for complications than surgical technique alone.

Large language models (LLM) have been promising recently in the medical field, with numerous applications in clinical neuroscience. OpenAI’s launch of Generative Pre-trained Transformer 3.5 (GPT-3.5) in November 2022 and its successor, Generative Pre-trained Transformer 4 (GPT 4) in March 2023 have garnered widespread attention and debate surrounding natural language processing (NLP) and LLM advancements. Transformer models are trained on natural language datasets to predict and generate sequences of characters. Using internal weights from training, they produce tokens that align with their understanding of the initial input. This paper delves into ChatGPT’s potential as a learning tool in neurosurgery while contextualizing its abilities for passing medical licensing exams and neurosurgery written boards. Additionally, possibilities for creating personalized case presentations and study material are discussed alongside ChatGPT’s capacity to optimize the research workflow and perform a concise literature review. However, such tools need to be used with caution, given the possibility of artificial intelligence hallucinations and other concerns such as user overreliance, and complacency. Overall, this opinion paper raises key points surrounding ChatGPT’s role in neurosurgical education.

Introduction: Operative cancellations adversely affect patient health and impose resource strain on the healthcare system. Here, our objective was to describe neurosurgical cancellations at five Canadian academic institutions.Methods: The Canadian Neurosurgery Research Collaborative performed a retrospective cohort study capturing neurosurgical procedure cancellation data at five Canadian academic centres, during the period between January 1, 2014 and December 31, 2018. Demographics, procedure type, reason for cancellation, admission status and case acuity were collected. Cancellation rates were compared on the basis of demographic data, procedural data and between centres.Results: Overall, 7,734 cancellations were captured across five sites. Mean age of the aggregate cohort was 57.1 +/- 17.2 years. The overall procedure cancellation rate was 18.2%. The five-year neurosurgical operative cancellation rate differed between Centre 1 and 2 (Centre 1: 25.9%; Centre 2: 13.0%, p = 0.008). Female patients less frequently experienced procedural cancellation. Elective, outpatient and spine procedures were more often cancelled. Reasons for cancellation included surgeon-related factors (28.2%), cancellation for a higher acuity case (23.9%), patient condition (17.2%), other factors (17.0%), resource availability (7.0%), operating room running late (6.4%) and anaesthesia-related (0.3%). When clustered, the reason for cancellation was patient-related in 17.2%, staffing-related in 28.5% and operational or resource-related in 54.3% of cases.Conclusions: Neurosurgical operative cancellations were common and most often related to operational or resource-related factors. Elective, outpatient and spine procedures were more often cancelled. These findings highlight areas for optimizing efficiency and targeted quality improvement initiatives. Annulations d'interventions neurochirurgicales au Canada : une é tude de cohorte ré trospective multicentrique.Introduction : Les annulations d'interventions chirurgicales ont des consé quences né gatives sur la santé des patients et pè sent sur les ressources des systè mes de santé. Notre objectif est ici de dé crire les annulations d'interventions neurochirurgicales dans cinq é tablissements universitaires canadiens.Mé thodes : Le Canadian Neurosurgery Research Collaborative a effectué une é tude de cohorte ré trospective aprè s avoir ré cupé ré des donné es portant sur l'annulation d'interventions neurochirurgicales dans cinq é tablissements universitaires canadiens, et ce, au cours de la pé riode allant du 1er janvier 2014 au 31 dé cembre 2018. Des donné es dé mographiques et d'autres donné es portant sur le type de d'intervention envisagé e, la raison de l'annulation, l'é tat de santé des patients au moment de l'admission et l'acuité des cas ont é té recueillies. Quant aux taux d'annulation, ils ont é té comparé s entre eux sur la base de donné es dé mographiques, de donné es lié es aux interventions et de donné es concernant les é tablissements.Ré sultats : Au total, 7 734 annulations ont é té enregistré es dans cinq é tablissements. L'â ge moyen des patients de notre cohorte gé né rale é tait de 57,1 +/- 17,2 ans. Le taux gé né ral d'annulation des interventions é tait de 18,2 %. Le taux d'annulation des interventions neurochirurgicales au cours d'une pé riode de cinq ans diffé rait entre les é tablissements 1 et 2 (é tablissement 1 : 25,9 % ; é tablissement 2 : 13,0 %, p = 0,008). Notons que les patients de sexe fé minin ont moins souvent subi une annulation d'intervention. Les interventions é lectives, ambulatoires et visant la colonne verté brale ont é té celles qui ont é té le plus souvent annulé es. Les motifs d'annulation comprenaient des facteurs lié s au chirurgien (28,2 %), à un cas plus grave (23,9 %), à l'é tat de santé du patient (17,2 %), à d'autres facteurs (17,0 %), à la disponibilité des ressources (7,0 %), à un retard dans la salle d'opé ration (6,4 %) et à des facteurs lié s à l'anesthé sie (0,3 %). Lorsqu'on les regroupe entre eux, les motifs d'annulation sont lié s aux patients dans 17,2 % des cas, au personnel dans 28,5 % des cas et aux interventions ou aux ressources dans 54,3 % des cas.Conclusions : Les annulations d'interventions neurochirurgicales é taient fré quentes et le plus souvent lié es à des facteurs opé rationnels ou en lien avec les ressources disponibles. Les interventions é lectives, ambulatoires et visant la colonne verté brale ont é té celles qui ont é té le plus souvent annulé es. Ces ré sultats mettent donc en é vidence des aspects dont l'efficacité peut ê tre optimisé e ainsi que des initiatives ciblé es d'amé lioration de la qualité.

OBJECTIVE:Blood-brain barrier dysfunction (BBBD) has been linked to various neurological disorders, including epilepsy. This study aims to utilize dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) to identify and compare brain regions with BBBD in patients with epilepsy (PWE) and healthy individuals. METHODS:We scanned 50 drug-resistant epilepsy (DRE) patients and 58 control participants from four global specialized epilepsy centers using DCE-MRI. The presence and extent of BBBD were analyzed and compared between PWE and healthy controls. RESULTS:Both greater brain volume and higher number of brain regions with BBBD were significantly present in PWE compared to healthy controls (p < 10-7). No differences in total brain volume with BBBD were observed in patients diagnosed with either focal seizures or generalized epilepsy, despite variations in the affected regions. Overall brain volume with BBBD did not differ in PWE with MRI-visible lesions compared with non-lesional cases. BBBD was observed in brain regions suspected to be related to the onset of seizures in 82% of patients (n = 39) and was typically identified in, adjacent to, and/or in the same hemisphere as the suspected epileptogenic lesion (n = 10). SIGNIFICANCE:These findings are consistent with pre-clinical studies that highlight the role of BBBD in the development of DRE and identify microvascular stabilization as a potential therapeutic strategy.

OBJECTIVE Despite efforts toward achieving gender-based equality in clinical trial enrollment, females are frequently underrepresented and gender-specific data analysis is lacking. Identifying and addressing gender bias in medical decision-making and outcome reporting may facilitate more equitable healthcare delivery. This study aimed to determine if gender differences exist in the clinical evaluation and surgical management of patients with degenerative lumbar conditions. METHODS Consecutive adult patients undergoing spinal surgery for degenerative lumbar conditions (disc herniation [DH], spinal canal stenosis [SCS], and degenerative spondylolisthesis [DS]) were prospectively enrolled across 16 tertiary academic centers. Outcome domains included pain, disability, health-related quality of life (HRQOL), expectations of surgery, and satisfaction with surgical outcome. Covariates pertaining to the preoperative use of healthcare resources, diagnostic testing, and visits to healthcare providers were compared between genders before and after propensity score matching for 13 baseline demographic and procedural variables. RESULTS Data were analyzed for 5038 patients (2396 female, 2642 male) with degenerative spinal pathologies including SCS (40.2%), DS (33.2%), and DH (26.6%). Surgical treatment effect was similar for both genders. For all conditions, female patients had worse pre- and postoperative pain, disability, and HRQOL. Significant gender differences were identified for marital status, education, employment status, exercise activities, and disability claims. Female patients were more likely to use select medications, diagnostic imaging tests, and nonsurgical therapeutic interventions, and access various healthcare providers. Findings were similar following post hoc propensity score matching. CONCLUSIONS In this multicenter, prospective, observational cohort study, male and female patients benefitted similarly from surgery for degenerative lumbar spine disease. However, female patients had worse preoperative clinical assessment scores and were more likely to use select healthcare resources.

BACKGROUND:Contrast-induced encephalopathy (CIE) is an adverse event associated with diagnostic and therapeutic endovascular procedures. Decades of animal and human research support a mechanistic role for pathological blood-brain barrier dysfunction (BBBd). Here, we describe an institutional case series and review the literature supporting a mechanistic role for BBBd in CIE. METHODS:A literature review was conducted by searching MEDLINE, Web of Science, Embase, CINAHL and Cochrane databases from inception to January 31, 2022. We searched our institutional neurovascular database for cases of CIE following endovascular treatment of cerebrovascular disease during a 6-month period. Informed consent was obtained in all cases. RESULTS:Review of the literature revealed risk factors for BBBd and CIE, including microvascular disease, pathological neuroinflammation, severe procedural hypertension, iodinated contrast load and altered cerebral blood flow dynamics. In our institutional series, 6 of 52 (11.5%) of patients undergoing therapeutic neuroendovascular procedures developed CIE during the study period. Four patients were treated for ischemic stroke and two patients for recurrent cerebral aneurysms. Mechanical stenting or thrombectomy were utilized in all cases. CONCLUSION:In this institutional case series and literature review of animal and human data, we identified numerous shared risk factors for CIE and BBBd, including microvascular disease, increased procedure length, large contrast volumes, severe intraoperative hypertension and use of mechanical devices that may induce iatrogenic endothelial injury.