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Background The Full Outline of UnResponsivness (FOUR) score is a neurological assessment score. Its theoretical benefit over preexisting scores is its evaluation of brainstem reflexes and respiratory pattern which may allow better assessment of patients with severe neurologic impairment. Objective Our goal was to perform a scoping systematic review on the available literature for FOUR score and outcome prediction in critically ill patients. The primary outcome of interest was patient global outcome, as assessed by any of: mortality, modified Rankin Score, Glasgow Outcome Score, or any other functional or neuropsychiatric outcome. Information on interobserver reliability was also extracted. Methods MEDLINE and five other databases were searched. Inclusion criteria were: humans, adults, and children; prospective randomized controlled trial; prospective cohort, cohort/control, case series, prospective, and retrospective studies. Two reviewers independently screened the results. Full texts for citations passing this initial screen were obtained. Inclusion and exclusion criteria were applied to each article to obtain final articles for review. Results on adult populations are presented here. Data are reported following the preferred reporting items for systematic reviews and meta-analyses guidelines. Results The initial search yielded 1709 citations. Of those used, 49 were based on adult and 6 on pediatric populations. All but 8 retrospective adult studies were performed prospectively. Patient categories included traumatic brain injury, intraventricular hemorrhage, intracerebral hemorrhage, subarachnoid hemorrhage, ischemic stroke, general/combined neurology and neurosurgery, post-cardiac arrest, medicine/general critical illness, and patients in the emergency department. A total of 9092 adult patients were studied. Fourteen studies demonstrated good interobserver reliability of the FOUR score. Nine studies demonstrated prognostic value of the FOUR score in predicting mortality and functional outcomes. Thirty-two studies demonstrated equivalency or superiority of the FOUR score compared to Glasgow Coma Score in prediction of mortality and functional outcomes. Conclusions The FOUR score has been shown to be a useful outcome predictor in many patients with depressed level of consciousness. It displays good inter-rater reliability among physicians and nurses.

Background: Extracranial traumatic vertebral artery injury (eTVAI) is common following non-penetrating head and neck trauma. Most cases are initially asymptomatic with an increased risk for stroke. Consensus is lacking regarding screening, treatment, and follow-up of asymptomatic patients with eTVAI. Our objective was to investigate national practice patterns reflecting these domains. Methods: An electronic survey was distributed via the Canadian Neurological Sciences Federation and Canadian Spine Society. Two case-based scenarios featured asymptomatic patients with eTVAI. Case 1: non-displaced cervical lateral mass fracture; angiography stratified by luminal diameter reduction. Case 2: complex C2 fracture; angiography featuring pseudoaneurysm dissection. Analysis: descriptive statistics. Results: Response Rate: 108 of 182 participants (59%), representing 20 academic institutions. Case 1: 78% of respondents would screen using CTA (97%), immediately (88%). Most respondents (97%) would initiate treatment, using aspirin (89%) for 3-6 months (46%). Case 2: 73% of respondents would screen using CTA (96%), immediately (88%). The majority of respondents (94%) would initiate treatment, using aspirin (50%) for 3-6 months (35%). Thirty-six percent of respondents would utilize endovascular therapy. In both cases, the majority of respondents would follow-up clinically or radiographically every 1-3 months, respectively. Conclusions: This study highlights consensus in Canadian practice patterns for the workup and management of asymptomatic eTVAI.

Background: Hemifacial Spasm (HFS) is rarely caused by a dolichoectatic vertebrobasilar artery (eVB) compression of the Facial Nerve. This can pose a surgical challenge when performing microvascular decompression as vessel mobilization is often difficult due to atherosclerosis, tethering from brainstem perforators, and large size. These patients are often not considered for surgery. Methods: A retrospective chart review of patients who were surgically treated by the senior author between 2003 and 2017 with an admitting diagnosis of HFS was performed. Patients with preoperative neuroimaging demonstrating eVB compression of their facial nerve/root were included. Results: During the 15-year review, 315 patients underwent microvascular decompression for HFS and 21 (6.7%) had dolichoectactic vertebrobasilar compressions. At final followup (>3 months) 19 patients (90.4%) experienced reduction in symptoms with 15 (71.4%) having complete resolution. One patient required re-operation and benefitted from subsequent symptom relief. The majority of culprit compression was found proximally on the pontine surface. Mobilization of the culprit vessel was achieved successfully in the majority of cases with Teflon pledgets. There were no perioperative strokes or death. Complications are presented Conclusions: Microvascular Decompression for Hemifacial Spasm caused by dolichoectatic vertebrobasilar artery compression can be performed with a high rate of safety and success in the setting of a high case volume centre.

Background: Our goal was to perform a scoping systematic review of the literature on the application of the FOUR score within critically ill patients. Methods: 6 databases were searched. Two reviewers independently screened the results. Inclusion and exclusion criteria were applied to each article to obtain final articles for review. Results: The initial search yielded 1709 citations. Of those used, 49 were based on adult and 6 on pediatric populations. All but 8 retrospective adult studies were performed prospectively. Patient categories included traumatic brain injury, intraventricular hemorrhage, intracerebral hemorrhage, subarachnoid hemorrhage, ischemic stroke, general/combined neurology and neurosurgery, post-cardiac arrest, medicine/general critical illness, and patients in the emergency department. A total of 9092 adult patients were studied. 14 studies demonstrated good inter-observer reliability of the FOUR score. 9 studies demonstrated prognostic value of the FOUR score in predicting mortality and functional outcomes. 31 studies demonstrated equivalency or superiority of the FOUR score compared to GCS in prediction of mortality and functional outcomes. Similar results were seen for the pediatric population. Conclusions: The FOUR score has been shown to be a useful outcome predictor in many patients with depressed level of consciousness. It displays good inter-rater reliability among physicians and nurses.

Background: Gross total resection of pediatric posterior fossa tumors is paramount towards improving progression-free survival. Fluorescein accumulates in tumoral tissue, where the blood-brain barrier is disrupted. It can therefore potentially aid in differentiating tumoral versus normal tissue. We aimed to evaluate the efficacy of fluorescent-guidance (using fluorescein) towards the resection of a pediatric cerebellar tumor, as the index case at our institution using this technique. Methods: 5 mg/kg of IV fluorescein sodium was injected upon induction of general anesthesia. During tumor resection, a yellow 560-nm filter (Kinevo microscope, Zeiss) was employed for fluorescent-guidance. The extent of resection was assessed via post-operative MRI. Results: There were no adverse side effects experienced by the patient. Tumoral material was clearly visualized under the yellow 560-nm filter, allowing for satisfactory gross total resection of the lesion (confirmed on post-operative MRI). Preliminary pathology was consistent with medulloblastoma. Conclusions: Fluorescent-guided resection of pediatric posterior fossa tumors appears to be a safe and useful adjunct for gross total resection of these lesions. To the best of our knowledge, this is the first reported case in Canada wherein IV fluorescein was used under a yellow 560-nm filter for resection of a posterior fossa medulloblastoma in a child.

Background: Delayed Cerebral Ischemia (DCI) is a complication of aneurysmal subarachnoid hemorrhage (aSAH) and is associated with significant morbidity and mortality. A paucity of high-quality evidence is available to guide the management of DCI. As such, our objective was to evaluate practice patterns of Canadian physicians regarding the management of aSAH and DCI. Methods: The Canadian Neurosurgery Research Collaborative (CNRC) performed a cross-sectional survey of Canadian neurosurgeons, intensivists, and neurologists who manage aSAH. The survey was distributed to members of the Canadian Neurosurgical and Neurocritical Care Societies, respectively. Responses were analyzed using quantitative and qualitative methods. Results: The response rate was 129/340 (38%). Agreement among respondents included the need for intensive care unit admission, use of clinical and radiographic monitoring, and prophylaxis for prevention of DCI. Indications for starting hyperdynamic therapy varied. There was discrepancy in the proportion of patients felt to require intravenous milrinone, intra-arterial vasodilators, or physical angioplasty for treatment of DCI. Most respondents reported their facility does not utilize a standardized definition for DCI. Conclusions: DCI is an important clinical entity for which no consensus exists in management among Canadian practitioners. The CNRC calls for the development of national standards in the diagnosis and management of DCI.

The quantification and objective documentation of autonomic dysfunction in traumatic brain injury (TBI) is neither well studied nor extensively validated. Most of the descriptions of autonomic dysfunction in the literature are in the form of vague non-specific clinical manifestations. Few studies propose the use of objective measures of assessing the extent of autonomic dysfunction to link them to the outcome of TBI. Our goal was to perform a scoping systematic review of the literature on the objective documentation of autonomic dysfunction in terms of functional and physiological variables to be linked to outcome of TBI. PubMed/MEDLINE®, BIOSIS, Scopus, Embase, Cochrane Libraries, and Global Health databases were searched. Two reviewers independently screened the results. Full texts for citations passing this initial screen were obtained. Inclusion and exclusion criteria were applied to each article to obtain final articles for review. The initial search yielded 2619 citations. Of 69 articles selected for final review, 14 were chosen based on the inclusion and exclusion criteria and are included in the results of this article. 9 of these articles assessed autonomic dysfunction using functional variables and 7 assessed autonomic dysfunction using physiological variables. Some studies included both functional and physiological variables. Of the nine studies linking autonomic dysfunction to functional variables, nine included heart rate variability (HRV), three included baroreflex sensitivity (BRS), and two included blood pressure variability (BPV). A total of 2714 adult patients were studied. Although the nature of association between autonomic dysfunction and outcome is unclear, the objective quantification of autonomic dysfunction seems to be associated with global patient outcome and other neurophysiological measures. Further studies are needed to validate its use and explore the underlying molecular mechanisms of the described associations.

Background BB guns or non-powder guns created in the modern era are able to reach exceedingly fast velocities as a result of advances in compressed-gas technology. While missile penetrating trauma has been well documented in neurosurgical literature, penetrating intracranial injury secondary to non-powder guns, along with their associated complications and treatments, is not well described, and even less so in the pediatric population. Case presentation Here, we describe an unusual case of a 6-year-old Indigenous child who was accidentally shot with a BB gun to the head. He subsequently developed delayed acute right-sided weakness due to symptomatic vasospasm. His symptoms resolved following hypertensive therapy, balloon angioplasty intervention, and intra-arterial milrinone therapy. Conclusions This case highlights the unique complication of delayed symptomatic vasospasm in a child following a non-missile intracranial penetrating injury. Intracranial vasospasm needs to be considered in the presence of delayed neurological deficit given its potential reversibility. This case also emphasizes the importance of gun safety and education when handling and storing these potential weapons around children.

Background: Canadian spine care delivery is in crisis owing to inordinate patient wait times. Relying on the current method of a simple count of patients awaiting surgery leads to disproportionate wait time estimations depending on pathology; for example, patients with scoliosis wait longer than those needing simple discectomies. Using the Spinal Invasiveness Score (SIS) to categorize surgeries is a comprehensive solution; it is a validated scoring system that assigns points based on surgical invasiveness across 6 parameters. Wait-lists can then be calculated based on SIS score, with additional benefits such as subcategorization of wait times and initiatives to target specific subcategories of procedures. This study aims to evaluate spine surgeons and hospital administrators perceptions of adopting the SIS model for spine surgery wait-list management. Methods: A qualitative descriptive study was conducted surveying spine surgeons and hospital administrators across Canada. Participants reviewed a case study comparing the current waitlist model with the SIS-based approach and were surveyed on their preferred method for wait time calculation. Responses were analyzed using thematic analysis to identify recurring themes around SIS's perceived benefits, limitations, and barriers to adoption. Results: Of the 21 respondents, 17 (81%) preferred the SIS approach over the existing system, including 9 of 11 surgeons and 8 of 10 administrators. Thematic analysis revealed several key perceived benefits of SIS including subcategorizing wait-lists (e.g., multilevel v. single-level; instrumented v. noninstrumented), better triaging of cases, and more accurate wait time calculation. Barriers identified included difficulty for the health system to capture SIS score for each surgery, cost of implementation, and SIS not capturing full complexity of cases such as elevated body mass index or revision status. Conclusion: The SIS method was overwhelmingly well received, with numerous benefits identified as well as potential barriers and room for improvement. The SIS score has shown early success in advocating for more tailored operating room (OR) scheduling, such as longer OR days to accommodate complex surgeries. With careful implementation and adaptation, SIS could become a key part of nationwide wait-list management strategies.