Due to lack of data on the epidemiology, cardiac, and neurological complications among Ontario visible minorities (Chinese and South Asians) affected by coronavirus disease (COVID-19), this population-based retrospective study was undertaken to study them systematically.

From January 1, 2020 to September 30, 2020 using the last name algorithm to identify Ontario Chinese and South Asians who were tested positive by PCR for COVID-19, their demographics, cardiac, and neurological complications including hospitalization and emergency visit rates were analyzed compared to the general population.

Chinese (N = 1,186) with COVID-19 were found to be older (mean age 50.7 years) compared to the general population (N = 42,547) (mean age 47.6 years) (p < 0.001), while South Asians (N = 3,459) were younger (age of 42.1 years) (p < 0.001). The 30-day crude rate for cardiac complications among Chinese was 169/10,000 (p = 0.069), while for South Asians, it was 64/10,000 (p = 0.008) and, for the general population, it was 112/10,000. For neurological complications, the 30-day crude rate for Chinese was 160/10,000 (p < 0.001); South Asians was 40/10,000 (p = 0.526), and general population was 48/10,000. The 30-day all-cause mortality rate was significantly higher for Chinese at 8.1% vs 5.0% for the general population (p < 0.001), while it was lower in South Asians at 2.1% (p < 0.001).

Chinese and South Asians in Ontario affected by COVID-19 during the first wave of the pandemic were found to have a significant difference in their demographics, cardiac, and neurological outcomes.

Coronavirus disease 2019 (COVID-19) has been associated with various neurological and atypical head/eyes/ears/nose/throat (HEENT) manifestations. We sought to review the evidence for these manifestations.

In this systematic review and meta-analysis, we compiled studies published until March 31, 2021 that examined non-respiratory HEENT, central, and peripheral nervous system presentations in COVID-19 patients. We included 477 studies for qualitative synthesis and 59 studies for meta-analyses.

Anosmia, ageusia, and conjunctivitis may precede typical upper/lower respiratory symptoms. Central nervous system (CNS) manifestations include stroke and encephalopathy, potentially with brainstem or cranial nerve involvement. MRI studies support CNS para-/postinfectious etiologies, but direct neuroinvasion seems very rare, with few cases detecting Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) in the CNS. Peripheral nervous system (PNS) manifestations include muscle damage, Guillain–Barre syndrome (GBS), and its variants. There was moderate-to-high study heterogeneity and risk of bias. In random-effects meta-analyses, anosmia/ageusia was estimated to occur in 56% of COVID-19 patients (95% CI: 0.41–0.71, I2:99.9%), more commonly than in patients without COVID-19 (OR: 14.28, 95% CI: 8.39–24.29, I2: 49.0%). Neurological symptoms were estimated to occur in 36% of hospitalized patients (95% CI: 0.31–0.42, I2: 99.8%); ischemic stroke in 3% (95% CI: 0.03–0.04, I2: 99.2%), and GBS in 0.04% (0.033%–0.047%), more commonly than in patients without COVID-19 (OR[stroke]: 2.53, 95% CI: 1.16–5.50, I2: 76.4%; OR[GBS]: 3.43,1.15–10.25, I2: 89.1%).

Current evidence is mostly from retrospective cohorts or series, largely in hospitalized or critically ill patients, not representative of typical community-dwelling patients. There remains a paucity of systematically gathered prospective data on neurological manifestations. Nevertheless, these findings support a high index of suspicion to identify HEENT/neurological presentations in patients with known COVID-19, and to test for COVID-19 in patients with such presentations at risk of infection.

This research aimed to study the short-term seizure outcomes following treatment with 8 mg/kg/day prednisolone in children with infantile spasms (IS) refractory to vigabatrin. We hypothesized that high-dose prednisolone may result in similar rates of electroclinical remission when compared to published ACTH rates.

All consecutive children with hypsarrhythmia or hypsarrhythmia variant on EEG with/without IS, who had been treated with vigabatrin as first-line anti-seizure medication (ASM) followed by high-dose oral prednisolone (8 mg/kg/day; maximum 60 mg/day) in cases who did not respond to vigabatrin, were included. Clinical and electroclinical response (ECR) at 2 weeks following initiation of treatment and adverse effects were assessed.

Sixty-five children were included. A genetic etiology was seen in 38.5% cases. Complete ECR was seen in 30.8% (20/65) of the patients 2 weeks after vigabatrin. Complete ECR was noted in 77.8% (35/45) of the patients, 2 weeks after prednisolone initiation in children who failed vigabatrin, and this was sustained at 6 weeks in 66.7% (30/45) patients. Prednisolone was generally well tolerated.

High-dose (8 mg/kg/day) oral prednisolone resulted in sustained complete ECR (at 6 weeks) in two-thirds of the children with hypsarrhythmia or hypsarrhythmia variant on EEG with/without parentally reported IS. It was generally well tolerated and found to be safe.

The PREDICT study assessed real-world, long-term health-related quality of life in adults with chronic migraine (CM) receiving onabotulinumtoxinA.

Canadian, multicenter, prospective, observational study in adults naïve to onabotulinumtoxinA for CM. OnabotulinumtoxinA (155–195 U) was administered every 12 weeks over 2 years (≤7 treatment cycles). Primary endpoint: mean change in Migraine-Specific Quality of Life Questionnaire (MSQ) at treatment 4 (Tx4) versus baseline. Secondary endpoints: mean change in MSQ at final visit versus baseline, and headache days.

184 participants (average age 45 years; 84.8% female; 94.6% Caucasian) received ≥1 onabotulinumtoxinA treatment; 150 participants completed 4 treatments (1 year) and 123 completed all 7 treatment cycles (2 years). Mean (SD) onabotulinumtoxinA dose per treatment cycle was 171 (18) U and treatment interval was 13.2 (1.8) weeks. Baseline mean (SD) 20.9 (6.7) headache days/month decreased (Tx1: −3.5 [6.3]; Tx4: −6.5 [6.6]; p < 0.0001 versus baseline). Mean (SD) increased from baseline in MSQ at Tx4 (restrictive: 21.5 [24.3], preventive: 19.5 [24.7], emotional: 22.9 [32.9]) and the final visit (restrictive: 21.3 [23.0], preventive: 19.2 [23.7], emotional: 27.4 [30.7]), exceeding minimal important differences (all p < 0.0001). Seventy-seven (41.8%) participants reported 168 treatment-emergent adverse events (TEAEs); 38 TEAEs (12.0%) were considered treatment-related. Four (2.2%) participants reported six serious TEAEs; none were considered treatment-related. No new safety signals were identified.

Real-world evidence from PREDICT demonstrates that onabotulinumtoxinA for CM in Canada improved MSQ scores and reduced headache frequency and severity, adding to the body of evidence on the long-term safety and effectiveness of onabotulinumtoxinA for CM.

There is international variability in whether neurological determination of death (NDD) is conceptually defined based on permanent loss of brainstem function or “whole brain death.” Canadian guidelines are not definitive. Patients with infratentorial stroke may meet clinical criteria for NDD despite persistent cerebral blood flow (CBF) and relative absence of supratentorial injury.

We performed a multicenter cohort study involving patients that died from ischemic or hemorrhagic stroke in Alberta intensive care units from 2013 to 2019, focusing on those with infratentorial involvement. Medical records were reviewed to determine the incidence and proportion of patients that met clinical criteria for NDD; whether ancillary testing was performed; and if so, whether this demonstrated the absence of CBF.

There were 95 (27%) deaths from infratentorial and 263 (73%) from supratentorial stroke. Sixteen patients (17%) with infratentorial stroke had neurological examination consistent with NDD (0.55 cases per million per year). Among patients that underwent confirmatory evaluation for NDD with an apnea test, ancillary test (radionuclide scan), or both, ancillary testing was more common with infratentorial compared with supratentorial stroke (10/12 (85%) vs. 25/47 (53%), p = 0.04). Persistent CBF was detected in 6/10 (60%) patients with infratentorial compared with 0/25 with supratentorial stroke (p = 0.0001).

Infratentorial stroke leading to clinical criteria for NDD occurs with an annual incidence of about 0.55 per million. There is variability in clinicians’ use of ancillary testing. Persistent CBF was detected in more than half of patients that underwent radionuclide scans. Canadian consensus is needed to guide clinical practice.

The modality of treatment of third nerve palsy (TNP) associated with intracranial aneurysms remains controversial. While treatment varies with the location of the aneurysm, microsurgical clipping of PComm aneurysms has generally been the traditional choice, with endovascular coiling emerging as a reasonable alternative.

Patients with TNP due to an intracranial aneurysm who subsequently underwent treatment at a mid-sized Canadian neurosurgical center over a 15-year period (2003–2018) were examined.

A total of 616 intracranial aneurysms in 538 patients were treated; the majority underwent endovascular coiling with only 24 patients treated with surgical clipping. Only 37 patients (6.9%) presented with either a partial or complete TNP and underwent endovascular embolization; of these, 17 presented with a SAH secondary to intracranial aneurysm rupture. Aneurysms associated with TNP included PComm (64.9%), terminal ICA (29.7%), proximal MCA (2.7%), and basilar tip (2.7%) aneurysms. In general, smaller aneurysms and earlier treatment were provided for patients for ruptured aneurysms with a shorter mean interval to TNP recovery. In the endovascularly treated cohort initially presenting with TNP, seven presented with a complete TNP and the remaining were partial TNPs. TNP resolved completely in 20 patients (55.1%) and partially in 10 patients (27.0%). Neither time to coiling nor SAH at presentation were significantly associated with the recovery status of TNP.

Endovascular coil embolization is a viable treatment modality for patients presenting with an associated cranial nerve palsy.

Aneurysmal subarachnoid hemorrhage (SAH) remains a devastating condition with a case fatality of 36% at 30 days. Risk factors for mortality in SAH patients include patient demographics and the severity of the neurological injury. Pre-existing conditions and non-neurological medical complications occurring during the index hospitalization are also risk factors for mortality in SAH. The magnitude of the effect on mortality of pre-existing conditions and medical complications, however, is less well understood. In this study, we aim to determine the effect of pre-existing conditions and medical complications on SAH mortality.

For a 25% random sample of the Greater Montreal Region, we used discharge abstracts, physician billings, and death certificate records, to identify adult patients with a new diagnosis of non-traumatic SAH who underwent cerebral angiography or surgical clipping of an aneurysm between 1997 and 2014.

The one-year mortality rate was 14.76% (94/637). Having ≥3 pre-existing conditions was associated with increased one-year mortality OR 3.74, 95% CI [1.25, 9.57]. Having 2, or ≥3 medical complications was associated with increased one-year mortality OR, 2.42 [95% CI 1.25–4.69] and OR, 2.69 [95% CI 1.43–5.07], respectively. Sepsis, respiratory failure, and cardiac arrhythmias were associated with increased one-year mortality. Having 1, 2, or ≥3 pre-existing conditions was associated with increased odds of having medical complications in hospital.

Pre-existing conditions and in-hospital non-neurological medical complications are associated with increased one-year mortality in SAH. Pre-existing conditions are associated with increased medical complications.

The use of stereotactic headframes for neurosurgical procedures requiring targeted localization continues to grow with new advancements in technology and treatment modalities. A configuration of the Leksell stereotactic G frame with a straight front bar, useful in epilepsy and laser cases, almost completely obscures oral access and presents a significant airway challenge for the anesthetist. Although previous papers have suggested that the entire headframe should be removed during an airway emergency, we describe a novel method to remove only the front bar.

We performed an observational mannequin study. Anesthesia personnel from a single center were asked to intubate a mannequin with the Leksell frame fully in situ and again with the front bar removed. In addition, the time to remove the entire frame versus only the front bar was investigated.

Eighteen anesthesia personnel participated in the study as well as four neurosurgeons. The average time to intubate the mannequin in the frame was 23.5 (11.4) seconds and with the front bar removed, 10.9 (2.5) seconds (p < 0.001). The average time taken to remove just the front bar by the neurosurgeons was 35.4 (7.3) seconds compared to an average of 83.3 (18.6) seconds to remove the headframe entirely (p < 0.001).

Our study demonstrates that intubating with the Leksell front bar in situ is possible with videolaryngoscopy under an ideal situation. More importantly, the removal of just the front bar is a simpler more streamlined approach requiring statistically less time to secure an airway.

Post-mortem examination of the nervous system is a complex task that culminates in “brain cutting”. It relies on expertise in neuroanatomy, clinical neurosciences, neuroimaging and experience in order to recognise the most subtle abnormalities. Like any specialist examination in medicine, it warrants formal training, a standardised approach and optimal conditions. Revelations of aberrant tissue retention practices of a select few pathologists (e.g. Goudge, Liverpool and Alder Hey inquiries) and a motivated sociopolitical climate led some Canadian jurisdictions to impose broad restrictions on tissue retention. This raised concerns that nervous system examinations for diagnosis, education and research were at risk by limiting examinations to the fresh or incompletely fixed state. Professional experience indicates that cutting an unfixed or partly fixed brain is inferior.

To add objectivity and further insight we sought the expert opinion of a group of qualified specialists. Canadian neuropathologists were surveyed for their opinion on the relative merits of examining brains in the fresh or fully fixed state.

A total of 14 out of 46 Canadian neuropathologists responded (30%). In the pervasive opinion of respondents, cutting and sampling a brain prior to full fixation leads to a loss of diagnostic accuracy, biosafety and academic deliverables.

Brain cutting in the fresh state is significantly impaired along multiple dimensions of relevance to a pathologist’s professional roles and obligations.