Background: The Early Minimally Invasive Removal of Intracerebral Hemorrhage (ENRICH) trial demonstrated that minimally invasive surgery to treat spontaneous lobar intracerebral hemorrhage (ICH) improved functional outcomes. We aimed to explore current management trends for spontaneous lobar ICH in Canada to assess practice patterns and determine whether further randomized controlled trials are needed to clarify the role of surgical intervention.Methods: Neurologists, neurosurgeons, physiatrists and trainees in these specialties were invited to complete a 16-question survey exploring three areas: (1) current management for spontaneous lobar ICH at their institution, (2) perceived influence of ENRICH on their practice and (3) perceived need for additional clinical trial data. Standard descriptive statistics were used to report categorical variables. The chi 2 test was used to compare responses across specialties and career stages.Results: The survey was sent to 433 physicians, and 101 (23.3%) responded. Sixty-eight percent of participants reported that prior to publication of the ENRICH trial, spontaneous lobar ICH was primarily managed conservatively, with surgery reserved for life-threatening situations. Forty-three percent of participants did not foresee a significant increase in surgical intervention at their institution. Of neurosurgical respondents, 33% remained hesitant to offer surgical intervention beyond lifesaving operations. Only 5% reported routinely using specifically designed technologies to evacuate ICH. Seventy percent reported that another randomized controlled trial comparing nonsurgical to surgical management for spontaneous lobar ICH is needed.Conclusions: There is significant practice variability in the management of spontaneous lobar ICH across Canadian institutions, stressing the need for additional clinical trial data to determine the role of surgical intervention. Contexte : L'essai clinique ENRICH a d & eacute;montr & eacute; qu'une chirurgie peu invasive pour traiter l'h & eacute;morragie intrac & eacute;r & eacute;brale lobaire (HICL) spontan & eacute;e am & eacute;liorait la sant & eacute; fonctionnelle des patients. Nous avons donc voulu explorer les tendances actuelles de la prise en charge de l'HICL spontan & eacute;e au Canada afin d'& eacute;valuer les modes de pratique et de d & eacute;terminer si d'autres essais cliniques randomis & eacute;s sont n & eacute;cessaires pour clarifier le r & ocirc;le de l'intervention chirurgicale.M & eacute;thodes : Des neurologues, neurochirurgiens, physiatres et stagiaires de ces sp & eacute;cialit & eacute;s ont & eacute;t & eacute; invit & eacute;s & agrave; r & eacute;pondre & agrave; un questionnaire de 16 questions portant sur trois aspects : (1) la prise en charge actuelle de l'HICL spontan & eacute;e dans leur & eacute;tablissement ; (2) l'influence per & ccedil;ue de l'essai clinique ENRICH sur leur pratique ; et (3) la perception que des donn & eacute;es tir & eacute;es d'essais cliniques suppl & eacute;mentaires sont n & eacute;cessaires. Des statistiques descriptives standards ont & eacute;t & eacute; utilis & eacute;es pour rendre compte des variables cat & eacute;gorielles. Le test du chi-carr & eacute; (chi 2) a & eacute;t & eacute; utilis & eacute; pour comparer entre elles les r & eacute;ponses des sp & eacute;cialistes et les & eacute;tapes de leur carri & egrave;re.R & eacute;sultats : Notre questionnaire a & eacute;t & eacute; envoy & eacute; & agrave; 433 m & eacute;decins parmi lesquels 101 (23,3 %) y ont r & eacute;pondu. Soixante-huit pour cent des participants ont d & eacute;clar & eacute; que l'HICL spontan & eacute;e & eacute;tait principalement trait & eacute;e de mani & egrave;re conservatrice avant la publication de l'essai clinique ENRICH, la chirurgie & eacute;tant r & eacute;serv & eacute;e aux situations mettant en jeu le pronostic vital. Quarante-trois pour cent des participants ne pr & eacute;voyaient pas d'augmentation notable des interventions chirurgicales au sein de leur & eacute;tablissement. Parmi les neurochirurgiens interrog & eacute;s, 33 % h & eacute;sitent encore & agrave; proposer une intervention chirurgicale au-del & agrave; des op & eacute;rations de sauvetage. Seuls 5 % d'entre eux ont aussi d & eacute;clar & eacute; utiliser syst & eacute;matiquement des technologies sp & eacute;cifiquement con & ccedil;ues pour & eacute;vacuer les HICL spontan & eacute;es. Enfin, soixante-dix pour cent ont d & eacute;clar & eacute; qu'un autre essai clinique randomis & eacute; comparant la prise en charge non chirurgicale & agrave; la prise en charge chirurgicale de l'HICL spontan & eacute;e & eacute;tait n & eacute;cessaire.Conclusions : La prise en charge de l'HICL spontan & eacute;e varie consid & eacute;rablement d'un & eacute;tablissement de sant & eacute; canadien & agrave; l'autre, ce qui souligne la n & eacute;cessit & eacute; de disposer de donn & eacute;es tir & eacute;es d'essais cliniques suppl & eacute;mentaires pour d & eacute;terminer le r & ocirc;le de l'intervention chirurgicale.

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.

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ABSTRACT: Introduction: Delayed cerebral ischemia (DCI) is a complication of aneurysmal subarachnoid hemorrhage (aSAH) and is associated with significant morbidity and mortality. There is little high-quality evidence available to guide the management of DCI. The Canadian Neurosurgery Research Collaborative (CNRC) is comprised of resident physicians who are positioned to capture national, multi-site data. The objective of this study was to evaluate practice patterns of Canadian physicians regarding the management of aSAH and DCI. Methods: We performed a cross-sectional survey of Canadian neurosurgeons, intensivists, and neurologists who manage aSAH. A 19-question electronic survey (Survey Monkey) was developed and validated by the CNRC following a DCI-related literature review (PubMed, Embase). The survey was distributed to members of the Canadian Neurosurgical Society and to Canadian members of the Neurocritical Care Society. Responses were analyzed using quantitative and qualitative methods. Results: The response rate was 129/340 (38%). Agreement among respondents was limited to the need for intensive care unit admission, use of clinical and radiographic monitoring, and prophylaxis for the prevention of DCI. Several inconsistencies were identified. Indications for starting hyperdynamic therapy varied. There was discrepancy in the proportion of patients who felt to require IV milrinone, IA vasodilators, or physical angioplasty for treatment of DCI. Most respondents reported their facility does not utilize a standardized definition for DCI. Conclusion: DCI is an important clinical entity for which no homogeneity and standardization exists in management among Canadian practitioners. The CNRC calls for the development of national standards in the definition, identification, and treatment of DCI.

OBJECTIVE Routine antiplatelet responsiveness testing for patients undergoing carotid artery stenting procedures is not performed at most endovascular centers and remains a topic of controversy within the neurointerventional community. The objective of this study was to determine if nonresponsiveness to acetylsalicylic acid or clopidogrel was associated with the development of symptomatic thromboembolic events in patients undergoing carotid stenting procedures. METHODS A prospective study was conducted at the Foothills Medical Centre in Calgary, Alberta, Canada, from August 2019 to July 2021. Patients undergoing carotid artery stenting procedures and who were receiving dual antiplatelet therapy were enrolled in the study. Responsiveness to the antiplatelet medications was determined through whole blood impedance aggregometry. The primary outcome was development of a symptomatic thromboembolic event within 90 days after the procedure. The treating physicians were blinded to the aggregometry results for the duration of the study. RESULTS One hundred two procedures were performed in 100 patients. Eight thromboembolic events (8%) occurred during the study. Age (p = 0.03) and nonresponsiveness to clopidogrel (p = 0.003) were associated with the development of thromboembolic events. The multivariable model showed that clopidogrel nonresponsiveness was independently associated with the development of a thromboembolic event (adjusted OR 6.14, 95% CI 1.25-30.11, p = 0.03). CONCLUSIONS This study demonstrated that patients who were identified as clopidogrel nonresponders, using whole blood impedance aggregometry, were at an increased risk of developing thromboembolic events. Larger studies are needed to assess the utility of routine platelet function testing prior to carotid artery stenting procedures.

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BACKGROUND:Endovascular thrombectomy (EVT) has revolutionized ischemic stroke care. We aimed to assess whether neighbourhood socioeconomic status is predictive of access to EVT after receipt of alteplase for ischemic stroke among patients living in Alberta, Canada, and whether this relation is mediated by the distance a person lives to the nearest comprehensive stroke centre (CSC).METHODS:We performed a retrospective study including all people older than 18 years living in Alberta who were admitted to hospital with an ischemic stroke and who received intravenous alteplase treatment between Jan. 1, 2017, and Dec. 31, 2019. Data were obtained through administrative data sets. The primary outcome was treatment with EVT. We assigned neighbourhood deprivation quintile based on the Material and Social Deprivation Index. We used logistic regression modelling to assess for a relation between deprivation and treatment with EVT. We adjusted for age, sex, stroke severity and distance to the nearest CSC. We calculated the average causal mediation effect of distance to the nearest CSC on the relation between neighbourhood deprivation level and treatment with EVT.RESULTS:The study cohort consisted of 1335 patients, of whom 181 (13.6%) had missing data and were excluded from the main regression analysis. Endovascular thrombectomy was performed or attempted in 314 patients (23.5%). In the primary model, patients from the most deprived neighbourhoods were less likely than those from less deprived neighbourhoods to have received EVT (adjusted odds ratio 0.43, 95% confidence interval 0.24 to 0.77). Neighbourhood deprivation level was not significantly associated with EVT when distance to the nearest CSC was included as a covariate. Mediation analysis suggested that 48% of the total effect that neighbourhood deprivation level had on the odds of receiving EVT was attributable to the distance a person lived from the nearest CSC.INTERPRETATION:The results suggest that people from more deprived neighbourhoods in Alberta were less likely to be treated with EVT than those from less deprived neighbourhoods. Improving access to EVT for people living in remote locations may improve the equitable distribution of this treatment.

The emergence of COVID-19 (SARS-CoV-2) led to distancing measures which acutely affected healthcare infrastructure, leading to limited in-person clinical visits and an increased number of virtual appointments. This study aimed to examine the effects this had on adults with hydrocephalus by describing the lived experiences of a cohort of patients at an outpatient hydrocephalus clinic. Between early May and early July of 2020, remote structured interviews were conducted with participants. Interviews were in-depth and open-ended, allowing participants to reflect and expand on the effects of the social distancing mandate on their well-being and quality of care. Three themes emerged: (1) impacts of changes in treatment provision, (2) impacts of changes in mitigating activities, and (3) impacts of changes on personal well-being. The comprehensive understanding of lived experiences may inform the future provision of healthcare services and social policy. Improved approaches to remote care telemedicine have the potential to facilitate high-quality care.

Introduction One of the biggest concerns associated with endovascular procedures is the development of thromboembolic events. To mitigate this risk, patients are placed on dual antiplatelet therapy. Interestingly, there is a known variation in one's ability to appropriately respond to antiplatelet medications and patients with decreased responsiveness may be at an increased risk of developing ischemic complications. Routine testing of antiplatelet responsiveness is not performed at most endovascular centres and is still a topic of controversy within the neurosurgical community. Previous studies have described the utility of platelet function testing within patients undergoing intracranial procedures, but very few studies have focused exclusively on patients undergoing extracranial carotid stenting procedures. Those that have, are retrospective in nature and the VerifyNow assay, which may not be as accurate as impedance aggregometry, has been the platelet function test of choice. Therefore, the objective of our study was to determine if non-responsiveness to acetylsalicylic acid and clopidogrel, as measured by whole blood impedance aggregometry, was associated with the development of symptomatic thromboembolic events in patients undergoing carotid stenting procedures. Methods A prospective study was conducted at the Foothills Medical Centre in Calgary, Alberta, Canada from August 2019 to February 2021. Patients undergoing carotid stenting procedures and who were on dual antiplatelet therapy consisting of acetylsalicylic acid and clopidogrel were enrolled in the study. Responsiveness to the antiplatelet medications was determined through whole blood impedance aggregometry and the treating neurointerventionalists were blinded to the results. Therefore, no changes were made to the antiplatelet medications based on the results of the platelet function tests. The primary outcome was the development of a symptomatic thromboembolic event at 90 days after the procedure. Demographic, clinical, radiological, and procedural variables were analyzed to determine which factors were associated with the development of thromboembolic events. Results One hundred and two procedures were performed in 100 patients and eight (8%) thromboembolic events occurred during the study. The non-response rate of clopidogrel and acetylsalicylic acid was 15% and 9%, respectively. Age (p=0.03) and non-responsiveness to clopidogrel (p=0.003) were associated with the development of thromboembolic events. Twenty-seven percent of the patients who were non-responsive to clopidogrel developed a thromboembolic event compared to only 5% of the patients who were responsive to clopidogrel. Acetylsalicylic acid non-responsiveness was not associated with the development of thromboembolic events (p=0.36). The multivariable model showed that clopidogrel non-responders were independently associated with the development of a thromboembolic event (adjusted OR 6.14, 95%CI 1.25, 30.11, p=0.03). Conclusion Our study demonstrated that patients who were identified as clopidogrel non-responders, using whole blood impedance aggregometry, were at an increased risk of developing thromboembolic events. The results of our study validate the need for larger observational studies or randomized controlled trials to assess the utility of routine platelet function testing prior to carotid stenting procedures. Disclosures S. Muram: None. K. Panchendrabose: None. M. Eagles: None. S. Abdul Salam: None. J. Wong: None. J. Riva-Cambrin: None. A. Mitha: 1; C; Stryker Neurovascular. 2; C; Cerus Endovascular, Stryker Neurovascular.

BACKGROUND: Hyperglycemia has been associated with poor outcomes in patients with aneurysmal subarachnoid hemorrhage (aSAH). However, there remains debate as to what optimal glucose targets should be in this patient population. OBJECTIVE: To assess whether we could identify an optimal glucose target for patients with aSAH. METHODS: We performed a post hoc analysis of the "clazosentan to overcome neurological ischemia and infarction occurring after subarachnoid hemorrhage" trial data set. Patients had laboratory results drawn daily for the entirety of their intensive care unit stay. Maximum blood glucose levels were assessed for a relationship with unfavorable outcomes using multiple logistic regression analysis. Maximum blood glucose levels were dichotomized based on the Youden index, which identified a maximum level of <9.2 mmol/L as the optimal cut point for prediction of unfavorable outcomes. Nearest neighbor matching was used to assess the relationship between maintaining glucose levels below the cut point and unfavorable functional outcomes (defined as a modified Rankin score of >2 at 3 mo post-aSAH). The matching was performed after calculation of a propensity score based on identified predictors of outcome and glucose levels. RESULTS: Three hundred eighty-nine patients were included in the matched analysis. Propensity scores were balanced on both the covariates and outcomes of interest. There was a significant average treatment effect (-0.143: 95% confidence interval -0.267 to -0.019) for patients who maintained glucose levels <9.2 mmol/L. CONCLUSION: Maintaining glucose levels below the identified cut point was associated with a decreased risk for unfavorable outcomes in this retrospective matched study.

OBJECTIVE External ventricular drainage (EVD) catheters are associated with complications such as EVD catheter infection (ECI), intracranial hemorrhage (ICH), and suboptimal placement. The aim of this study was to investigate the rates of EVD catheter complications and their associated risk factor profiles in order to optimize the safety and accuracy of catheter insertion. METHODS A total of 348 patients with urgently placed EVD catheters were included as a part of a prospective multicenter observational cohort. Strict definitions were applied for each complication category. RESULTS The rates of misplacement, ECI/ventriculitis, and ICH were 38.6%, 12.2%, and 9.2%, respectively. Catheter misplacement was associated with midline shift (p = 0.002), operator experience (p = 0.031), and intracranial length (p < 0.001). Although mostly asymptomatic, ICH occurred more often in patients receiving prophylactic low-molecular-weight heparin (LMWH) (p = 0.002) and those who required catheter replacement (p = 0.026). Infectious complications (ECI/ventriculitis and suspected ECI) occurred more commonly in patients whose catheters were inserted at the bedside (p = 0.004) and those with smaller incisions (≤ 1 cm) (p < 0.001). ECI/ventriculitis was not associated with preinsertion antibiotic prophylaxis (p = 0.421), catheter replacement (p = 0.118), and catheter tunneling length (p = 0.782). CONCLUSIONS EVD-associated complications are common. These results suggest that the operating room setting can help reduce the risk of infection, but not the use of preoperative antibiotic prophylaxis. Although EVD-related ICH was associated with LMWH prophylaxis for deep vein thrombosis, there were no significant clinical manifestations in the majority of patients. Catheter misplacement was associated with operator level of training and midline shift. Information from this multicenter prospective cohort can be utilized to increase the safety profile of this common neurosurgical procedure.

OBJECTIVE:Previous works investigating rates of adverse events (AEs) in spine surgery have been retrospective, with data collection from administrative databases, and often from single centers. To date, there have been no prospective reports capturing AEs in spine surgery on a national level, with comparison among centers. METHODS:The Spine Adverse Events Severity system was used to define the incidence and severity of AEs after spine surgery by using data from the Canadian Spine Outcomes and Research Network (CSORN) prospective registry. Patient data were collected prospectively and during hospital admission for those undergoing elective spine surgery for degenerative conditions. The Spine Adverse Events Severity system defined minor and major AEs as grades 1-2 and 3-6, respectively. RESULTS:There were 3533 patients enrolled in this cohort. There were 85 (2.4%) individual patients with at least one major AE and 680 (19.2%) individual patients with at least one minor AE. There were 25 individual patients with 28 major intraoperative AEs and 260 patients with 275 minor intraoperative AEs. Postoperatively there were 61 patients with a total of 80 major AEs. Of the 487 patients with minor AEs postoperatively there were 698 total AEs. The average enrollment was 321 patients (range 47-1237 patients) per site. The rate of major AEs was consistent among sites (mean 2.9% ± 2.4%, range 0%-9.1%). However, the rate of minor AEs varied widely among sites-from 7.9% to 42.5%, with a mean of 18.8% ± 9.7%. The rate of minor AEs varied depending on how they were reported, with surgeon reporting associated with the lowest rates (p < 0.01). CONCLUSIONS:The rate of major AEs after lumbar spine surgery is consistent among different sites but the rate of minor AEs appears to vary substantially. The method by which AEs are reported impacts the rate of minor AEs. These data have implications for the detection and reporting of AEs and the design of strategies aimed at mitigating complications.

After years of research on treatment of aneurysmal subarachnoid hemorrhage (aSAH), including randomized clinical trials, few treatments have been shown to be efficacious. Nevertheless, reductions in morbidity and mortality have occurred over the last decades. Reasons for the improved outcomes remain unclear. One randomized clinical trial that has been examined in detail with these questions in mind is Clazosentan to Overcome Neurological Ischemia and Infarction Occurring After Subarachnoid Hemorrhage (CONSCIOUS-1). This was a phase-2 trial testing the effect of clazosentan on angiographic vasospasm (aVSP) in patients with aSAH. Clazosentan decreased moderate to severe aVSP. There was no statistically significant effect on the extended Glasgow outcome score (GOS), although the study was not powered for this endpoint. Data from the approximately 400 patients in the study were detailed, rigorously collected and documented and were generously made available to one investigator. Post-hoc analyses were conducted which have expanded our knowledge of the management of aSAH. We review those analyses here.

OBJECTIVE:YouTube has become an important information source for pediatric neurosurgical patients and their families. The goal of this study was to determine whether the informative quality of videos of endoscopic third ventriculostomy (ETV) and endoscopic third ventriculostomy with choroid plexus cauterization (ETV + CPC) is associated with metrics of popularity. METHODS:This cross-sectional study used comprehensive search terms to identify videos pertaining to ETV and ETV + CPC presented on the first 3 pages of search results on YouTube. Two pediatric neurosurgeons, 1 neurosurgery resident, and 2 patient families independently reviewed the selected videos. Videos were assessed for overall informational quality by using a validated 5-point Global Quality Score (GQS) and compared to online metrics of popularity and engagement such as views, likes, likes/views ratio, comments/views ratio, and likes/dislikes ratio. Weighted kappa scores were used to measure agreement between video reviewers. RESULTS:A total of 58 videos (47 on ETV, 7 on ETV + CPC, 4 on both) of 120 videos assessed met the inclusion criteria. Video styles included "technical" (62%), "lecture" (24%), "patient testimonial" (4%), and "other" (10%). In terms of GQS, substantial agreement was seen between surgeons (kappa 0.67 [95% CI 0.55, 0.80]) and excellent agreement was found between each surgeon and the neurosurgical resident (0.77 [95% CI 0.66, 0.88] and 0.89 [95% CI 0.82, 0.97]). Only fair to moderate agreement was seen between professionals and patient families, with weighted kappa scores ranging from 0.07 to 0.56. Academic lectures were more likely to be rated good or excellent (64% vs 0%, p < 0.001) versus surgical procedure and testimonial video types. There were significant associations between a better GQS and more likes (p = 0.01), views (p = 0.02), and the likes/dislikes ratio (p = 0.016). The likes/views ratio (p = 0.31) and comments/views ratio (p = 0.35) were not associated with GQS. The number of likes (p = 0.02), views (p = 0.03), and the likes/dislikes ratio (p = 0.015) were significantly associated with video style (highest for lecture-style videos). CONCLUSIONS:Medical professionals tended to agree when assessing the overall quality of YouTube videos, but this agreement was not as strongly seen when compared to parental ratings. The online metrics of likes, views, and likes/dislikes ratio appear to predict quality. Neurosurgeons seeking to increase their online footprint via YouTube would be well advised to focus more on the academic lecture style because these were universally better rated.

OBJECTIVE:Patients with good-grade aneurysmal subarachnoid hemorrhage (aSAH) are thought to recover well, yet some do not. This work sought to identify predictors of unfavorable functional outcome after good-grade aSAH. METHODS:We performed a post-hoc analysis of the CONSCIOUS-1 trial. Patients with World Federation of Neurosurgical Societies grades I or II aSAH were included. The primary outcome was unfavorable functional outcome (defined as a modified Rankin Scale score >2) at 12 weeks. Parametric and nonparametric testing were used as appropriate. Variables were classified as modifiable or nonmodifiable, depending on whether they were present at patient admission. Stepwise logistic regression models were created for modifiable and nonmodifiable predictors of outcome. Independent predictors in the respective multivariate analyses were combined into a final multivariate regression model. RESULTS:We included 301 patients, 67 of whom (22%) had an unfavorable outcome. Of the nonmodifiable predictors, higher admission systolic blood pressure (P = 0.002) and female sex (P = 0.011) were independently associated with unfavorable outcome. Potentially modifiable independent predictors of outcome were delayed cerebral ischemia (P = 0.039), higher maximum temperature (0.036), suffering a respiratory system complication (P = 0.004), and suffering an intracranial hemorrhagic complication (P = 0.022). All variables found to be independently predictive of poor outcome in their respective models retained statistical significance in the combined multivariate analysis. CONCLUSIONS:About 1 in 5 good-grade aSAH patients enrolled in CONSCIOUS-1 suffered an unfavorable functional outcome. Admission systolic blood pressure, female sex, hyperthermia, delayed cerebral ischemia, respiratory complications, and intracranial hemorrhagic complications may be predictive of outcome.

Background Anti-platelet therapy is an important part of the treatment regimen in patients who are receiving a cerebrovascular stent, in order to reduce the incidence of thromboembolic complications. However, there is a known variation in patient response to anti-platelet medications. Theoretically, patients with decreased responsiveness may be at increased risk of ischemic complications while those with increased responsiveness may be at a heightened risk of bleeding. The objective of this investigation was to determine if patients with an increased response to clopidogrel were at an increased risk of developing post-procedural hematomas. Methods A prospective Research Ethics Board (REB) approved study was performed on consecutive patients undergoing endovascular placement of a cerebrovascular stent at the Foothills Medical Centre in Calgary, Alberta from 2019–2020. Inclusion criteria were patients over 18 years of age, and on dual anti-platelet therapy consisting of aspirin and clopidogrel for at least 3 days prior to the procedure. Platelet function testing was performed on blood samples taken before insertion of the stent using whole blood impedance aggregometry to determine the responsiveness to aspirin and clopidogrel. As per the REB protocol, treating neurointerventionalists were blinded to the aggregometry results. The primary study endpoint was the development of hemorrhagic complications during or after the procedure. Parametric and receiver operator curve analysis was used to assess for predictors of our primary outcome. Results To determine the cut-offs for ASA and clopidogrel responsiveness, whole blood aggregometry was first performed on 25 control patients who were not on anti-platelet agents. Subsequently, 50 consecutive patients undergoing cerebrovascular stenting procedures fit our inclusion criteria. 7 (14.0%) of these patients developed a hematoma either intracranially (n=1) or at the puncture site (n=6). Age, gender, smoking status, access site, or stent location were not associated with hemorrhagic complications. Based on our controls, ASA hyper-responders could not be identified using whole blood aggregometry due to the normal response being 0–1 ohms. With these cut-offs, however, 49 (98%) of our patients were responsive to aspirin. Using whole blood aggregometry on patients receiving a cerebrovascular stent, the optimal electrical impedance value was identified as 2 ohms developed a hematoma. This association was found to be statistically significant (p=0.016). Conclusion Dual anti-platelet therapy is an important part of the treatment regimen in any patient who receives a cerebrovascular stent, but there are variations in patient response to these medications. Our study suggests that patients who have an increased response to clopidogrel may be at a higher risk of developing hemorrhagic complications. Disclosures S. Muram: None. K. Panchendrabose: None. M. Eagles: None. M. Suheel: None. A. Mitha: None.

ABSTRACT: Spinal dysraphism is an umbrella term that encompasses a number of congenital malformations that affect the central nervous system. The etiology of these conditions can be traced back to a specific defect in embryological development, with the more disabling malformations occurring at an earlier gestational age. A thorough understanding of the relevant neuroembryology is imperative for clinicians to select the correct treatment and prevent complications associated with spinal dysraphism. This paper will review the neuroembryology associated with the various forms of spinal dysraphism and provide a clinical-pathological correlation for these congenital malformations.

Eagles, Matthew E MD; Muram, Sandeep MD; Ayling, Oliver G S MD, MS; Tso, Michael K MD; Macdonald, R. Loch MD, PhD Author Information

IntroductionMoyamoya disease causes progressive stenosis of the supraclinoid internal carotid arteries with subsequent development of moyamoya collaterals. The mainstay treatment is surgical revascularization using direct or indirect bypass techniques. The use of antiplatelet agents is advocated to facilitate blood flow, maintain bypass patency, and reduce thrombotic events. We searched published literature to determine the benefits of antiplatelet therapy in this patient population.MethodsWe performed a literature search of published papers in the English language using EMBASE, PUBMED, and Web of Science databases. With the assistance of a librarian, we used various combinations of keywords such as Moyamoya disease, ischemic stroke, hemorrhagic stroke, antiplatelet, and the names of individual antiplatelet agents. Titles and abstracts were screened by the first two authors (MAS and MEE), with a full-text review of relevant papers. Articles were included if they examined the effect of antiplatelet therapy on ischemic or hemorrhagic stroke or survival in patients with moyamoya disease.ResultsOut of 132 retrieved studies, we identified five eligible studies published between 2014 and 2019 and included 26,605 patients (9499 on antiplatelet therapy, and 17106 controls) with follow up ranging from post-operative period to 6.3 years. Only one study had a prospective design and two studies were multi-center. Three of the studies included post-bypass patients, and one included only asymptomatic moyamoya disease. The antiplatelet therapy regimens varied across the studies and included ASA, clopidogrel, or cilostazol.Three studies had a control arm that did not receive any antiplatelet therapy. In these studies, the pooled risk for a composite outcome (any ischemic or hemorrhagic stroke, or death) was lower in the antiplatelet group compared to controls (9% vs 11%; relative risk 0.85, 95% CI: 0.79 to 0.92).ConclusionsThe use of antiplatelet therapy in patients with moyamoya disease may confer better stroke-free survival. Multicenter prospective studies with a uniform antiplatelet protocol are needed to elucidate the potential benefits of this intervention.DisclosuresM. Suheel: None. M. Eagles: None. M. Almekhlafi: None.

Despite guidelines, many individuals are not routinely tested for HIV within healthcare settings. Our objective was to quantify and characterize preceding clinical encounters by newly-diagnosed persons living with HIV in southern Alberta, Canada. We discuss the clinical impact of missed HIV testing, and options for remediation. Clinical encounters prior to HIV diagnosis including the discharge diagnosis were collected between 1 April 2011 and 1 April 2016. We followed the HIV Indicator Diseases across Europe Study criteria to identify HIV Clinical Indicator Conditions (HCICs) present at clinical encounters. Patients accessing prior care were compared to those who had not previously accessed care. Of 393 individuals, 231 (58.7%) had ≥1 encounter prior to diagnosis; 224 (57%) of encounters occurred in outpatient clinics, 130 (33.1%) in emergency departments, and 39 (9.9%) in urgent care clinics. Approximately 25% (n = 57) of patients who engaged healthcare had ≥ 1 recognized HCIC but did not receive HIV testing. The most frequent HCICs were infection (n = 34; 60%) and hematological disorders (n = 12; 21%). The median CD4 cell count at HIV diagnosis for patients with an HCIC was 127 cells/mm3. In this population, three of five patients had accessed healthcare prior to diagnosis with one of four presenting with HCICs but were not offered HIV testing. Protocols beyond the current recommendations are urgently required to address missed HIV diagnostic opportunities who engaged healthcare.