bluuebunny/crossref_metadata_2025 huggingface dataset:
P.006 Keeping neurosarcoidosis on the differential
Authors: Spinelli E , Blevins G , Mailo J , Atilano L , Leonard H , Yeh EA , Kolski H
Published: June 2016

Background: Sarcoidosis is a multiorgan autoimmune disease characterized by the presence of non-caseating granulomas. The diagnosis can be difficult, particularly with central nervous system (CNS) involvement, and pathology outside of the CNS has to be carefully evaluated. Early and correct diagnosis is crucial for appropriate management particularly in children where sarcoidosis and neurosarcoidosis are rare. Methods: We describe a 16 year old previously healthy boy who presented with progressive pyramidal neurological signs and symptoms localizable primarily to the brain stem. Results: Initial imaging revealed striking brainstem, as well as cerebral, cerebellar and spinal cord perivascular enhancement. Lung involvement was subclinical with a miliary pattern on chest imaging and needle biopsy revealed an interstitial lymphocytic infiltration. Extensive serum and CSF rheumatological, autoimmune and infectious investigations were noncontributory. Serum ACE levels were at first within normal limits. Steroid treatment stabilized symptoms and perhaps coincidentally, separate rituximab treatments were followed within days by vertigo (with a new pontine lesion) or a respiratory decompensation. A wedge lung biopsy revealed granulomatosis. Current treatment consists of mycophenolate, methotrexate with a prednisone wean. Conclusions: This case report reinforces the varied manifestations and mimics of sarcoidosis (including CLIPPERS) and highlights the need for a high index of suspicion despite apparently negative investigations.
P.007 Onset of facial weakness correlated with muscle strength in infantile facioscapulohumeral dystrophy (FSHD)
Authors: Mah JK , Feng J , Carty C , Chen Y , Duong T ,   C (CINRG) Investigators
Published: June 2016

Background: We investigated motor function associations with age, gender, and D4Z4 fragment size among participants with infantile FSHD. Methods: We collected standardized motor assessments including goniometry, manual muscle testing (MMT), quantitative muscle testing (QMT), and FSHD clinical severity scores (CSS) at 12 CINRG sites. To measure associations, we used linear regression models adjusted for age at enrollment, onset of weakness, gender, and D4Z4 repeats. Results: 53 participants (59% female, mean age 23.1±14.6 years) were enrolled. Weakness was most pronounced at the shoulder girdle and rectus abdominis (median MMT 30-38% of normal). Older enrollment age was associated with greater CSS (p=0.005) and reduced range of motion in shoulder abduction, shoulder flexion, elbow flexion, and ankle dorsiflexion (all p<0.01). Females and participants with larger D4Z4 repeats had milder shoulder/arm weakness and lesser disease severity (all p<0.05). Increased age at onset of facial weakness was significantly associated with greater total muscle strength, as measured by QMT and MMT (both p=0.002). Conclusions: We confirm the descending pattern of muscle involvement and milder disease severity in females or those with larger D4Z4 repeats. Furthermore, earlier age at onset of facial weakness was associated with greater muscle weakness. Future longitudinal assessments will describe rates of disease progression in this population.
P.012 Spinal durotomy repair simulator for deliberate microsurgical practice: integration into a residency training module
Authors: Lau JC , Denning L , Lownie SP , Peters TM , Chen EC
Published: June 2016

Background: Deliberate practice is one aspect of gaining competency in surgical skills. We have previously integrated a vascular microsurgery module into our residency training curriculum, and have recently described our experience with constructing patient-specific spine models for simulating lumbar spinal durotomy repair. The goal of this project is to develop the necessary infrastructure to facilitate practice on the spine model during residency. Methods: A 3D-printed plastic lumbar spine model was created from a patient computed tomography scan. L2 was manually laminectomized, and paraspinal tissues were simulated using Polyvinyl Chloride (PVC) Plastisol. Harvested bovine pericardium was sewn into tubular form as a dural substitute. The pericardial tubes were tied at either end and attached to intravenous tubing to create a closed loop water system. Results: We are developing a video tutorial describing how to setup and use the model. Residents will be recorded while performing a 1.5 cm durotomy and repair using a surgical microscope available in our training laboratory (Drake-Hunterian Neurovascular Laboratory, London, Ontario, Canada). Residents are asked to grade the realism of the model using a questionnaire. Metrics of quality are to be determined. Conclusions: Our proposed model is a cost-effective, easy-to-prepare lumbar spinal simulator that facilitates microsurgical practice during neurosurgical residency.
P.015 Demographics of Canadian neurosurgery residents – a national cross-sectional study from the Canadian Neurosurgery Research Collaborative
Authors: Winkler-Schwartz A , Bigder M , Dakson A , Elliott C , Guha D , Kameda-Smith M , Lavergne P , Makarenko S , Taccone M , Tso M , Wang B , Iorio-Morin C
Published: June 2016

Background: The Canadian Neurosurgery Research Collaborative (CNRC) is a new consortium of neurosurgery residency programs set-up to facilitate the planning and implementation of multi-center studies. As a trainee-led organization, it will focus on resident-initiated, resident-driven projects. The goal of this study is to assess the demographics of Canadian neurosurgery residents, with particular focus on their academic and subspecialty interests. Methods: After approval by the CNRC, an online survey will be sent to all Canadian neurosurgery residents and fellows with reminders at 2, 4 and 6 weeks. Anonymous, basic demographic data will be collected. Specific interest towards the various subspecialties, research and academic vs community practice will be measured. The data will be crossed with the ongoing Canadian Neurosurgery Operative Landscape study to assess the impact of case volume on academic and subspecialty interests. Results: This is the first study providing a snapshot of Canadian neurosurgery residents at all levels of training. The study is ongoing and the official results will be presented at the meeting. As one of the first CNRC studies, it will also demonstrate the effectiveness of the collaborative. Conclusions: Understanding the demographics and interests of Canadian neurosurgery residents will allow the CNRC to better fulfill its mission.
P.020 Septo-optic dysplasia plus manifesting with medically refractory epilepsy
Authors: Al.Khateeb MO , Mirsattari S , Diosy D , McLachlan R
Published: June 2016

Background: Septo-Optic Dysplasia is a rare disorder with developmental malformations that was first reported by De Morsier.SOD associated with refractory epilepsy has not been well studied. We report six cases with SOD in patients with malformation of cortical development(MCD) and medically refractory epilepsy that underwent video-EEG telemetry. Methods: Six cases of SOD plus were admitted to the Epilepsy Monitoring Unit at London Health Sciences Centre because of medically refractory epilepsy. Functional hemispherectomy in one patient resulted in significant reduction of her seizures while insertion of a vagus nerve stimulator was not successful in controlling seizures in another patient. Right temporal resection for one patient resulted in about 60% reduction in her seizures. The remaining three patients were not surgical candidates and they remained on antiepileptic drugs. Results: MCD was present in 4/6 patients. Bilateral optic nerve hypoplasia was found in 50% of the patients. EEG was abnormal in all cases(6/6).Intractable epilepsy was found in 6/6 patients. Conclusions: SOD plus was associated with medically refractory epilepsy.
P.023 Clinical spectrum of epilepsy associated with polymicrogyria and candidacy for surgical management
Authors: Mai LM , Steven DA , Parrent AG , Mirsattari SM , Burneo JG
Published: June 2016

Background: Polymicrogyria (PMG), a malformation of cortical development, describes an area of cerebral cortex with excessively small convolutions. This study examines the clinical spectrum of epilepsy associated with PMG, a condition which commonly presents as medically-refractory epilepsy. Methods: All patients investigated in the Epilepsy Monitoring Unit from 2006 to 2015 at our centre and identified to have PMG by MRI were studied by retrospective chart review. Results: We identified 8 patients (4 male), mean age 33 years (range: 28 to 46). Seven had childhood onset of epilepsy. All experienced focal-onset seizures; 6 had occasional evolution to generalized, bilaterally convulsive seizures. PMG was associated with schizencephaly in 3 cases. Five patients were investigated with intracranial electrodes. Two patients underwent resective surgery, 1 achieved seizure-freedom, and 1 had class III (ILAE classification) following parietal corticectomy. Two patients underwent placement of vagus nerve stimulation and one a stimulator of the anterior nuclei of the thalami. Conclusions: Medically-refractory cases of PMG should be considered for presurgical evaluation, despite only a small portion being amenable to resective surgery. Extensive cortical malformation on MRI made intracranial electrodes necessary to identify the epileptic zone. Epilepsy surgery remains an important consideration given the possibility of seizure-freedom, as achieved in our patient.
P.026 Focal DBS of Posterior Cingulate Cortex for Refractory Nonlesional Epilepsy: A Case Report
Authors: Wong AW , Moien-Afshari F
Published: June 2016

Background: Deep brain stimulation for epilepsy is becoming an effective option for the treatment of refractory epilepsy. This is the case of a 19-year-old male patient who has had refractory seizures since 2.5 years old. Seizures occur up to 100 times per day, including gelastic, complex partial, and generalized tonic-clonic types. Methods: Continuous video-EEG monitoring, technetium 99 m ECD SPECT, PET-CT and 3T MRI are used for localization. Depth electrodes are implanted in right frontal orbital, cingulate and lateral frontal regions. Results: Video-EEG records 79 seizures arising from the right frontocentral region. Clinically, patient assumes a fencing posture, with left arm extension. Some seizures undergo secondary generalization. SPECT reveals subtle asymmetric hyperperfusion in right mesial frontal area, while PET-CT and MRI do not show focal lesion(s).Stereo-EEG recording and stimulation confirm seizure onset and trigger zone in the premotor cingulate posterior region. Treatment with stimulation in this region at 130-150 Hz, 4-5 mA, and pulse duration 0.1 ms reduces seizure frequency from 100/day to 3/week. Seizures last only 2-3 seconds, without postictal confusion leading to improvements in neuropsychological function. AED dosages are not reduced. Conclusions: Successful intracranial EEG localization of otherwise non-lesional non-resectable seizure focus permits the use of deep brain stimulation that effectively reduces refractory seizure frequency.
P.036 Clarithromycin induced sleep paralysis: a case report and review of literature
Authors: Nazeran A , Hafezi R , MoienAfshari F
Published: June 2016

Background: Clarithromycin is a macrolide antibiotic, which has been successfully used for treating narcolepsy without cataplexy and primary hypersomnia. Sleep-paralysis has not been reported as a side effect of this medication. Methods: We report a 44-year-old right-handed female, who presented with three episodes of paralysis over 2-day. Each spell occurred upon awakening or while falling asleep lasting less than 2-minute. Only one episode was accompanied by tingling and numbness. She denied cataplexy, sleep attacks, hypnopompic and hypnagogic hallucinations. She had no history of similar episodes. She had never experienced migraine with or without aura. She was obese and suffered nocturnal snoring. She had recently been started on Clarithromycin for pneumonia. Her neurological examination was normal. Results: Brain MRI was normal. Stroke work up including carotids CT angiogram, 24-hour Holter monitoring and echocardiogram were unremarkable. Polysomnogram when she was not on Clarithromycin indicated mild obstructive sleep apnea and no narcolepsy. She had no further episodes of sleep paralysis after Clarithromycin was discontinued. Conclusions: We believe that administration of Clarithromycin was the cause of sleep paralysis. We hope that this case report increases awareness about this particular side effect of Clarithromycin and leads to further investigation about the etiology of sleep paralysis.
P.038 A case report of an interesting paraneoplastic voltage-gated channelopathy
Authors: Richard A , Legault C , de Villers-Sidani E , Gendron D
Published: June 2016

Background: Morvan syndrome is an autoimmune paraneoplastic disorder affecting of voltage-gated potassium channels, most commonly the CASPR-2 subunit. The disorder is primarily characterized by hyperexcitability of both the central and peripheral nervous system accompanied by autonomic dysfunction. Clinically, the syndrome manifests as confusion, hallucinations, insomnia, hyperhidrosis, orthostatic hypotension, and muscle cramps with myoclonus. Methods: Patient chart, imaging, electrophysiology, and laboratory findings were reviewed from the time of MS diagnosis and through the course of treatment until symptom resolution. Results: Here we report a case of Morvan Syndrome in a 56 year old male with a previous history of thymic squamous carcinoma accompanied by paraneoplastic myasthenia gravis and myositis. His clinical presentation was notable for subacute onset of muscle cramping, insomnia, which progressed to also include visual and auditory hallucinations. He also had notable dysautonomic symptoms including orthostatic blood pressure changes, sialorrhea, and hyperhidrosis. The diagnosis was confirmed with a positive serum assay for antibodies against the CASPR-2 subunit of voltage-gated potassium channels. Conclusions: This case is notable because to our knowledge it one of the first to document a voltage-gated channelopathy in association with previous thymic cancer (and not thymoma). Moreover, this is a patient presenting with two other other autoimmune syndromes, i.e. myasthenia gravis and myositis.
P.041 Does brain tissue oxygenation (BtO2) predict cognitive decline in patients undergoing hemodialysis? A feasibility study
Authors: Vanderlinden JA , Scott S , Holden R , Boyd JG
Published: June 2016

Background: Cognitive impairment is highly prevalent in individuals with end stage kidney disease (ESKD) undergoing hemodialysis. The cause is not understood. Our overall hypothesis is that repetitive cerebral hypoperfusion during hemodialysis contributes to accelerated cognitive dysfunction in this patient population. Methods: All participants underwent a baseline assessment with the KINARM, a robotic device that provides quantitative metrics of the sensorimotor control of the upper limb in humans. For patients undergoing hemodialysis, BtO2 was monitored during one dialysis session per week. Follow up KINARM assessment was done at 3 months. Results: To date, 7 patients have completed baseline testing, with 3 being re-evaluated at 3 months. At baseline, patients were impaired on of the 8 tasks, with the exception of a test of working memory. There was a variable correlation between hemodynamics (e.g. blood pressure and heart rate), fluid removal, and BtO2 levels. At 3 months, the 3 patients improved on the majority of the performance metrics assessed with the KINARM. Conclusions: The KINARM is a feasible instrument to measure cognitive dysfunction in individuals with ESKD. In a small cohort, there is improvement in neurocognitive function 3 months after the initiation of dialysis.
P.042 Associations of pain and depression with marital status in patients diagnosed with Parkinson’s disease
Authors: Rana A , Abdullah I , Qureshi AM , Mumtaz A , Rana M A.
Published: June 2016

Background: Depression and pain are significant clinical problems that are comorbid with Parkinson’s disease (PD). However, the relationship of these variables with the marital status of patients with PD has not been explored in previous studies. The goal of this study was to assess the possible relationship between depression prevalence, depression severity, and pain interference with the marital status of the sufferers of PD. Methods: This study included 40 patients and 40 healthy control participants who were assessed for depression prevalence and pain interference using The Hospital Anxiety and Depression Scale and the Brief Pain Inventory, respectively. Results: When compared to the control groups, the PD (Single) group was found to have the highest prevalence of depression, followed by the PD (Married) group whereas the Control (Single) group was found to have a higher prevalence than the Control (Married) group (P<0.0001). A main effect was found on depression severity (P<0.0001), but no significant differences were observed between the PD groups. Lastly, PD (Single) patients had significantly greater pain interference scores than the PD (Married) patients (P<0.05) with no other significant case-control or control-control group differences. Conclusions: Patient-spouse relationship may have a mitigating effect on patient outcomes of depression prevalence and pain interference.
P.045 Quality of life and treatment satisfaction in onabotulinumtoxinA-treated cervical dystonia patients: multicentre, prospective, observational study, posture
Authors: Petitclerc M , Bhogal M , Dhani S , Belle Blagrove L
Published: June 2016

Background: Health-related quality of life (HRQoL) data is valuable, but limited. This analysis describes the impact of onabotulinumtoxinA treatment on HRQoL and level of treatment satisfaction in cervical dystonia (CD) patients. Methods: A multicenter, prospective, observational study in CD patients initiating onabotulinumtoxinA treatment (NCT01655862); ≤8 treatments administered at the physician’s discretion. Primary measures (baseline, 4/8 weeks post-treatment, and before final treatment): pain numeric rating scale (PNRS) and cervical dystonia impact profile questionnaire (CDIP-58). Secondary measures (8 weeks post-treatment): patient/physician treatment satisfaction. Results: 61 patients (31.3-86.3 years old) were enrolled (efficacy cohort); majority had moderately severe CD (77.0%) and were female (77%). CDIP-58 domain and PNRS scores decreased from baseline, with significant changes (p<.0001) by 4 weeks post-treatment 3 (mean±SD): symptoms (-18.8±16.1), daily activities (-7.2±13.7), psychosocial sequelae (-17.4±13.4), and PNRS (-1.8±3.3). Most patients (78.0% and 94.4%) felt their condition was improved and majority of physicians (68.9% and 75.0%) indicated satisfaction with patients’ responses following treatments 1 and 2, respectively. 27 patients reported 56 treatment-related adverse events (52 resolved, 4 ongoing); none were serious. Conclusions: No new safety signals were identified. Patients and physicians appear to be satisfied with onabotulinumtoxinA treatment for CD. Results suggest that onabotulinumtoxinA treatment may help improve HRQoL.
P.046 Can targeted exercises for nerve movement be effective for primary restless leg syndrome in adults with and without musculoskeletal pain?
Authors: Gibbons SG
Published: June 2016

Background: Restless leg syndrome (RLS) is common with musculoskeletal pain conditions and has been associated with small fiber neuropathy. There are few reports of non pharmacological management of RLS. The purpose of this paper was to report the use nerve mobilization exercises in a group of patients with primary RLS with and without co-morbid chronic non specific low back pain (LBP). Methods: 26 consecutive patients (11M/14F) with primary RLS and LBP attended a mean of 12 physiotherapy sessions (range 4-16). Patients were given 3 neural mobilization exercises to do twice daily 15-20 repetitions. Outcome measures were: Global Rating of Change Scale (GROC); Restless Legs Syndrome Rating Scale (RLS-RS); and RLS Ordinal Scale (RLS-OS). Based on the RLS-RS 1 was very severe, 8 were severe and 17 were moderate. Results: Follow up was a mean of 14 months (range12-16). Mean baseline for the RLS-RS was 22.8. The mean change was 20.3 (range 14-26). The mean baseline for the RLS-OS was 4.3. The mean score at follow up was 1.2 (range 1-4). GROC changed a mean of 6.2 (range 3-7). Conclusions: The results suggest that targeted exercises may be useful in managing primary RLS. A level 1 clinical trial is warranted. Further research is needed to identify the mechanism of action.
P.050 Autoimmune encephalitis associated with GAD65 antibodies: brief review of the relevant literature
Authors: Gagnon M , Savard M
Published: June 2016

Background: Recently, many cases of autoimmune encephalitis with positive GAD65 (Glutamic acid decarboxylase) antibodies have been described in the literature. However, it remains an understudied topic. Methods: We conducted a search on reported cases of anti-GAD65 encephalitis. Specific variables were identified as general characteristics, clinical manifestations, MRI and EEG findings, concomitant systemic autoimmune disorders and cancer, and outcome and autoantibodies findings. Results: We identified a total of 58 cases, from one to 70 years old. It most frequently presented with seizures (97%) and memory impairment (59%). It commonly occurred in association with systemic autoimmune disease, particularly diabetes (28%). Brain MRI was usually abnormal (78%); involvement of temporal lobes was more frequent than multifocal abnormalities (59% vs 16%). GAD65 antibodies were reported positive in CSF and/or serum (31% in serum only). Other antibodies such as GABABR, GABAAR and VGKC were concurrently reported positive in some cases (19%). However, we found that the vast majority of cases were not tested for all those cell-surface antibodies. Overall, no distinctive pattern of clinical and paraclinical findings was found. Persistent impairments were common. Optimal treatment remained undefined. Conclusions: Prospective studies recruiting patients with autoimmune encephalitis are needed to better elucidate the contributions of GAD65 autoantibodies, and to evaluate treatment and outcomes in this population.
P.055 Bilateral facial nerve gadolinium enhancement and GBS
Authors: Alshurem M , O’Ferrall EK
Published: June 2016

Background: Facial diplegia with parasthesia (FDP) is a rare variant of Guillain–Barre syndrome (GBS), and has been reported in less than 1% of GBS cohorts. Here we describe a case of FDP with novel imaging findings and discuss the differential diagnosis. Methods: Case: A 39-year-old man referred to the emergency department with a 2 week history of right facial palsy progressed to bilateral facial palsy. His exam demonstrated severe, complete facial diplegia with only very mild limb weakness and present but diminished deep tendon reflexes. Results: Cerebrospinal fluid analysis showed albuminocytologic dissociation. Electromyography was consistent with a demyelinating process. MRI with contrast revealed bilateral enhancement of the facial nerves in the intracanalicular portion and in the region of the geniculate ganglion. A diagnosis of GBS was made and the patient was treated with IVIG. Over the course of several weeks the patient improved. Conclusions: Although nerve root enhancement of the spinal cord is described with GBS, nerve root enhancement effecting cranial nerves has only rarely been described. In addition, the relative limb-sparing with complete facial paralysis in this case is also an unusual phenotype. The Gadolinium enhancement of the bilateral facial nerves is thought to represent blood brain barrier breakdown due to GBS.
P.056 Survey of Canadian myotonic dystrophy patients’ access to computer technology
Authors: Climans SA , Piechowicz C , Koopman WJ , Venance SL
Published: June 2016

Background: Myotonic dystrophy is an autosomal dominant condition affecting distal hand strength, energy and cognition. There is a neuromuscular patient portal under development that has the potential to give voices and resource access to patients, regardless of location via the internet and social media. The current state of access to technology and underlying factors affecting use and interest were explored. Methods: Surveys were mailed to 156 participants with myotonic dystrophy type 1 (DM1) through the Canadian Neuromuscular Disease Registry. The survey questions touched on demographics, technology use, internet use, and interest in the portal. Results: Seventy-two participants (43 female) responded so far and 50% were younger than 46 years. Most (62/72) used the internet and 94% of participants had access to an internet-connected device. Almost half of the responders (34/72) used social media. The complexity and cost of technology were commonly cited reasons not to use technology. The majority of responders (79%) were interested in a myotonic dystrophy patient portal. Conclusions: DM1 patients have access to and use technology such as computers and mobile phones. They expressed interest in a portal that would provide them with access to relevant information such as guidelines, self-management modules, educational videos, and support groups.
P.057 Distal hereditary motor neuropathy type I due to the GARS: c.1415A>G, p.His472Arg mutation
Authors: Florendo-Cumbermack AG , Kimpinski K , Venance S
Published: June 2016

Background: The distal hereditary motor neuropathies (dHMN) have been characterized through case reports and family studies. Their genetic characterization remains a work in progress. An appreciation of the genetic underpinnings may lead to treatment options in the future. Hence reports, like this one, which add to this understanding, remain extremely important. Methods: The clinical presentations, electrophysiology and genetics of two patients with the dHMN I phenotype are described. Results: A mother and son presented with slowly progressive distal weakness of the lower extremities with onset in the first and second decades. Distal weakness of the upper extremities developed later. Examination 20 and 50 years after onset revealed wasting and weakness of distal upper and lower extremity muscles with absent distal and preserved proximal deep tendon reflexes. Sensory examination was normal. Electrodiagnostic studies demonstrated a motor axonopathy. Genetics testing revealed a missense mutation on chromosome 7, exon 11 of the GARS gene: c.1415A>G (p.His472Arg). Conclusions: GARS mutations have been identified in patients with the dHMN I (juvenile onset distal weakness and wasting) and dHMN V (upper limb predominant) phenotypes. However, this mutation has not previously been directly linked to the dHMN I phenotype.
P.058 Length dependent sensorimotor peripheral neuropathy often results in ventral abdominal sensory loss
Authors: Gervais CB , Ross MA , Goodman BP , Angel LA , Benn SE
Published: June 2016

Background: Length-Dependent Sensorimotor Peripheral Neuropathy (LDSMPN) affects the longest nerve fibers in the body. Less well-appreciated, and absent from the current literature, is that LDSMPN affecting thoracic segments gives rise to ventral abdominal sensory loss on clinical exam. Methods: Consecutive patients seen for LDSMPN (n=30) were evaluated prospectively for the presence or absence of ventral abdominal sensory loss. Demographic variables, symptoms, quantitative neurologic findings (Neuropathy Impairment Score [NIS]) and final diagnosis were examined using descriptive statistics. Results: Ventral abdominal sensory loss was documented in 20/30 LDSMPN patients (66.7%), mean age was 64.1 years (range 33-81), M:F gender ratio was 19:11, mean NIS was 21.4 (range 0-77). NCS/EMG abnormalities were found in 25/30 patients, with 5/30 having a clinical exam and/or other electrophysiological evidence convincing for LDSMPN. LDSMPN patients without ventral abdominal sensory loss (n=10) had a mean age of 61.2 (range 45-73), M:F of 7:3, and mean NIS of 20.9 (range 0-54). Conclusions: 1) Ventral abdominal sensory loss appears to be common in patients diagnosed with LDSMPN of a variety of causes; 2) in addition to those innervating distal limb territories, distal sensory fibers from the thoracic region represent another category of length dependent involvement in LDSMPN; 3) the clinical examination of LDSMPN should include the ventral abdomen.
P.061 Multi-modal synchrotron imaging techniques to quantify elemental and molecular changes after stroke in an animal model
Authors: Ahmed S , Hackett M , Caine S , Sylvain N , Hou H , Weese Maley S , Kelly ME
Published: June 2016

Background: Effects of stroke at the cellular and sub-cellular level remain poorly understood by conventional techniques. We use synchrotron-based imaging techniques to study elemental and biochemical changes in the infarct and penumbra after stroke in an experimental model. Methods: Ischemic stroke is induced in mice using the previously validated photothrombotic model. Animals are sacrificed at various time-points after stroke. Fourier transform infrared spectroscopic imaging (FTIRI) is used to gather sub-cellular (<1 µm spatial resolution) imaging data of lipid oxidation and protein aggregation in the areas of interest. X-ray fluorescence (XRF) imaging is used to image the distribution of bio-important elements at the cellular and sub-cellular spatial resolutions. Routine histology and immunohistochemistry are used to co-localize cell-types to areas of interest. Results: Preliminary XRF results indicate significant reduction in the concentration of multiple elements in the infarct, compared to the penumbra, at day 1 post-stroke. Some elements begin to return to normal concentration in the penumbra at day 3. FTIRI data shows that lipid and total protein levels decrease, while aggregate protein levels increase in the penumbra. Conclusions: Multi-modality synchrotron imaging can be used to map elements as well as bio-molecules in a stroke model. A better understanding of these changes can guide therapeutic interventions after stroke.
P.063 Durability over time of strategies to reduce door-to-needle times in thrombolysis of acute ischaemic stroke
Authors: Moussaddy A , Chen B , Keezer M , Deschaintre Y , Poppe AY
Published: June 2016

Background: Faster administration of tissue plasminogen activator (tPA) for patients with acute ischaemic stroke yields greater clinical benefits. We implemented door-to-needle (DTN) time reduction strategies at our centre and evaluated their short- and long-term effects on in-hospital treatment delays and clinical outcomes. Methods: Stroke team pre-notification, direct computed tomography (CT) transfer, not routinely waiting for labs and tPA delivery on CT table were implemented in June 2013. We included all thrombolysed patients admitted directly to our hospital between January 2012 and March 2015. In-hospital delays and clinical outcomes (Modified Rankin scale, mRS) at 3 months were compared between patients pre- and post-modification, and the latter period was divided into early and late phases to assess the durability of our modifications. Results: Forty-eight individuals were treated pre-modification, compared to 58 post-modification. The median DTN time was reduced from 75 (interquartile range: 60-93) minutes to 46 (33-59) minutes (p<0.0001). The median DTN time in the early and late post-modification phases was not different (41 versus 46 minutes, p=0.4085). Functional outcome at 3 months was not different in the two groups (proportion of mRS≤1: 34% versus 28%, p=0.882). Conclusions: We were able to decrease our DTN time for treatment of acute stroke by implementing simple modifications and these improvements persisted over time.
P.064 Delays in the emergency department for stroke patients, medical complications and predictors of outcomes: the McGill experience
Authors: Legault C , Chen B , Vieira L , (Montreal) B Lo , Wadup L , Cote R
Published: June 2016

Background: The Canadian Stroke Best Practice recommends admission of patients to a specialised stroke unit within three hours. We aimed at assessing delays in our emergency department (ED) and correlating these with medical complications and clinical outcomes. Methods: Predictors and outcomes This is a retrospective review of patients (n=353) admitted with ischemic strokes (January 2011-March 2014). We assessed the length of stay in ED, medical complications in ED and in the stroke unit, functional status (modified Rankin Scale) at discharge and survival. Results: The median delay in ED was 13.8 hours. The rate of medical complications in the ED was 14% (most common being delirium), compared to the stroke unit with 46.7% (most common being pneumonia). Worse functional outcome was correlated with diagnosis of pneumonia (standardised β coefficient=0.2, p=0.001) and presence of brain oedema in the stroke unit (standardised β coefficient=0.2, p<0.01). Increased risk of death was correlated with brain oedema (OR=649.2, 95%CI=19-2184, p<0.01) and sepsis in the stroke unit (OR=26.8, 95%CI=2.1-339, p<0.01). Conclusions: We found a significant delay in the admission of our patients from the ED to the stroke unit, which is not in keeping with the present guidelines. Medical complications were correlated with worse outcomes. Future analyses will correlate ED delays with clinical outcomes.
P.066 Failing a dysphagia screen after acute ischemic stroke is highly predictive of poor outcomes
Authors: Joundi RA , Martino R , Saposnik G , Fang J , Giannakeas V , Kapral MK
Published: June 2016

Background: Bedside dysphagia screening is recommended for all patients with acute ischemic stroke, in order to detect swallowing impairment early and prevent complications. However, limited data are available on outcomes associated with failing a dysphagia screen. Methods: We used the Ontario Stroke Registry to identify patients who were admitted to Regional Stroke Centres from 2010-2013 and received a dysphagia screen within 72 hours. We used multivariable regression to determine outcomes of patients who failed the dysphagia screen. Results: Among 5145 patients who underwent dysphagia screening, 2458 (47.8%) failed and 2687 (52.2%) passed. Patients who failed had more co-morbidities and presented with more severe strokes (mean NIHSS 11.0 vs. 5.4). Among those who failed, 9% required permanent feeding tubes, versus 0.1% among those who passed. After controlling for age, co-morbidities, and stroke severity, failing a bedside swallowing screen remained highly predictive of poor outcomes, including decubitus ulcer (adjusted odds ratio aOR 10.5), pneumonia (aOR 4.6), discharge to long-term care (aOR 4.1) and 30-day mortality (aOR 4.5; 16.6% vs. 2.2%). *All p <0.0001 Conclusions: Patients who failed a dysphagia screen on admission had dramatically worse outcomes after controlling for baseline factors. A bedside dysphagia screen provides immediate risk stratification for acute stroke patients and can be used to guide appropriate care.
P.067 Incidence of tissue-defined stroke and large vessel occlusion in acute stroke alerts in a non-teaching hospital system
Authors: Doherty D , Morrissette M , Spinos E , Mattingly TK
Published: June 2016

Background: Stroke alerts are used to triage patients with acute neurologic change for rapid imaging evaluation. CTA has been advocated to rapidly triage stroke patients for endovascular therapy. However, the yield of this approach is not well established. We evaluated the stroke alert yield in a non-teaching hospital system. Methods: A retrospective review of radiology reports for stroke alerts using PACS archive. Cases were then followed for 72 hours to determine the types of advanced imaging obtained and the findings of those studies. Results: From January to March 2014, 269 stroke alert head CTs were performed. Subsequent imaging included 128 MRIs (48%), 25 CTAs (9%) and 2 angiograms (0.7%). There were 58 (22%) tissue-defined strokes and 16 were non-lacunar (6% stroke alerts). 61% of stroke alert head CTs were negative or reported microvascular change. Other findings included large vessel occlusion (5%), intracranial stenosis (1.5%), extracranial stenosis(1.5 %), intracranial hemorrhage (9%) and masses (13%). Conclusions: Most stroke alerts were negative for tissue-defined stroke. Based on this data, universal use of CTA in the ER to triage patients with acute neurologic symptoms may not be appropriate. An updated triage system to facilitate endovascular rescue is being analyzed for changes to advanced imaging utilization and yield.
P.072 The spectrotemporal characteristics of NMDA receptor encephalitis
Authors: Richard A , Zanos T , Dubeau F , de Villers-Sidani E
Published: June 2016

Background: NMDA receptor encephalitis (NMDA-RE) is an autoimmune disorder caused by antibodies to the NR1-NR2B heterodimer of the NMDA receptor. Currently, disease status is tracked primarily by the presence of auto-antibodies in the cerebrospinal fluid (CSF) and serum. Using serological and CSF markers along with clinical parameters to track disease progress can be challenging since patient symptoms and disease progress can vary widely. Methods: EEGs were reviewed in a 31 year old male patient with proven NMDA-RE. EEG data were sampled from various times before and after diagnosis, as well as during various stages of treatment. All analyses were performed using Matlab (Mathworks). Results: We showed that using a simple 1/f model of spectral behaviour (Buzsaki and Draguhn, 2004), we could fit the power spectra of the raw data at various instances during routine EEGs. We have demonstrated that the values of specific fitting parameters vary in relationship to the patient’s clinical status across various stages of illness. Conclusions: The aim of this project was to explore the potential utility of EEG as a complement to the usual clinical metrics used in monitoring NMDA-RE. The analysis techniques presented here highlight the use of EEG as a practical, minimaly-invasive tool to monitor progress and potentially aid in clinical decision making.
P.075 Rates of infection following craniotomy or craniectomy with subsequent cranioplasty in traumatic brain injury
Authors: Cadieux M , Gallagher C
Published: June 2016

Background: Postoperative infection is a significant cause of morbidity and mortality in traumatic brain injury (TBI) patients who undergo craniotomy and/or craniectomy. Data on the rates of infections associated with these procedures are limited. We present a single-center retrospective study on the rates of infection in post-traumatic craniotomies, craniectomies and cranioplasties. Methods: Data on 100 TBI adult patients who underwent a craniotomy, craniectomy and/or cranioplasty from 2011-2015 will be analyzed. Demographic and perioperative data including open/closed TBI, peri/postoperative infections, duration of procedure, type and mode of bone flap preservation will be retrieved. Results: Following our data collection (to be completed by the end of February), we expect infection rates of 3-20% in our study. Upon instituting a protocol similar to the Hydrocephalus Clinical Research Network’s (HCRN) ventriculoperitoneal shunt (VP) protocol, we hope to reduce our post-TBI craniotomy/craniectomy/cranioplasty infections rates to less than 10%. Our projection is based on the HCRN protocol’s 3.15% absolute risk reduction of VP shunt infections. Conclusions: The results of this study will emphasize the need for instituting robust perioperative protocols to reduce infections. Further research will be pursued following this study to establish a protocol similar to the VP shunt protocol from the HCRN, in an attempt to reduce perioperative rates of infection.
P.080 Traumatic brain injury in a rural indigenous population in Canada: a community-based approach to surveillance
Authors: Lasry O , Dudley RW , Fuhrer R , Torrie J , Carlin R , Marcoux J
Published: June 2016

Background: Indigenous populations are disproportionately affected by traumatic brain injury (TBI). These populations rely on large jurisdiction surveillance efforts to inform their prevention strategies, which may not address their needs. This study describes the TBI determinants of a Quebec indigenous population, the Cree served by the Terres-Cries-de-la-Baie-James health region, and compares them to the determinants of two neighbouring health regions and the entire Province of Quebec. Methods: We conducted a retrospective population-based cohort study of incident TBI hospitalizations, stratified by the aforementioned health regions, in Quebec from 2000-2012. MED-éCHO administrative data were used for case finding. A sub-analysis of the Terres-Cries-de-la-Baie-James adults was completed to assess for determinants of TBI severity and outcomes. Regression models, multiple imputations and a sensitivity analysis were used to account for biased associations. Results: 172 incident TBI hospitalizations occurred in the Terres-Cries-de-la-Baie-James region from 2000-2012. The incidence rate was 92.1 per 100,000 person-years and the adjusted IRR was 1.86 (95% CI 1.56-2.17) when compared to the entire province. Determinants of TBI for the Terres-Cries-de-la-Baie-James were significantly different from those of neighboring populations and the entire province. Conclusions: TBI surveillance information from large jurisdiction initiatives can be misleading for indigenous communities. Community-based surveillance provides evidence that these populations should use to prioritize prevention strategies.
P.082 Traumatic inter hemispheric subdural hematomas – clinical presentation, management and outcome
Authors: Bokari R , Schur S , Couturier C , Al-Azri A , Marcoux J , Maleki M
Published: June 2016

Background: There is currently little data on the incidence, clinical outcome and management of traumatic interhemispheric subdural hematomas (IHSDHs). Methods: All patients admitted with an acute subdural hematoma (SDH) over a 5-year period at a Level I trauma center were included. A detailed review of all cases of large IHSDH (≥7 mm) was performed to document clinical presentation, management and outcomes. Results: Of 1182 patients with acute subdural hematomas (SDHs), 420 had IHSDHs (24%), and 50 were large IHSDHs. For patients with large IHSDH, the average age was 76 years (±11) and 44% were female. The average GCS was 12 on presentation (±4), and the average GOSE was 4 (±2). 66% of patients had associated cranial/ intracranial injuries (fracture, subarachnoid/epidural/SDH) and 26% required operations for acute convexity SDH. Three patients required operations for their IHSDH by inter hemispheric approach. By 10 weeks, 82% had a complete resolution of the IHSDHs. Conclusions: IHSDHs are often referred to as rare entities. Our results show they are common. Conservative management is often appropriate to manage even large IHSDHs, as most resolve spontaneously. This study will help document the occurrence of falx syndrome, as well as the management and outcomes of larger IHSDHs.
P.086 The clinical significance of trigeminal neuralgia nomenclature
Authors: Nolin SV , Barchet L , Kaufmann A
Published: June 2016

Background: A diagnosis of trigeminal neuralgia (TN) may be broadly applied to many neuralgic facial pains, while more stringent criteria are required for management decisions, outcome assessment, and pathophysiological correlations. Our aim was to evaluate existing classification systems of facial pain. Methods: The study population was comprised of 534 Manitobans referred to neurosurgery for facial pain from 2001 to 2013. A retrospective chart review identified presenting features; pain distribution, nature, and duration. The recorded diagnoses (rDx) were then re-classified according to the International Classification of Headache Disorders (ICHD-3) and Burchiel System of TN1 and TN2. Results: There was complete correlation between rDx and ICHD-3 for typical TN (tTN) in 266(49.8%) patients, atypical TN (aTN) in 39(7.3%), and idiopathic facial pain (IFP) in 59(11%). Idiopathic trigeminal neuropathy (iTn) in 35(6.6%) was not classified in ICHD-3. Burchiel-TN1 included heterogeneous diagnoses including tTN (266), aTN (27), iTn (2) and IFP (8); Burchiel-TN2 included aTN (10), iTn (23), and IFP (15). Another 135(25.5%) had other facial pain diagnoses. Conclusions: Classification of TN is especially important when selecting and evaluating surgical treatments. Diagnostic criteria should clearly differentiate between unique conditions and ideally have basis on underlying etiology. The ICHD-3 nomenclature best satisfies these aims although should be expanded to include iTn.
P.089 Recovery from chronic secondary adrenal insufficiency in patients with pituitary disorders
Authors: Munro V , Tugwell B , Doucette S , Clarke DB , Lacroix A , Imran SA
Published: June 2016

Background: Patients with pituitary disorders may be placed on steroid replacement for secondary adrenal insufficiency (SAI), generally after pituitary surgery; however, data regarding recovery of long-term SAI are lacking. We conducted a study to assess the longer term recovery rate of SAI in patients with pituitary disorders. Methods: We identified all SAI patients from prospectively entered data in the Halifax Neuropituitary Database from November 1, 2005 to September 30, 2014, who had required glucocorticoid therapy for >3 months, and a minimum follow-up of 6 months. Exclusion: ACTH-secreting adenomas; peri-operative glucocorticoid treatment only; glucocorticoids for non-pituitary conditions. Results: 55 patients fulfilled the criteria, 41 (75%) of which had transsphenoidal surgery. Nine (16.4%) patients had complete recovery of SAI over a median of 20 months (range: 8–51). Smaller tumour size and initial cortisol >175 nmol/L had increased likelihood of recovery; those with secondary hypogonadism or growth hormone deficiency were less likely to recover. Conclusions: This is the first study to examine long-term recover of SAI in patients with pituitary disorders: approximately 1 in 6 patients recover adrenal function, up to 5 years after diagnosis. Consequently, patients with SAI should undergo regular testing to prevent unnecessary chronic glucocorticoid therapy.
P.091 Intracerebral hemorrhage secondary to multiple myeloma: a systematic review
Authors: Kameda M , Koziarz A , Aref M , Badhiwala J , Reddy K , Almenawer SA
Published: June 2016

Background: Multiple myeloma (MM) as a cause of spontaneous intracranial hemorrhage has not been well established. Methods: We report a patient who developed a spontaneous intracerebral hemorrhage secondary to MM and conduct a systematic review of the literature. In addition, we discuss the underlying pathophysiology. Results: A 67-year-old relatively healthy female with a recent history of low back pain presented with an altered level of consciousness and left sided hemiplegia. CT demonstrated a large right temporal intracerebral hemorrhage. CT angiogram ruled out a vascular abnormality; however, multiple abnormal bony lesions were incidentally noted. Other causes for intracranial bleed were ruled out. She underwent a craniotomy for hematoma evacuation. Intra-operatively, the skull was noted to be abnormal and hematoma was not associated with a mass lesion. In addition, serum and urine electrophoresis were found to be positive for monoclonal free kappa light chains. Subsequent bone biopsy confirmed the diagnosis of MM. Our literature search identified 2 reported cases of spontaneous subdural hematomas and 2 patients with spontaneous intracerebral hematomas secondary to MM. Moreover, only 4 reports in the literature document intracranial hemorrhage secondary to a mass developed from MM. Conclusions: Multiple myeloma is perhaps an under-reported possible cause for spontaneous intracerebral hematoma.