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Serge Makarenko, Vincent Ye, Peter A. Gooderham, and Ryojo Akagami

OBJECTIVE

Historically, descriptions of visual acuity and visual field change following intracranial procedures have been very rudimentary. Clinicians and researchers have often used basic descriptions, such as “improved,” “worsened,” and “unchanged,” to describe outcomes following resections of tumors affecting the optic apparatus. These descriptors are vague, difficult to quantify, and challenging to apply in a clinical perspective. Several groups have attempted to combine visual acuity and visual fields into a single assessment score, but these are not user-friendly. The authors present a novel way to describe a patient’s visual function as a combination of visual acuity and visual field assessment that is simple to use and can be used by surgeons and researchers to gauge visual outcomes following tumor resection.

METHODS

Visual acuity and visual fields were combined into 3 categories designed around the definitions of legal blindness and fitness to drive in Canada. The authors then applied the scale (the Unified Visual Function Scale, or UVFS) to their previously published case series of perisellar meningiomas to document and test overall visual outcomes for patients undergoing tumor resection. The results were compared with previously documented visual loss scales in the literature.

RESULTS

Using the UVFS the authors were able to capture the overall visual change; the scale was sensitive enough to define the overall visual improvement or worsening quantitatively, using categories that are clinically relevant and understandable.

CONCLUSIONS

The UVFS is a robust way to assess a patient’s vision, combining visual fields and acuity. The implementation of pre- and postoperative assessment is sensitive enough to assess overall change while also providing clinically relevant information for surgeons, and allows for comparisons between treatment groups.

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Christopher R. Honey, Peter Gooderham, Murray Morrison, and Zurab Ivanishvili

The authors describe a novel cranial neuropathy manifesting with life-threatening episodic hemilaryngopharyngeal spasm (HELPS). A 50-year-old woman presented with a 4-year history of intermittent throat contractions, escalating to life-threatening respiratory distress. Botulinum toxin injections into her right vocal cord reduced the severity of her spasms, but the episodes continued to occur. MRI demonstrated a possible neurovascular conflict involving the cranial nerve IX–X complex and the posterior inferior cerebellar artery. Microvascular decompression of the upper rootlets of the vagal nerve eliminated her HELPS without complication. The authors propose a mechanism of HELPS implicating isolated involvement of the upper motor rootlets of the vagus nerve.

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Charlotte Dandurand, Lily Zhou, Swetha Prakash, Gary Redekop, Peter Gooderham, and Charles S. Haw

OBJECTIVE

The main goal of preventive treatment of unruptured intracranial aneurysms (UIAs) is to avoid the morbidity and mortality associated with aneurysmal subarachnoid hemorrhage. A comparison between the conservative approach and the surgical approach combining endovascular treatment and microsurgical clipping is currently lacking. This study aimed to conduct an updated evaluation of cost-effectiveness comparing the two approaches in patients with UIA.

METHODS

A decision tree with a Markov model was developed. Quality-adjusted life-years (QALYs) associated with living with UIA before and after treatment were prospectively collected from a cohort of patients with UIA at a tertiary center. Other inputs were obtained from published literature. Using Monte Carlo simulation for patients aged 55, 65, and 75 years, the authors modeled the conservative management in comparison with preventive treatment. Different proportions of endovascular and microsurgical treatment were modeled to reflect existing practice variations between treatment centers. Outcomes were assessed in terms of QALYs. Sensitivity analyses to assess the model’s robustness and completed threshold analyses to examine the influence of input parameters were performed.

RESULTS

Preventive treatment of UIAs consistently led to higher utility. Models using a higher proportion of endovascular therapy were more cost-effective. Models with older cohorts were less cost-effective than those with younger cohorts. Treatment was cost-effective (willingness to pay < 100,000 USD/QALY) if the annual rupture risk exceeded a threshold between 0.8% and 1.9% in various models based on the proportion of endovascular treatment and cohort age. A higher proportion of endovascular treatments and younger age lowered this threshold, making the treatment of aneurysms with a lower risk of rupture more cost-effective.

CONCLUSIONS

Preventive treatment of aneurysms led to higher utility compared with conservative management. Models with a higher proportion of endovascular treatment and younger patient age were most cost-effective.