Current Trends in Neurosurgical Management of Adult Diffuse Low-Grade Gliomas in Canada.

There is considerable variability in the management of diffuse low-grade gliomas (LGGs). To characterize treatment paradigms, a survey of Canadian neurosurgeons was performed with forty neurosurgeons responding. Their responses show that the management of patients with LGGs has evolved in the past decade and findings from the RTOG9802 trial have been integrated into the practice of Canadian neurosurgeons. Most respondents stated that the patient selection and treatment strategy advocated by the RTOG9802 trial needs further evaluation. Overall, there is a trend toward more aggressive surgical resections, and future investigations will have to more accurately stratify patient risk profiles.

From millstones to milestones: Scaffolding a house of public health on political science foundations.

Background: We analyze the University of British Columbia's Department of Political Science's first course on health, "Global Politics and Health," to determine whether one course could inform political science students to tackle health issues. The major concept was global public health is politics writ large, as determinants of health are rooted in economic and social power. Course objectives encouraged student agency in ameliorating population health status. Methods: We use three surveys, with qualitative and quantitative components, to assess interest and knowledge of public health issues, and determine whether student agency increased as the course progressed. Results: We confirmed that political science develops an excellent foundation for the analysis of issues related to global public health status. One course can stimulate curiosity in health issues. Unexpectedly, we discovered that students' greatest learning outcome integrated personal, interpersonal, and scholarly analyses of health issues. This provided an avenue for students outside of the health sciences to frame mental health, sexuality, and other stigmatized subjects within scholarly discourse. After the course, virtually all students had developed a sense of agency, hope, and tools to understand the roots of mental and physical health. Following case studies on various countries, students quickly grasped the significant impact of politics and economics on people's health. Discussion: We recommend that political science departments offer courses that focus on health for all alongside existing courses on healthcare systems' politics. Furthermore, departments of public health may benefit from including political science courses as core elements of their curriculum to assist graduates in navigating the highly politicized infrastructure of public health. Both disciplines stand to gain from this interdisciplinary opportunity-- in the service of better health for all.

Headache Outcomes After Treatment of Unruptured Intracranial Aneurysm: A Systematic Review and Meta-Analysis.

Background and Purpose- While unruptured intracranial aneurysms may be discovered incidentally in the workup of chronic headache, it remains unclear whether their treatment ultimately impacts headache severity. We aim to conduct a systematic review and meta-analysis assessing headache severity after treatment of unruptured intracranial aneurysm. Methods- MEDLINE and EMBASE were systematically reviewed. Results- Data from 7 studies met inclusion criteria (309 nonduplicated patients). The standard mean difference in pre- and post-intervention headache severity was estimated at -0.448 (95% CI, -0.566 to -0.329) under a random effects model. No significant heterogeneity was noted nor was any significant publication bias demonstrated. Conclusions- This is the first systematic review assessing postoperative headache severity following treatment of unruptured intracranial aneurysm. While a significant reduction in headache severity was observed, further investigation into this phenomenon is recommended before it influences clinical practice. Future study should stratify headache outcomes by aneurysm size, location, and treatment modality.

Emotional Lability as a Symptom of Extra-axial Posterior Fossa Tumors: a Case-Control Review of Neuroanatomy and Patient-Reported Quality of Life.

Introduction Emotional lability (EL), the uncontrollable and unmotivated expression of emotion, is a rare and distressing symptom of brainstem compression. In published case reports, EL from an extra-axial posterior fossa tumor was alleviated by tumor resection. The primary aim herein was to radiographically establish the degree of compression from mass lesions onto brainstem structures. Secondarily, we compared changes in patient-reported quality of life (QOL) pre- and postoperatively. Methods A retrospective review of posterior fossa tumors treated between 2002 and 2018 at Vancouver General Hospital revealed 11 patients with confirmed EL. Each case was matched to three controls. A lateral brainstem compression scale characterized mass effect at the level of the medulla, pons, and midbrain in preoperative axial T2-weighted fluid-attenuated inversion recovery magnetic resonance imaging (FLAIR MRI) scans. Compression and clinical variables were compared between patient groups. Short Form-36 version 1 health surveys were retrospectively obtained from patient charts to compare pre- versus postoperative changes in survey scores between EL and control patients. Results EL symptoms ceased postoperatively for all EL patients. EL tumors exert greater compression onto the pons ( p = 0.03) and EL patients more commonly have cerebellar findings preoperatively ( p = 0.003). Patients with EL-causing tumors experienced greater improvement postoperatively in "Health Change" ( p = 0.05), which was maintained over time. Conclusion Findings suggest that compression onto the pons inhibits control over involuntary, stereotyped expression of emotion. This adds to evidence that EL may be attributed to cerebellum deafferentation from cortical and limbic structures through the basis pontis, leading to impaired modulation of emotional response. QOL results augment benefits of offering patients EL-alleviating tumor resection surgery.

Cost-effectiveness analysis in patients with an unruptured cerebral aneurysm treated with observation or surgery.

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.

Quality of life scores in patients with unruptured cerebral aneurysm: Prospective cohort study.

BACKGROUND: Living with the diagnosis of an unruptured cerebral aneurysm can understandably cause distress to a patient. The goal of preventive treatment is to increase the number of years with good quality of life (QoL). OBJECTIVE: This study aimed to measure the effect of unruptured intracranial aneurysm treatment on change in QoL scores measured by the SF36 and EQ-5D-5L. METHODS: We prospectively collected SF36 and EQ-5D-5L survey data for patients with unruptured intracranial aneurysms at two time-points over 1 year between 2 treatment groups: observation and intervention (microsurgical and endovascular). Multivariable linear regression was used to examine treatment group differences in the mean change in scores from baseline to 1 year when adjusted for covariates. RESULTS: 92 patients were included in the observation group and 68 patients were included in the intervention group, for a total of 160 patients. The intervention group had lower SF36 total scores at baseline (p = 0.001). With multivariate linear regression models, the effect of treatment on mean change in SF36 total score from baseline to 1 year was not statistically significant (p = 0.4); similarly, there was no difference in mean change in EQ-5D-5L. CONCLUSION: In this large prospective study, preventive aneurysm treatment was not associated with a significant change in QoL score at 1 year compared to observation as measured by the SF36 and EQ-5D-5L. Further studies are needed to explore the lower QoL scores in patients seeking treatment and its impact on management decision making.

Functional Outcomes After Treatment of Posterior Inferior Cerebellar Artery Aneurysms.

Objective Aneurysms of the posterior inferior cerebellar artery (PICA) are a rare cause of subarachnoid hemorrhage. Treatment for this type of aneurysm may be microsurgical clipping or endovascular. This decision is based on patient characteristics, aneurysm location and dimensions, along with surgeon and institutional experience. In this study we aim to assess the outcomes of surgical and endovascular treatment of PICA aneurysms. Methods We retrospectively reviewed the charts of 52 patients who were admitted to Vancouver General Hospital for ruptured or symptomatic PICA aneurysms between 2005 and 2015. Modified Rankin scores were assigned at the time of discharge and at two subsequent follow-up time points. The mean short-term follow-up period post-operatively was 11.1 months and the mean long-term follow-up period was 19.3 months. Clinical and radiological characteristics were collected for all patients. Results Of the 52 patients, two died prior to obtaining treatment. Of the 50 patients who were treated for their PICA aneurysm, 39 presented with subarachnoid hemorrhage while 11 had symptomatic unruptured PICA aneurysms. Overall, 11 patients had endovascular treatment (coil embolization) while 39 patients underwent microsurgical clipping/trapping of the aneurysm. At the time of hospital discharge, patients in the microsurgical group trended towards a better the modified Rankin Scale score (2.3) compared to the endovascular group, though this did not reach significance (3.0) (p=0.20). The long-term score in the endovascular group (1.6) was also comparable to the microsurgical group (1.9) (p=0.55). Conclusion While the early outcomes in patients treated endovascularly appear better, there is no statistically significant difference in outcomes between the microsurgical and endovascular treatment groups at short- and long-term follow-up.

Basilar Apex Aneurysm: Case Series, Systematic Review, and Meta-analysis.

BACKGROUND: A lower rate of aneurysmal recanalization in stent assisted coiling versus coiling alone has been observed in aneurysms overall. This study aims to primarily stratify and compare degree of occlusion per treatment modality in basilar apex aneurysms. Secondary outcomes were retreatment, posttreatment hemorrhage, and procedure-related complications. METHODS: Medical literature including MEDLINE and EMBASE database was searched. We performed metaregressions, bias analysis, and fail-safe N. We controlled for the quality of the studies. RESULTS: Data from eligible studies (N = 12) and study center patients (n = 117) were pooled for a total of 396 nonduplicated patients. Stent-assisted coiling had a lower rate of retreatment (17% vs. 24%) and higher rate of posttreatment hemorrhage (5% vs. 3%) compared with coiling. Stent-assisted coiling had a higher rate of complete occlusion (55% vs. 45%) and a lower rate of residual aneurysm (15% vs. 23%) compared with coiling. Comparative analyses were performed. Microsurgical technique remained the most morbid treatment modality with the best rate of complete occlusion (93%) and lowest rates of rehemorrhage (2%) and retreatment (5%). CONCLUSIONS: This is the first and largest meta-analysis focused on patients treated for basilar apex aneurysm. We report higher rehemorrhage rates with stent-assisted coiling. This study provides benchmark data to guide clinicians in future treatment decision making and encourages future research to stratify outcomes.

Cannabis use and outcomes after aneurysmal subarachnoid hemorrhage: A nationwide retrospective cohort study.

BACKGROUND: Cannabis is the most consumed recreational drug in the world. It is possible that cannabis has an association with an increased risk of vasospasm-related strokes and delayed cerebral ischemia (DCI), which are major causes of morbidity and mortality in aneurysmal subarachnoid hemorrhage (aSAH). Hence, this study aimed to explore the independent relationship between cannabis use and outcomes after aSAH using the 2016 United States Nationwide Inpatient Sample. METHODS: This study was conducted using the 2016 National Inpatient Sample with ICD-10 codes. Multivariate logistic regression was used to examine the association between cannabis use, the primary (inpatient mortality) and secondary outcomes. RESULTS: There were 42,394 patients identified with aSAH, of whom 925 were identified as cannabis users. Cannabis users and non-users were similar in terms of severity of aSAH. Although the unadjusted mortality rate was lower among cannabis users (16%) than non-users (22%), (p = 0.04), both the age-adjusted odds ratio (OR) (0.83, 95% confidence interval (CI): 0.56; 1.24) and the multivariate-adjusted OR (0.87, 95% CI: 0.54; 1.42) did not reach statistical significance. Secondary outcomes did not reach statistical significance. CONCLUSION: In this nationwide cohort, cannabis users with aSAH had similar outcomes compared to nonusers. However, these results are likely limited by underreporting of cannabis use. Future prospective studies are needed to elucidate the pathophysiology and association between cannabis and outcomes following aSAH.