Abstract The main objective of this study was to assess the long‐term cost‐effectiveness of five alternative diagnostic strategies for identification of severe carotid stenosis in recently symptomatic patients. A decision‐analytical model with Markov transition states was constructed. Data sources included a prospective study involving 167 patients who had screening Doppler ultrasound (DUS), confirmatory contrast‐enhanced magnetic resonance angiography (CEMRA) and confirmatory digital subtraction angiography (DSA), individual patient data from the European Carotid Surgery Trial and other published clinical and cost data. A “selective” strategy, whereby all patients receive DUS and CEMRA (only proceeding to DSA if the CEMRA is positive and the DUS is negative), was most cost‐effective. This was both the cheapest imaging and treatment strategy ($35,205 per patient) and yielded 6.1590 quality‐adjusted life years (QALYs), higher than three alternative imaging strategies. Probabilistic sensitivity analysis demonstrated that there was less than a 10% probability that imaging with either DUS or DSA alone are cost‐effective at the conventional $50,000/QALY threshold. In conclusion, DSA is not cost‐effective in the routine diagnostic workup of most patients. DUS, with additional imaging in the form of CEMRA, is recommended, with a strategy of “CEMRA and selective DUS review” being shown to be the optimal imaging strategy. Ann Neurol 2005;58:506–515
INTRODUCTION: Aneurysmal subarachnoid haemorrhage (aSAH) remains a complex and multidisciplinary pathology. With endovascular methods expanding fewer patients are treated surgically. METHODS: All patients following surgery for aSAH between 2007 - 2019 were included. Baseline characteristics outcomes were analysed. We compared outcomes between experienced (=50 independent cases) and non-experienced surgeons (<50 independent cases), and high-volume (=20 cases/year) and low-volume surgeons (<20 cases/year). RESULTS: 970 patients with 1003 aneurysms were identified with median age 56. 73.8% were WFNS grade 1 or 2. The majority of aneurysm were on the middle cerebral artery (41.4%), anterior communicating artery (27.6%) and posterior communicating artery (17.5%). 37.4% of aneurysm were <7 mm in size. Technical error rate was 6%, resulting in a post-operative infarct in 4.9% of patients. 19 patients (2%) died within 30 days of admission. There were no significant changes in technical error rates or post-operative infarcts or death (p = 0.79 and p = 0.77 respectively) over the study period. There was no difference in post-operative infarctions between experienced and non-experienced surgeons (p = 0.28), but there was a difference when comparing high-volume vs. low-volume surgeons (p = 028). CONCLUSION: We present real world data on surgical indications and outcomes after aSAH. We believe that this constitutes important data demonstrating good retention of skills and good clinical outcomes in a very dynamic field of cerebrovascular surgery. We also demonstrate a relationship between surgical case volume and outcomes.
Abstract Cavernomas presenting with seizures refractory to medical treatment may require surgical excision for seizure control. If superficial, they can be surgically accessible but can pose additional risks when located in or near eloquent cortex. In this 3D operative video we illustrate the technique for the resection of a left temporal cavernoma located near eloquent cortex for speech with awake surgery and cortical mapping to avoid a speech deficit postoperatively. Informed consent was obtained for this procedure. Navigation is used to localize the cavernoma following which a large craniotomy is performed exposing the temporal lobe, frontal lobe, and sylvian vein. Bipolar stimulation is used to localize speech with the patient awake until speech arrest occurs. The cavernoma is situated immediately inferior to the sulcus over which speech arrest occurs. The sulcus immediately above the cavernoma is opened and adjacent arteries are carefully preserved. The glial plane around the cavernoma is used to dissect the cavernoma from the surrounding cortex. Care is taken to remove the haemosiderin as this can act as a precipitant for ongoing seizures. In this case the patient had no neurological deficits following surgery and was seizure free.
Within medical settings there is a growing interest in exploring touchless interaction technologies. The primary motivation here is to avoid contact during interaction with data so as to maintain asepsis. However, there is another important property of touchless interaction that has significant implications for their use within such settings -- namely that interaction behaviour is spatially distal from the device being interacted with. To further understand these implications we present fieldwork observations of work practice in neurosurgery theatres. Drawing on the notion of interaction proxemics and the theory of F-formations, our analysis articulates the spatial organization of collaborative work practices and interaction in these settings. From this understanding of spatial practices, we discuss opportunities and difficulties relating to the design of touchless interaction technologies for in surgical settings.
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