Canadian Journal of Neurological Sciences最新文献

Background: Patients undergoing craniotomy experience a higher risk of seizures in the ensuing months. Consensus is lacking regarding the appropriate timeframe for safe return to driving following craniotomy in patients not otherwise limited by neurological deficits or a history of epilepsy.

Methods: We performed a systematic literature review on driving recommendations post-craniotomy. We then performed a scoping review on the risk of seizure post-craniotomy and used risk calculations and accepted risk thresholds from the epilepsy literature to develop an evidence-based approach to driving recommendations post-craniotomy.

Results: The systematic review of driving recommendations revealed national guidelines (the United Kingdom, New Zealand, Australia). We transposed risk calculations and accepted risk thresholds from the epilepsy literature (accident risk ratio [ARR] < 2; chance of occurrence of a seizure in the next year < 20%) to patients who undergo a craniotomy. Using data from a large meta-analysis of seizure risk post-craniotomy, we calculated ARRs for various underlying pathologies at different postoperative timepoints and compared them with accepted risk thresholds from the epilepsy literature. We determine that patients who undergo a craniotomy for a higher-risk condition (like high-grade glioma) may resume driving after at least 1 month without seizure, whereas those patients undergoing a craniotomy for lower-risk conditions (like infratentorial pathology) may resume driving without consideration for the risk of seizure.

Conclusion: This systematic review of the literature and evidence-based approach to risk threshold calculations derived from the epilepsy literature provides a preliminary framework to guide clinicians regarding recommendations for return to driving following craniotomy.

Background: Rural areas are often challenged in delivering time-sensitive hyper-acute stroke care. TeleStroke can improve access to time-sensitive reperfusion therapies. We aimed to evaluate our experience with TeleStroke and to explore if it facilitates reperfusion therapy in patients with acute ischemic stroke (AIS).

Methods and analysis: The Manitoba TeleStroke Program was rolled out across seven sites between November 2014 and January 2019. We retrospectively included consecutive patients with suspected AIS within 4.5 hours of onset, between November 2014 to December 2022. Demographic data, process metrics, and outcome measures were collected. The primary outcome was safety and efficacy measured in terms of 90-day modified Rankin score (mRs). A descriptive and analytical analysis was performed.

Results: Of the 1,748 TeleStroke patients (median age 71 years, female 810 [46.3%]), 696 (39.8%) were identified as AIS. Of these, 265 (38.1%) received intravenous thrombolysis. Ninety-day mortality was 53 (20.0%) among those receiving thrombolysis and 117 (44.2%) had a favorable outcome of mRs≤2. Among patients receiving thrombolysis, nine (3.4%) had a symptomatic intracranial hemorrhage. Arrival by ambulance occurred in 1115 (63.8%) cases, median last-seen-normal-to-door time was 121 minutes, and median door-to-needle time was 55 minutes. When comparing "AIS-without thrombolysis" and "AIS with thrombolysis," the median last-seen-normal-to-door was 210 versus 90 minutes (p < 0.001); and the median door-to-CT scanner was 24 versus 22 minutes (p = 0.009).

Conclusion: Intravenous thrombolysis for patients with AIS was found to be effective and safe in the Manitoba TeleStroke Program. Lessons learnt from our study will help improve the TeleStroke program in Manitoba and beyond.

Objective: To evaluate the impact of discharge destination on long-term functional outcomes in patients with aneurysmal subarachnoid hemorrhage (aSAH) and its association with achieving functional independence.

Methods: This retrospective cohort study included patients with aSAH treated endovascularly at a tertiary neurovascular center between October 2019 and November 2024. Patients who died before hospital discharge were excluded. Group comparisons were performed using one-way analysis of variance, Kruskal-Wallis, paired-sample t-tests and Pearson's χ². Multivariable logistic regression was used to assess the association between discharge site and functional independence achievement, adjusting for age, sex, World Federation of Neurosurgical Societies (WFNS) grade and modified Rankin Scale (mRS) score at discharge.

Results: A total of 213 patients (mean age 55.9 ± 13.7 years; 77% female) were included. Hypertension (57.7%) and previous smoking (45.1%) were the most common risk factors. Significant differences in age, sex, WFNS grade and modified Fisher Scale scores were observed across discharge groups. While patients discharged home had better overall outcomes, those with poor WFNS grades showed greater reductions in mRS at 6 and 12 months when discharged to an acute rehabilitation center. Regression analysis demonstrated that discharge to an acute rehabilitation center was independently associated with higher odds of functional independence, while discharge to a primary care hospital decreased these odds.

Conclusion: Discharge to a primary care hospital after aSAH was associated with worse long-term outcomes. In contrast, early transfer to an acute rehabilitation center significantly improved functional independence, particularly among patients with poor baseline neurological status.

Aim: To quantify optic nerve hypoplasia/septo-optic-pituitary dysplasia (ONH/SOD) all-cause mortality rate and risk of death in Manitoba, Canada.

Method: A retrospective population-based study with a case-control design was undertaken using the Manitoba Population Research Data Repository. Cases were 124 ONH/SOD patients diagnosed during 1990-2019, matched to 620 unrelated population-based controls on year of birth, sex and area of residence. Both cases and controls were followed until March 31, 2022, or until they moved out of the province or died. Crude mortality rate was estimated. Cox proportional hazards models were used to test for differences in all-cause mortality between cases and controls. Hazard ratios (HR) with 95% confidence intervals (CIs) were estimated.

Results: Six of 124 (4.8%) cases with ONH/SOD and 8 of 620 (1.3%) controls died during the study's follow-up period. The median (25^th-75^th percentiles) age of death of ONH/SOD patients was 4.6 (2.7-9.1) years. The median duration of follow-up was 12.0 years for the cases and 11.4 years for the controls. The crude mortality rate (95% CIs) was 3.7 (1.7-8.3) per 1000 person-years in patients with ONH/SOD and 1.0 (0.5-2.1) per 1000 person-years in unrelated matched controls. All-cause mortality was significantly higher in ONH/SOD patients compared to unrelated controls (HR = 3.7, 95% CI = 1.3-10.5).

Conclusion: Patients with ONH/SOD have a higher risk of death compared to unrelated controls. Healthcare professionals should be familiar with the morbidities and comorbidities associated with ONH/SOD and the complications that may lead to their demise, since they can be managed to reduce the mortality risk.

Introduction: Cenobamate is a novel anti-seizure medication (ASM) in the alkyl carbamate family with a dual mechanism of action: targeting persistent sodium currents and positively modulating γ-aminobutyric acid type A receptors independent of benzodiazepines. Approved by Health Canada in June 2023, it offers an additional treatment option for seizures. This study's objective was to review the real-world experience with cenobamate in a Provincial Comprehensive Epilepsy Program, soon after its availability in Canada.

Methods: A retrospective study of all patients prescribed cenobamate from June 2023 to May 2025.

Results: The study population comprised 36 patients with a median age of 18 years (range: 8-23 years). Seizure etiology was structural (n = 18) and genetic (n = 13). Prior to starting cenobamate, patients had tried a mean of 10 ASMs. Additionally, 19 (53%) had undergone epilepsy surgery, 3 (8%) had failed the ketogenic diet and 11 (31%) were treated with neuromodulation. Following a mean duration of 10.5 months of treatment with cenobamate, 50% (18/36) had a > 50% seizure reduction, and 20% (7/36) had a 25%-50% reduction of seizures. Fourteen percent (5/38) of patients were seizure-free at the most recent follow-up. The median dose was 200 mg (range: 62.5-400 mg). Eighteen patients (50%) experienced adverse effects (AEs), including dizziness, drowsiness, nausea and vomiting. However, only two patients discontinued cenobamate due to AEs. No patients discontinued cenobamate due to a lack of efficacy.

Conclusion: This real-world study demonstrates the efficacy and tolerability of cenobamate in patients with highly drug-resistant epilepsy.