Value of treatment by comprehensive stroke services for the reduction of critical gaps in acute stroke care in Europe.

Stroke is the second leading cause of death and dependency in Europe and costs the European Union more than €30bn, yet significant gaps in the patient pathway remain and the cost-effectiveness of comprehensive stroke care to meet these needs is unknown. The European Brain Council Value of Treatment Initiative combined patient representatives, stroke experts, neurological societies and literature review to identify unmet needs in the patient pathway according to Rotterdam methodology. The cost-effectiveness of comprehensive stroke services was determined by a Markov model, using UK cost data as an exemplar and efficacy data for prevention of death and dependency from published systematic reviews and trials, expressing effectiveness as quality-adjusted life-years (QALYs). Model outcomes included total costs, total QALYs, incremental costs, incremental QALYs and the incremental cost-effectiveness ratio (ICER). Key unmet needs in the stroke patient pathway included inadequate treatment of atrial fibrillation (AF), access to neurorehabilitation and implementation of comprehensive stroke services. In the Markov model, full implementation of comprehensive stroke services was associated with a 9.8% absolute reduction in risk of death of dependency, at an intervention cost of £9566 versus £6640 for standard care, and long-term care costs of £35 169 per 5.1251 QALYS vs. £32 347.40 per 4.5853 QALYs, resulting in an ICER of £5227.89. Results were robust in one-way and probabilistic sensitivity analyses. Implementation of comprehensive stroke services is a cost-effective approach to meet unmet needs in the stroke patient pathway, to improve acute stroke care and support better treatment of AF and access to neurorehabilitation.

Determinants of clinical effectiveness and significant neurological diagnoses in an urgent brain cancer referral pathway in the United Kingdom.

BACKGROUND: Cerebral tumours can rapidly progress to life-threatening complications yet referral pathways often result in non-significant diagnoses. We aimed to identify the determinants of referrals resulting in significant neurological diagnoses after specialist review. METHODS: We reviewed all urgent brain cancer referrals to the neurology service at a British district general hospital between January 2009 and September 2013. Time to appointment, frequency of significant neurological diagnoses, appropriateness of referrals and referral heterogeneity across GP practices were measured as determinants of non-significant diagnoses. RESULTS: 31/105 patients received significant neurological diagnoses (29.5%), including ten (9.5%) tumours (7 malignant), although 2 patients were admitted prior to clinic. There was significant heterogeneity between primary care physicians in referral frequency (p = 0.008) and significant diagnoses (p = 0.005). Non-significant diagnoses were more common in inappropriate referrals and if patients were unaware of the potential diagnosis. Seizures or subacute focal symptoms were more likely to result in a significant neurological diagnosis than isolated headache syndromes (odds ratio 3.45, 1.34-18.4, p = 0.008). DISCUSSION: Despite a significant number of important neurological diagnoses and tumours, there were frequent inappropriate or low-risk referrals resulting in non-significant diagnoses, particularly if a headache syndrome was the sole reason for referral.

Acute vasospasm following transcallosal resection of a xanthogranulomatous colloid cyst of the 3rd ventricle.

We present the first case of a 57 year old man who developed severe, acute vasospasm following transcallosal resection of an unusual, xanthogranulomatous colloid cyst. The 16 year history of growth of this cyst may have resulted in its unusual pathology, and the subsequent vasospastic reaction to its excision. We discuss the potential pathological relationship between the inflammatory nature of the cyst, chemical meningitis and vasospasm, and what this implies about vasospasm in general. The severe, life-threatening vasospasm affected all four major vessels and required aggressive management by endovascular injection of nimodipine and angioplasty, with good recovery. The case illustrates a previously undescribed sequel of surgery for this condition, demonstrates an effective treatment and offers possible insights into the pathogenesis of vasospasm.