Canadian Journal of Neurological Sciences最新文献

Background: There is an increasing number of patients with cancer and acute ischemic stroke (AIS). We aim to compare outcomes in patients treated with thrombolysis for AIS with a history of cancer to those without.

Methods: This is a post hoc analysis of the Intravenous tenecteplase compared with alteplase for acute ischaemic stroke in Canada (AcT) trial, evaluating tenecteplase versus alteplase in patients with AIS within 4.5 h of onset. ICD-10 codes via administrative data linkage were used to identify a history of cancer. Primary outcome was modified Rankin Scale (mRS) 0-2 at 90 days. Other outcomes included mRS 0-1 at 90 days, return to pre-stroke function, mortality and bleeding. Analysis was done using logistic regression for binary outcomes adjusted for age, stroke severity, presence of cancer history and time from onset to needle. A generalized linear regression model was used for numeric outcomes, with effect measures reported as adjusted risk ratios (aRR).

Results: Of the 1577 patients enrolled, 37 (2.35%) had a prior diagnosis of cancer. At 90 days, cancer patients were less likely to achieve 90-day mRS 0-2 (aOR of 0.33 [95% CI 0.15-0.75]) and had higher mortality (aOR 3.75 [95% CI 1.76-7.75]) as compared to those without cancer. Length of stay was longer in patients with cancer than those without cancer (median 11.5 days [IQR 7-24.5] vs 5 days [IQR 3-11], respectively, aRR 2.76 [95% CI 2.58-2.94]).

Conclusion: Patients with AIS and a history of cancer had worse functional outcomes, prolonged length of stay and higher rates of mortality as compared to those with no diagnosis of cancer.

Background: Social deprivation is associated with worse functional recovery and social participation after stroke. Home-based, individualized rehabilitation provided by Community Stroke Rehabilitation Teams (CSRTs) improves these outcomes. This study aimed to show that CSRTs offered an effective specific rehabilitation for socially deprived patients.

Methods: This was a retrospective study conducted in real-care conditions. Social deprivation was assessed by the Evaluation de la Précarité et des Inégalités de santé dans les Centres d'Examens de Santé score. The outcome questionnaires included the Frenchay Activity Index (FAI) and the EuroQol-5Dimension. We compared these outcomes between deprived and non-deprived (ND) populations. Rehabilitation of the deprived population was assessed by comparing interventions across both groups.

Results: We included 198 deprived patients and 140 ND patients. Deprived patients were more often women (p = 0.027), more likely to live alone at home (p = 0.01), and were referred later to a CSRT, despite having greater activity limitations at baseline (p < 0.001). They also had a lower FAI at baseline (13.2 vs. 16.6; p = 0.007). Although their FAI improved over time (+2.4 ± 5.5; p < 0.001), the improvement was modest and insufficient to close the gap with the ND group (15.7 vs. 20.7; p < 0.001). Regarding program characteristics, the deprived population received input from a greater number of healthcare professionals (2.7 ± 1.2 vs 2.4 ± 1.3; p = 0.017) and more often from the intervention "Health professional relationship" (34.2% vs 15.6%; p = 0.005).

Conclusion: These findings highlight the intersectionality of stroke-related challenges and the critical need to design post-stroke rehabilitation strategies that are more equitable and responsive to gender and social determinants of health.

Objective: Early placement of a ventricular access device (VAD) in premature post-hemorrhagic ventricular dilatation based on ventricular size criteria, coupled with an aggressive tapping regimen to control ventricular size, may improve developmental outcomes. As this treatment paradigm represents a significant departure from traditional care, we present results of an institutional quality improvement protocol implementation study focusing on safety and resource use for those seeking to implement a similar care pathway.

Methods: Infants treated under the new ventricular size-driven protocol were retrospectively compared to a historical cohort managed according to clinical symptomatology. Process and compliance measures related to protocol implementation were tracked, as were complications and measures of resource use.

Results: Ventricular access device (VAD) placement occurred earlier and at a smaller ventricle size, but beyond the protocol-mandated timeframe. Although more resource-intensive than customary care, compliance with protocol-directed screening ultrasounds and VAD aspirations by trained clinicians was high. Intensive ultrasound surveillance altered the management of only one infant during their treatment course. An increased rate of complications related to earlier and more aggressive treatment in these fragile infants was not observed.

Conclusions: Protocol compliance was satisfactory and no safety issues were noted. Although VAD placement occurred sooner, a majority of infants received intervention outside of the mandated timeframe and at a ventricular size above the desired intervention threshold. Minimizing transfer delays from peripheral neonatal intensive care units and improving access to the operating room were identified as areas for improvement. It appears possible to decrease the frequency of ultrasound surveillance without compromising safety.

Background: Stroke remains a leading cause of death in British Columbia (BC), Canada. Understanding whether mortality declines are driven by prevention (reduced incidence) or improved survival (treatment) can inform public health and acute care planning.

Methods: We conducted a population-based study of 123,075 stroke events from 2002 to 2022 among BC residents aged 35-110 years, using linked administrative datasets. We calculated age-standardized rates of stroke events, 30-day case fatality and mortality, stratifying the rates by sex, age, income and geography. Regression models estimated temporal changes and relative contributions of declining event rates and case fatality to mortality reductions.

Results: Age-standardized stroke event rates declined by 33% in females (208-140 per 100,000) and 25% in males (248-187) but increased among adults aged 35-54 (+14% females, +27% males). Females experienced a higher burden of stroke events as pre-admission deaths, particularly among 85+. Case fatality fell by 22% in females (40-31 per 100 events) and 15% in males (37-32), with the greatest improvements in younger adults. Mortality declined by 53% in females (72-34 per 100,000) and 43% in males (72-41) primarily driven by declines in case fatality. Disparities by sex, income and geography persisted.

Conclusion: Improved survival is the main driver of declining stroke mortality in BC, particularly in recent years. Socioeconomic, sex and age disparities persist, warranting focused strategies to address inequities and the rising stroke burden among younger populations.

Background: Rett Syndrome (RTT) is an X-linked neurodevelopmental disorder, characterized by the gradual loss of motor, verbal and social skills. This study describes the epidemiology and healthcare resource utilization (HCRU) of RTT in Ontario, Canada.

Methods: Rett Syndrome (RTT) cases (≥ one ICD-10-CA code F84.2) were identified utilizing the Institute for Clinical Evaluative Sciences (ICES) data. Incident cases were identified between September 2017 and August 2023, while prevalent cases were captured from April 2002 to August 2023. Prevalent cases identified before September 2017 were indexed on that date. Demographic and clinical characteristics were collected and analyzed descriptively. Prevalence and incidence were calculated. Healthcare resource utilization (HCRU) was analyzed as the number of cases with at least one touchpoint and the number of touchpoints.

Results: In total, 246 RTT cases were indexed; 40% from central Ontario, 95% female, median age 21 years. From September 2017 to August 2023, 57 incident cases and 257 prevalent cases were reported in Ontario. Common comorbidities included developmental disability (85.4%), epilepsy (49.6%) and gastrointestinal symptoms (42.3 %). Most patients had at least one outpatient visit (primary care 96.7%, specialist 86.6%), emergency department visit (76.8%) and inpatient hospitalization (54.5%). During the 5-year follow-up period, most cases (95.1%) had at least one public claim for all-cause medication. Disease-specific medication claims included antibiotics (69.1%) and anti-seizure medications (73.6%).

Conclusion: This study provides population-based estimates of RTT in Ontario. Findings highlight the high burden of illness in RTT in terms of comorbidity prevalence and HCRU. Further research may identify opportunities to improve healthcare outcomes in this population.

A perceived barrier to effective treatment of pediatric-onset multiple sclerosis (POMS) is access to disease-modifying therapies (DMTs). An online Canada-wide survey of POMS DMT prescribers was used to identify patterns in, and barriers to, DMT access. Nineteen prescribers provided responses. Overall, DMT access via private versus government drug plans was variable. First-generation (e.g., beta-interferon) DMTs were more accessible via government plans versus second-generation DMTs (e.g., ocrelizumab). Most DMTs were available through private insurance plans. B-cell depleting therapies were the most difficult to access. Variability in DMT access for POMS raises concerns about health equity and care optimization.

Introduction: Anterior skull base meningiomas account for 6% to 13% of all meningiomas. The extended endoscopic endonasal approach (EEA) to these meningiomas offers many advantages such as early devascularization, adequate tumor resection and preservation of neurovascular structures. This study aims to evaluate the clinical outcomes of patients undergoing EEA for anterior skull base meningiomas, including recurrence rate and prognostic factors.

Methods: This is a retrospective study conducted on adult patients who underwent EEA for anterior skull base meningiomas at The Ottawa Hospital Civic Campus between October 2014 and October 2023.

Results: Twenty-five patients underwent EEA for anterior skull base meningiomas. The mean preoperative tumor volume was significantly larger in the olfactory groove (OG) group (19.54 cm³) compared to the tuberculum sellae (TS) group (7.04 cm³). Mean surgical duration was 351 minutes, and mean blood loss was 472 ml. A nasoseptal flap was used in 92% of cases. CSF leaks occurred in four cases (16%) and were managed with lumbar drainage. Total or near-total resection was achieved in 87.5% of OG cases and 82.4% of TS cases. Subtotal resections were significantly associated with larger tumor volumes (p = 0.03). Most of our cohort's histopathological findings were World Health Organization grade I meningiomas (92%). Our mean follow-up was 5.56 years and tumor recurrence was seen in one patient.

Conclusion: Extended EEA for anterior skull base meningiomas is a safe and effective technique enabling total resection with a low recurrence rate. Optimal patient selection and multilayered reconstruction are critical to minimize complications.

Background: In Canada, the management of migraine is commonly carried out by primary care providers. Guidelines for the acute and preventative management of migraine in Canada are published by the Canadian Headache Society (CHS). There are currently limited data describing prescribing patterns among clinicians caring for patients with migraine in Canada.

Aims: Our aim for this exploratory study was to characterize the current pharmacological treatments prescribed for patients with migraine in Nova Scotia, Canada, seeking care through their primary care providers.

Methods: We conducted a retrospective cross-sectional analysis of deidentified electronic medical record (EMR) data collected from January 2019 to December 2023 from the Maritime Research Network for Family Practice (MaRNet-FP) to identify prescribing patterns for the acute and preventative management of migraine in Nova Scotia.

Results: In total, 3075 active patients who received a diagnosis of migraine were identified in the MaRNet-FP EMR database (6.53% of total patients). Migraine patients were predominantly female (81%) with an average age of 44 ± 16 years. Between 2019 and 2023, 50% of patients with a migraine diagnosis received a prescription for a medication that can be used for the acute management of migraine, most commonly, nonsteroidal anti-inflammatory drugs and triptans. Over the same period, 60.4% of patients were prescribed a medication that can be used for the prevention of migraine, the most common of which were anti-depressants and beta-blockers.

Conclusion: Our findings demonstrate alignment with CHS guidelines but highlight potential undertreatment of migraine.