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Wang XJ, Deng Y, Li XQ, Jiang FF, Jia WY, Zhang HC, Chen FY, Liu BY. The effect of green channel for stroke patients on treatment of severe aneurysmal subarachnoid hemorrhage. Chin J Traumatol 2023:S1008-1275(23)00126-8. [PMID: 38129241 DOI: 10.1016/j.cjtee.2023.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 10/30/2023] [Accepted: 11/20/2023] [Indexed: 12/23/2023] Open
Abstract
PURPOSE To explore the effect of green channel for stroke patients on the treatment of severe aneurysmal subarachnoid hemorrhage. METHODS This is a retrospective case-control study. The clinical data of patients with severe aneurysmal subarachnoid hemorrhage admitted to the emergency department of our hospital from January 2015 to June 2022 were retrospectively analyzed. Patients diagnosed with subarachnoid hemorrhage, confirmed intracranial aneurysm by preoperative CT angiography or digital subtraction, graded Hunt-Hess grade III, IV, and V, < 72 h from the onset to the time of consultation received surgical treatment in our hospital were included in this study. Patients with serious underlying diseases, such as heart, liver, kidney diseases, or malignant tumors, traumatic subarachnoid hemorrhage, previous history of cerebral hemorrhage, and incomplete data were excluded. The control group included patients with severe aneurysmal subarachnoid hemorrhage admitted from January 2015 to December 2018 before the establishment of the green channel for stroke patients, and the observation group included patients with severe aneurysmal subarachnoid hemorrhage admitted from January 2019 to June 2022 after the establishment of the green channel. The control group received routine treatment in the emergency department; the observation group received improved treatment of green channel for stroke patients. Gender, age, Hunt-Hess grade on admission, modified Rankin scale (mRS) on admission, aneurysm location, aneurysm size and whether accompanied by intracerebral hemorrhage, the time from onset to emergency department, the time from emergency department to vascular diagnostic examination, the time from onset to surgery, the time from emergency department to surgery, the time from hospital admission to surgery, length of hospital stay, complications, treatment effect were analyzed and compared between the 2 groups. SPSS 23.0 software was utilized to conduct comparisons between the 2 groups. The t-test, Chi-square test, or Mann-Whitney U test was chosen based on the data type. Statistical significance was established when p < 0.05. RESULTS A total of 71 patients were included in this study, of whom 37 were in the control group and 34 were in the observation group. There were no statistical differences in age, gender, Hunt-Hess grade, mRS scores, aneurysm location, aneurysm size, intracerebral hemorrhage, the time from onset to emergency department, length of hospital stay, complications between the observation group and the control group (all p > 0.05). The time (min) from visit to vascular diagnostic test (60.50 vs. 120.00, p = 0.027), the time (min) from onset to surgery (1792.00 vs. 2868.00, p = 0.023), the time (min) from emergency department to surgery (1568.50 vs. 2778.00, p = 0.016), the time (min) from hospital admission to surgery (1188.50 vs. 2708.00, p = 0.043), all of them were shorter in the observation group than those in the control group. The relative values of admission and 7-day postoperative mRS scores and the relative values of admission and discharge mRS scores ≥ 2 were used as the criteria for determining better efficacy, and the treatment effect was better than that in the control group, and the differences were statistically significant (admission to 7 days postoperative mRS score ≥ 2, 17 (50.0 %) vs. 8 (21.6 %), p = 0.012; admission to discharge mRS score ≥ 2, 19 (55.9 %) vs. 11 (29.7 %), p = 0.026). CONCLUSION The green channel for stroke patients with severe aneurysmal subarachnoid hemorrhage can effectively shorten the time from arrival at the emergency department to vascular diagnostic examination and the time from the emergency department to surgery, and achieve a better therapeutic effect, which is worth popularizing and applying.
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Affiliation(s)
- Xue-Jiao Wang
- Department of Neurosurgery, The Third People's Hospital of Datong, Datong, 037008, Shanxi province, China
| | - Yu Deng
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100050, China
| | - Xiao-Qing Li
- Central Laboratory of Datong, The Third People's Hospital of Datong, Datong, 037008, Shanxi province, China
| | - Feng-Feng Jiang
- Stroke Prevention Office, The Third People's Hospital of Datong, Datong, 037008, Shanxi province, China
| | - Wen-Yan Jia
- Department of Neurosurgery, The Third People's Hospital of Datong, Datong, 037008, Shanxi province, China
| | - He-Chun Zhang
- Department of Neurosurgery, The Third People's Hospital of Datong, Datong, 037008, Shanxi province, China
| | - Feng-Ying Chen
- Stroke Prevention Office, The Third People's Hospital of Datong, Datong, 037008, Shanxi province, China
| | - Bai-Yun Liu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100050, China; Beijing Key Laboratory of Central Nervous System Injury, Beijing Neurosurgical Institute, Capital Medical University, Beijing, 100069, China; Center for Nerve Injury and Repair, Beijing Institute of Brain Disorders, Beijing, 100069, China; China National Clinical Research Center for Neurological Diseases, Beijing, 100069, China.
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Buscot MJ, Chandra RV, Mainguard J, Nichols L, Blizzard L, Stirling C, Smith K, Lai L, Asadi H, Froelich J, Reeves MJ, Thani N, Thrift A, Gall S. Association of Onset-to-Treatment Time With Discharge Destination, Mortality, and Complications Among Patients With Aneurysmal Subarachnoid Hemorrhage. JAMA Netw Open 2022; 5:e2144039. [PMID: 35061040 PMCID: PMC8783267 DOI: 10.1001/jamanetworkopen.2021.44039] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
IMPORTANCE Rapid access to specialized care is recommended to improve outcomes after aneurysmal subarachnoid hemorrhage (SAH), but understanding of the optimal onset-to-treatment time for aneurysmal SAH is limited. OBJECTIVE To assess the optimal onset-to-treatment time for aneurysmal SAH that maximized patient outcomes after surgery. DESIGN, SETTING, AND PARTICIPANTS This cohort study assessed 575 retrospectively identified cases of first-ever aneurysmal SAH occurring within the referral networks of 2 major tertiary Australian hospitals from January 1, 2010, to December 31, 2016. Individual factors, prehospital factors, and hospital factors were extracted from the digital medical records of eligible cases. Data analysis was performed from March 1, 2020, to August 31, 2021. EXPOSURES Main exposure was onset-to-treatment time (time between symptom onset and aneurysm surgical treatment in hours) derived from medical records. MAIN OUTCOMES AND MEASURES Clinical characteristics, complications, and discharge destination were extracted from medical records and 12-month survival obtained from data linkage. The associations of onset-to-treatment time (in hours) with (1) discharge destination of survivors (home vs rehabilitation), (2) 12-month survival, and (3) neurologic complications (rebleed, delayed cerebral ischemia, meningitis, seizure, hydrocephalus, and delayed cerebral injury) were investigated using natural cubic splines in multivariable Cox proportional hazards and logistic regression models. RESULTS Of the 575 patients with aneurysmal SAH, 482 patients (mean [SD] age, 55.0 [14.5] years; 337 [69.9%] female) who received endovascular coiling or neurosurgical clipping were studied. A nonlinear association of treatment delay was found with the odds of being discharged home vs rehabilitation (effective df = 3.83 in the generalized additive model, χ2 test P = .002 for the 4-df cubic spline), with a similar nonlinear association remaining significant after adjustment for sex, treatment modality, severity, Charlson Comorbidity Index, history of hypertension, and hospital transfer (likelihood ratio test: df = 3, deviance = 9.57, χ2 test P = .02). Both unadjusted and adjusted cox regression models showed a nonlinear association between time to treatment and 12-month mortality with the lowest hazard of death with receipt of treatment at 12.5 hours after symptom onset, although the nonlinear term became nonsignificant upon adjustment. The odds of being discharged home were higher with treatment before 20 hours after onset, with the probability of being discharged home compared with rehabilitation or other hospital increased by approximately 10% when treatment was received within the first 12.5 hours after symptom onset and increased by an additional 5% from 12.5 to 20 hours. Time to treatment was not associated with any complications. CONCLUSIONS AND RELEVANCE This cohort study found evidence that more favorable outcomes (discharge home and survival at 12 months) were achieved when surgical treatment occurred at approximately 12.5 hours. These findings provide more clarity around optimal timelines of treatment with people with aneurysmal SAH; however, additional studies are needed to confirm the findings.
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Affiliation(s)
- Marie-Jeanne Buscot
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania, Australia
| | - Ronil V. Chandra
- NeuroInterventional Radiology, Monash Health, Melbourne, Victoria, Australia
- School of Clinical Sciences Monash Health, Monash University, Melbourne, Victoria, Australia
| | - Julian Mainguard
- NeuroInterventional Radiology, Monash Health, Melbourne, Victoria, Australia
| | - Linda Nichols
- School of Nursing, University of Tasmania, Hobart, Tasmania, Australia
| | - Leigh Blizzard
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania, Australia
| | | | - Karen Smith
- Ambulance Victoria, Melbourne, Victoria, Australia
| | - Leon Lai
- School of Clinical Sciences Monash Health, Monash University, Melbourne, Victoria, Australia
- Department of Neurosurgery, Monash Health, Melbourne, Victoria, Australia
| | - Hamed Asadi
- NeuroInterventional Radiology, Monash Health, Melbourne, Victoria, Australia
| | - Jens Froelich
- NeuroInterventional Radiology, Royal Hobart Hospital, Hobart, Tasmania, Australia
| | - Mathew J. Reeves
- Department of Epidemiology, Michigan State University, East Lansing
| | - Nova Thani
- Department of Neurosurgery, Royal Hobart Hospital, Hobart, Tasmania, Australia
| | - Amanda Thrift
- School of Clinical Sciences Monash Health, Monash University, Melbourne, Victoria, Australia
| | - Seana Gall
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania, Australia
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Forgacs PB, Allen BB, Wu X, Gerber LM, Boddu S, Fakhar M, Stieg PE, Schiff ND, Mangat HS. Corticothalamic Connectivity in Aneurysmal Subarachnoid Hemorrhage: Relationship with Disordered Consciousness and Clinical Outcomes. Neurocrit Care 2021; 36:760-771. [PMID: 34669180 DOI: 10.1007/s12028-021-01354-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 09/10/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND We present an exploratory analysis of the occurrence of early corticothalamic connectivity disruption after aneurysmal subarachnoid hemorrhage (SAH) and its correlation with clinical outcomes. METHODS We conducted a retrospective study of patients with acute SAH who underwent continuous electroencephalography (EEG) for impairment of consciousness. Only patients undergoing endovascular aneurysm treatment were included. Continuous EEG tracings were reviewed to obtain artifact-free segments. Power spectral analyses were performed, and segments were classified as A (only delta power), B (predominant delta and theta), C (predominant theta and beta), or D (predominant alpha and beta). Each incremental category from A to D implies greater preservation of corticothalamic connectivity. We dichotomized categories as AB for poor connectivity and CD for good connectivity. The modified Rankin Scale score at follow-up and in-hospital mortality were used as outcome measures. RESULTS Sixty-nine patients were included, of whom 58 had good quality EEG segments for classification: 28 were AB and 30 were CD. Hunt and Hess and World Federation of Neurological Surgeons grades were higher and the initial Glasgow Coma Scale score was lower in the AB group compared with the CD group. AB classification was associated with an adjusted odds ratio of 5.71 (95% confidence interval 1.61-20.30; p < 0.01) for poor outcome (modified Rankin Scale score 4-6) at a median follow-up of 4 months (interquartile range 2-6) and an odds ratio of 5.6 (95% confidence interval 0.98-31.95; p = 0.03) for in-hospital mortality, compared with CD. CONCLUSIONS EEG spectral-power-based classification demonstrates early corticothalamic connectivity disruption following aneurysmal SAH and may be a mechanism involved in early brain injury. Furthermore, the extent of this disruption appears to be associated with functional outcome and in-hospital mortality in patients with aneurysmal SAH and appears to be a potentially useful predictive tool that must be validated prospectively.
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Affiliation(s)
- Peter B Forgacs
- Department of Neurology, Weill Cornell Brain and Spine Institute, Weill Cornell Medicine, 525 E 68 Street, 610, New York, NY, 10065, USA
| | - Baxter B Allen
- Department of Neurology, Weill Cornell Brain and Spine Institute, Weill Cornell Medicine, 525 E 68 Street, 610, New York, NY, 10065, USA
| | - Xian Wu
- Department of Population Health Sciences, Weill Cornell Brain and Spine Institute, Weill Cornell Medicine, New York, NY, USA
| | - Linda M Gerber
- Department of Population Health Sciences, Weill Cornell Brain and Spine Institute, Weill Cornell Medicine, New York, NY, USA
| | - Srikanth Boddu
- Department of Neurological Surgery, Weill Cornell Brain and Spine Institute, Weill Cornell Medicine, New York, NY, USA
| | - Malik Fakhar
- Department of Neurology, Weill Cornell Brain and Spine Institute, Weill Cornell Medicine, 525 E 68 Street, 610, New York, NY, 10065, USA.,Department of Neurology, University of Arizona College of Medicine, Phoenix, AZ, USA
| | - Philip E Stieg
- Department of Neurological Surgery, Weill Cornell Brain and Spine Institute, Weill Cornell Medicine, New York, NY, USA
| | - Nicholas D Schiff
- Department of Neurology, Weill Cornell Brain and Spine Institute, Weill Cornell Medicine, 525 E 68 Street, 610, New York, NY, 10065, USA
| | - Halinder S Mangat
- Department of Neurology, Weill Cornell Brain and Spine Institute, Weill Cornell Medicine, 525 E 68 Street, 610, New York, NY, 10065, USA. .,Department of Neurological Surgery, Weill Cornell Brain and Spine Institute, Weill Cornell Medicine, New York, NY, USA.
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Best Motor Response Predicts Favorable Outcome for "True" WFNS Grade V Patients with Aneurysmal Subarachnoid Hemorrhage. J Stroke Cerebrovasc Dis 2021; 30:106075. [PMID: 34481320 DOI: 10.1016/j.jstrokecerebrovasdis.2021.106075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Revised: 08/13/2021] [Accepted: 08/16/2021] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND The universal application of ultra-early surgery for World Federation of Neurological Societies (WFNS) grade V aneurysmal subarachnoid hemorrhage (aSAH) patients may lead to the increased implementation of unnecessary treatment. Therefore, this study aimed to refine the patient selection process for timely definitive treatment. METHODS From January 2011 to March 2020, a total of 517 aSAH patients were treated at our institution. Among these, 177 aSAH patients with WFNS grade V on admission were identified from our database. Patients with improved grades in response to the initial supportive treatment, with clinical or radiological signs of herniation, and with irreversible signs of brain damage such as bilaterally dilated pupils and global ischemia on follow-up CT scan were excluded. The outcome of definitive treatment for 54 patients without herniation who remained with WFNS grade V after the initial supportive treatment were analyzed to seek any factor for a favorable outcome (modified Rankin scale 0-2). RESULTS Among 54 patients, 19 (35.2%) had a favorable outcome after a definitive treatment. Multivariate logistic regression analysis showed that the best motor response (BMR) 4 on Glasgow Coma Scale was significantly associated with favorable outcomes (odds ratio, 3.76; 95% confidence interval, 1.09-13.0, p = 0.03). The positive predictive value of BMR 4 was 48.3%. CONCLUSIONS Albeit being simple, BMR 4 may facilitate the prompt aggressive treatment for patients with WFNS grade V including those with "true" grade V who do not have any clinical and radiological signs of herniation.
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Poor grade subarachnoid hemorrhage: Treatment decisions and timing influence outcome. Should we, and when should we treat these patients? BRAIN HEMORRHAGES 2021. [DOI: 10.1016/j.hest.2020.09.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
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Phuong Nguyen T, Rehman S, Stirling C, Chandra R, Gall S. Time and predictors of time to treatment for aneurysmal subarachnoid haemorrhage (aSAH): a systematic review. Int J Qual Health Care 2021; 33:6127110. [PMID: 33533408 DOI: 10.1093/intqhc/mzab019] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 01/17/2021] [Accepted: 02/02/2021] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Aneurysmal subarachnoid haemorrhage (aSAH) is a serious form of stroke, for which rapid access to specialist neurocritical care is associated with better outcomes. Delays in the treatment of aSAH appear to be common and may contribute to poor outcomes. We have a limited understanding of the extent and causes of these delays, which hinders the development of interventions to reduce delays and improve outcomes. The aim of this systematic review was to quantify and identify factors associated with time to treatment in aSAH. METHODS This systematic review was performed according to the Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines and was registered in PROSPERO (Reg. No. CRD42019132748). We searched four electronic databases (MEDLINE, EMBASE, Web of Science and Google Scholar) for manuscripts published from January 1998 using pre-designated search terms and search strategy. Main outcomes were duration of delays of time intervals from onset of aSAH to definitive treatment and/or factors related to time to treatment. RESULTS A total of 64 studies with 16 different time intervals in the pathway of aSAH patients were identified. Measures of time to treatment varied between studies (e.g. cut-off timepoints or absolute mean/median duration). Factors associated with time to treatment fell into two categories-individual (n = 9 factors, e.g. age, sex and clinical characteristics) and health system (n = 8 factors, e.g. pre-hospital delay or presentation out-of-hours). Demographic factors were not associated with time to treatment. More severe aSAH reduced treatment delay in most studies. Pre-hospital delays (patients delay, late referral, late arrival of ambulance, being transferred between hospitals or arriving at the hospital outside of office hours) were associated with treatment delay. In-hospital factors (patients with complications, procedure before definitive treatment, slow work-up and type of treatment) were less associated with treatment delay. CONCLUSIONS The pathway from onset to definitive treatment of patients with aSAH consists of multiple stages with multiple influencing factors. This review provides the first comprehensive understanding of extent and factors associated with time to treatment of aSAH. There is an opportunity to target modifiable factors to reduce time to treatment, but further research considering more factors are needed.
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Affiliation(s)
- Thuy Phuong Nguyen
- Menzies Institute for Medical Research, University of Tasmania, 17 Liverpool Street, Hobart, Tasmania 7000, Australia
| | - Sabah Rehman
- Menzies Institute for Medical Research, University of Tasmania, 17 Liverpool Street, Hobart, Tasmania 7000, Australia
| | - Christine Stirling
- School of Nursing, University of Tasmania, Tasmania 71 Brooker Avenue, Hobart, Tasmania 7001, Australia
| | - Ronil Chandra
- Neuro Interventional Radiology, Monash Health, 246 Clayton Road, Clayton, Victoria 3168, Australia.,Medicine Monash Health, Monash University, Wellington Rd, Clayton, Victoria 3800, Australia
| | - Seana Gall
- Menzies Institute for Medical Research, University of Tasmania, 17 Liverpool Street, Hobart, Tasmania 7000, Australia.,Medicine Monash Health, Monash University, Wellington Rd, Clayton, Victoria 3800, Australia
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Ariyada K, Ohida T, Shibahashi K, Hoda H, Hanakawa K, Murao M. Long-term Functional Outcomes for World Federation of Neurosurgical Societies Grade V Aneurysmal Subarachnoid Hemorrhage after Active Treatment. Neurol Med Chir (Tokyo) 2020; 60:390-396. [PMID: 32669527 PMCID: PMC7431870 DOI: 10.2176/nmc.oa.2020-0052] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
This study investigated the long-term outcomes of patients with World Federation of Neurosurgical Societies (WFNS) grade V aneurysmal subarachnoid hemorrhage (SAH) who underwent early aneurysm repair. We evaluated consecutive patients with WFNS grade V aneurysmal SAH from April 2010 to March 2015 who underwent aneurysm repair within 72 h after onset. We assessed the functional outcomes at discharge and 3 years after onset using the modified Rankin Scale (mRS). The primary outcome was defined as a favorable functional outcome (mRS ≤2). We identified 145 patients with grade V SAH during the study period. Of these, 44 patients (19 males and 25 females; median age, 64 years; range, 24–79 years) met the inclusion criteria. For aneurysm repair, surgical clipping and coiling were performed in 40 (90.9%) and 4 (9.1%) patients, respectively. Although no patient had a favorable functional outcome at discharge, 11 (25.0%) patients had a favorable functional outcome at the end of follow-up. The number of patients with a favorable outcome significantly increased during the first year (P = 0.012) and during the follow-up period (P <0.001). Patients who underwent active rehabilitation had significant improvement. Our study showed that one-fourth of the patients who underwent early aneurysm repair with WFNS grade V SAH achieved a mRS score of ≤2 over a 3-year period. It might be important to consider age and rehabilitation for better clinical outcomes. Larger studies are required to adequately assess the long-term functional outcomes and other multi-faceted prognoses.
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Affiliation(s)
- Kenichi Ariyada
- Department of Neurosurgery, Tokyo Metropolitan Bokutoh Hospital
| | - Tomoya Ohida
- Department of Neurosurgery, Tokyo Metropolitan Bokutoh Hospital
| | - Keita Shibahashi
- Tertiary Emergency Medical Center, Tokyo Metropolitan Bokutoh Hospital
| | - Hidenori Hoda
- Tertiary Emergency Medical Center, Tokyo Metropolitan Bokutoh Hospital
| | - Kazuo Hanakawa
- Department of Neurosurgery, Tokyo Metropolitan Bokutoh Hospital
| | - Masahiko Murao
- Department of Neurosurgery, Tokyo Metropolitan Bokutoh Hospital
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Kan P, Sweid A, Srivatsan A, Jabbour P. Expanding Indications for Flow Diverters: Ruptured Aneurysms, Blister Aneurysms, and Dissecting Aneurysms. Neurosurgery 2019; 86:S96-S103. [DOI: 10.1093/neuros/nyz304] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Accepted: 05/26/2019] [Indexed: 11/13/2022] Open
Abstract
Abstract
BACKGROUND
The safety and efficacy of flow diversion (FD) in the treatment of cerebral aneurysms have been reported by many studies. FD has enabled the treatment of complex aneurysms and aneurysms that were previously untreatable by conventional means. It has achieved high rates of obliteration with essentially no recanalization, and its indications have continued to expand, now including ruptured aneurysms, blister aneurysms, and dissecting aneurysms.
OBJECTIVE
To provide a review on the outcomes of studies covering the use of FD in the settings of ruptured, blister, and dissecting aneurysms. In addition, to discuss dual antiplatelet therapy (DAPT) used in preparation for FD deployment in these scenarios, including associated complications with DAPT use in the acute rupture setting.
METHODS
References for this topical review were identified by PubMed searches between January 2000 and January 2019. The search terms “aneurysm”, “flow diverter”, “stent”, “pipeline”, “ruptured”, “blister”, and “dissecting aneurysms” were used.
RESULTS
FD carries a higher complication rate in the acute rupture setting than for unruptured aneurysms. Patient selection is of paramount importance for achieving good functional and angiographic outcomes. DAPT still remains challenging, especially in ruptured aneurysms. Advancements in surface modification of flow diverters can reduce the risk of thromboembolism and perhaps lead to a safer antiplatelet regimen.
CONCLUSION
In summary, FD shows promise to be an effective treatment for ruptured, blister, and dissecting aneurysms.
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Affiliation(s)
- Peter Kan
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Ahmad Sweid
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Aditya Srivatsan
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Pascal Jabbour
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
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Hoogmoed J, de Oliveira Manoel AL, Coert BA, Marotta TR, Macdonald RL, Vandertop WP, Verbaan D, Germans MR. Why Do Patients with Poor-Grade Subarachnoid Hemorrhage Die? World Neurosurg 2019; 131:e508-e513. [PMID: 31398522 DOI: 10.1016/j.wneu.2019.07.221] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Accepted: 07/29/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Poor-grade subarachnoid hemorrhage (SAH) has been associated with a high case fatality, either in the acute phase or in the later stages. The exact causes of death in these patients are unknown. METHODS We performed a retrospective study of all consecutive patients with SAH with World Federation of Neurosurgical Societies grade IV or V on admission from 2009 to 2013 at 2 tertiary referral centers in Amsterdam, the Netherlands, and Toronto, Ontario, Canada, who had died during their hospital stay. RESULTS Of 357 patients, 152 (43%) had died. Of these 152 patients, 87 (24%) had not undergone aneurysm treatment. The median interval to death was 3 days (interquartile range, 1-12 days) after initial hemorrhage. The major cause of death in both centers was withdrawal of life support (107 patients [71%]; 74 of 94 [79%] in Amsterdam and 33 of 58 [58%] in Toronto; P < 0.01), followed by brain death in 23 (15%; 16 of 58 [28%] in Amsterdam vs. 7 of 94 [7%] in Toronto; P < 0.01). The remaining causes of death represented <15%. CONCLUSIONS The decision to withdraw life support was the major reason for death of patients with poor-grade SAH for an overwhelming majority of the patients. The exact reasons for withdrawal of life support, other than cultural and referral differences, were undetermined. Insight into the reasons of death should be prospectively studied to improve the care and clinical outcomes of patients with poor-grade SAH.
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Affiliation(s)
- Jantien Hoogmoed
- Department of Neurosurgery, Neurosurgical Center Amsterdam, Amsterdam University Medical Center, Amsterdam, The Netherlands.
| | - Airton L de Oliveira Manoel
- Neurology and Neurosurgery Department, Universidade Federal de São Paulo, São Paulo, Brazil; Department of Critical Care Medicine, Trauma and Neurosurgical Intensive Care Unit, University of Toronto, Toronto, Ontario, Canada; Division of Interventional Neuroradiology, Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada; Neuroscience Research Program, Keenan Research Centre, Li Ka Shing Knowledge Institute, University of Toronto, Toronto, Ontario, Canada
| | - Bert A Coert
- Department of Neurosurgery, Neurosurgical Center Amsterdam, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Thomas R Marotta
- Division of Interventional Neuroradiology, Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada; Neuroscience Research Program, Keenan Research Centre, Li Ka Shing Knowledge Institute, University of Toronto, Toronto, Ontario, Canada
| | - R Loch Macdonald
- Department of Critical Care Medicine, Trauma and Neurosurgical Intensive Care Unit, University of Toronto, Toronto, Ontario, Canada; Division of Neurosurgery, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - W Peter Vandertop
- Department of Neurosurgery, Neurosurgical Center Amsterdam, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Dagmar Verbaan
- Department of Neurosurgery, Neurosurgical Center Amsterdam, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Menno R Germans
- Department of Neurosurgery, University Hospital Zurich, Zurich, Switzerland; Clinical Neuroscience Center, University Hospital Zurich, Zurich, Switzerland
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Hoogmoed J, Coert BA, van den Berg R, Roos YBWEM, Horn J, Vandertop WP, Verbaan D. Early Treatment Decisions in Poor-Grade Patients with Subarachnoid Hemorrhage. World Neurosurg 2018; 119:e568-e573. [PMID: 30077026 DOI: 10.1016/j.wneu.2018.07.212] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Revised: 07/23/2018] [Accepted: 07/24/2018] [Indexed: 11/25/2022]
Abstract
BACKGROUND Patients with World Federation of Neurosurgical Societies (WFNS) grade V subarachnoid hemorrhage (SAH) mostly have a poor outcome. Correct identification of patients who might benefit from treatment remains challenging. We investigated which disease-related characteristics, present at admission, could identify patients with chance of good outcome. METHODS In total, 146 consecutive patients with WFNS grade V SAH (2002-2013) were included. Demographic and disease-related characteristics were compared between patients with a good outcome (Glasgow Outcome Scale 4 and 5) and a poor outcome (Glasgow Outcome Scale 1-3). Subgroups were made of patients with aneurysm treatment according to outcome; 1) good outcome; 2) poor outcome, with optimal general treatment; and 3) poor outcome, general treatment discontinued. RESULTS In total, 34 of the 146 patients had a good outcome (36% of all treated patients); 16 (47%) of these presented with a Glasgow Coma Scale score of 3, versus 65 (58%) of patients with a poor outcome (P = 0.33). Eleven (33%) patients in the good outcome group presented with pupillary abnormalities; 4 (12%) even had bilaterally fixed and dilated pupils, versus 49 (46%) in patients with a poor outcome (P < 0.01). In 51 patients, the aneurysm was not treated; all died. CONCLUSIONS More than one third of all treated patients with WFNS grade V SAH had a good outcome. All patients in whom the aneurysm was not treated died. Reliable identification of patients who will reach good outcome, on the basis of symptoms on admission, seems impossible, as these symptoms are not discriminating enough.
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Affiliation(s)
- Jantien Hoogmoed
- Department of Neurosurgery, Neurosurgical Center Amsterdam, Academic Medical Center, Amsterdam, The Netherlands.
| | - Bert A Coert
- Department of Neurosurgery, Neurosurgical Center Amsterdam, Academic Medical Center, Amsterdam, The Netherlands
| | - René van den Berg
- Department of Radiology, Academic Medical Center, Amsterdam, The Netherlands
| | - Yvo B W E M Roos
- Department of Neurology, Academic Medical Center, Amsterdam, The Netherlands
| | - Janneke Horn
- Department of Intensive Care Medicine, Academic Medical Center, Amsterdam, The Netherlands
| | - W Peter Vandertop
- Department of Neurosurgery, Neurosurgical Center Amsterdam, Academic Medical Center, Amsterdam, The Netherlands
| | - Dagmar Verbaan
- Department of Neurosurgery, Neurosurgical Center Amsterdam, Academic Medical Center, Amsterdam, The Netherlands
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11
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Zhang X, Tang H, Huang Q, Hong B, Xu Y, Liu J. Total Hospital Costs and Length of Stay of Endovascular Coiling Versus Neurosurgical Clipping for Unruptured Intracranial Aneurysms: Systematic Review and Meta-Analysis. World Neurosurg 2018; 115:393-399. [PMID: 29656151 DOI: 10.1016/j.wneu.2018.04.028] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Revised: 04/03/2018] [Accepted: 04/04/2018] [Indexed: 10/17/2022]
Abstract
OBJECTIVE Comparison of feasibility and safety between endovascular coiling versus neurosurgical clipping for the management of unruptured intracranial aneurysms (UIAs) has been incrementally reported. However, economic comparison has been rarely reported. This meta-analysis aims at qualitatively and quantitatively analyzing the difference of hospital costs and length of stay between endovascular versus neurosurgical treatment in UIA. METHODS MEDLINE, the Cochrane database, EMBASE, and Web of Science database were searched for cohort studies describing economic hospital cost or length of stay in patients with UIA. Two authors independently assessed study eligibility and rated quality using the Newcastle Ottawa Scale. Ravmen 5.2 was used to perform forest plot analysis. RESULTS Nine studies describing 24,856 UIAs treated with neurosurgical clipping and 31,309 UIAs treated with endovascular coiling were included. Meta-analysis revealed that the total hospital costs (THCs) were similar between coiling and clipping in UIA patients (standard mean difference [SMD]: -0.33, 95% confidence interval: -0.68 to 0.02, I2 = 99%, P = 0.07). Subgroup analysis showed that THCs of coiling were significantly lower than clipping in the United States but opposite in South Korea. One-year medical costs of coiling were similar in both groups (SMD: -0.04, 95% CI: -0.08 to 0.00, I2 = 0%, P = 0.07). In addition, the length of stay of coiling were significantly shorter than that of clipping (SMD: 0.69, 95% CI: 0.56-0.81, I2 = 95%, P < 0.001). CONCLUSION Generally, no significant difference in THCs and 1-year medical costs between coiling versus clipping in UIAs was observed. However, the length of stay of endovascular coiling was much shorter than neurosurgical clipping and decreased over time.
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Affiliation(s)
- Xiaoxi Zhang
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Haishuang Tang
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Qinghai Huang
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Bo Hong
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Yi Xu
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Jianmin Liu
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, China.
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12
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Han Y, Ye F, Long X, Li A, Xu H, Zou L, Yang Y, You C. Ultra-Early Treatment for Poor-Grade Aneurysmal Subarachnoid Hemorrhage: A Systematic Review and Meta-Analysis. World Neurosurg 2018; 115:e160-e171. [PMID: 29649648 DOI: 10.1016/j.wneu.2018.03.219] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Revised: 03/29/2018] [Accepted: 03/30/2018] [Indexed: 02/05/2023]
Abstract
BACKGROUND It remains unknown if ultra-early (within 24 hours after onset) treatment can improve the prognosis in patients with poor-grade aneurysmal subarachnoid hemorrhage (aSAH). We aimed to evaluate the effect of ultra-early treatment on functional outcomes and mortality in patients with poor-grade aSAH via a systematic review and meta-analysis. METHODS We performed a literature search in the PubMed, MEDLINE, and Web of Science databases. Primary outcomes were death and functional outcome assessed at any time period. Secondary outcomes were the rebleeding rate before an aneurysm occlusion procedure and the incidence of intraoperative technique difficulty (ITD). The results are reported as odds ratio (OR) with 95% confidence interval (CI). RESULTS A total of 14 articles containing 1111 patients met our inclusion criteria and were included in our analysis. The pooled incidence was 47% (95% CI, 40%-54%) for favorable outcome across 13 studies, 26% (95% CI, 19%-32%) for mortality in 11 studies, 10% (95% CI, 3%-16%) for rebleeding in 5 studies, and 20% (95% CI, 10%-31%) for ITD in 5 studies after ultra-early treatment of poor-grade aSAH. Compared with delayed treatment (>24 hours), the ultra-early treatment failed to improve outcomes (OR, 1.23; 95% CI, 0.75-2.01; P = 0.40) or reduce mortality (OR, 0.84; 95% CI, 0.58-1.22; P = 0.45), but tended to prevent preoperative rebleeding (OR, 0.59; 95% CI, 0.32 to 1.07; P = 0.08) in 6, 4, and 4 case-control studies, respectively. CONCLUSIONS Our findings show no significant change both in functional outcome and mortality between ultra-early and delayed treatment although ultra-early treatment may be associated with lower rebleeding rate.
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Affiliation(s)
- Yangyun Han
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, P.R. China; Department of Neurosurgery, People's Hospital of Deyang City, Deyang, Sichuan, P.R. China
| | - Feng Ye
- Department of Neurosurgery, People's Hospital of Deyang City, Deyang, Sichuan, P.R. China
| | - Xiaodong Long
- Department of Neurosurgery, People's Hospital of Deyang City, Deyang, Sichuan, P.R. China
| | - Aiguo Li
- Department of Neurosurgery, People's Hospital of Deyang City, Deyang, Sichuan, P.R. China
| | - Hong Xu
- Department of Neurosurgery, People's Hospital of Deyang City, Deyang, Sichuan, P.R. China
| | - Linbo Zou
- Department of Neurosurgery, People's Hospital of Deyang City, Deyang, Sichuan, P.R. China
| | - Yumin Yang
- Department of Neurosurgery, People's Hospital of Deyang City, Deyang, Sichuan, P.R. China
| | - Chao You
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, P.R. China.
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13
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Cho WS, Kim JE, Park SQ, Ko JK, Kim DW, Park JC, Yeon JY, Chung SY, Chung J, Joo SP, Hwang G, Kim DY, Chang WH, Choi KS, Lee SH, Sheen SH, Kang HS, Kim BM, Bae HJ, Oh CW, Park HS. Korean Clinical Practice Guidelines for Aneurysmal Subarachnoid Hemorrhage. J Korean Neurosurg Soc 2018. [PMID: 29526058 PMCID: PMC5853198 DOI: 10.3340/jkns.2017.0404.005] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Despite advancements in treating ruptured cerebral aneurysms, an aneurysmal subarachnoid hemorrhage (aSAH) is still a grave cerebrovascular disease associated with a high rate of morbidity and mortality. Based on the literature published to date, worldwide academic and governmental committees have developed clinical practice guidelines (CPGs) to propose standards for disease management in order to achieve the best treatment outcomes for aSAHs. In 2013, the Korean Society of Cerebrovascular Surgeons issued a Korean version of the CPGs for aSAHs. The group researched all articles and major foreign CPGs published in English until December 2015 using several search engines. Based on these articles, levels of evidence and grades of recommendations were determined by our society as well as by other related Quality Control Committees from neurointervention, neurology and rehabilitation medicine. The Korean version of the CPGs for aSAHs includes risk factors, diagnosis, initial management, medical and surgical management to prevent rebleeding, management of delayed cerebral ischemia and vasospasm, treatment of hydrocephalus, treatment of medical complications and early rehabilitation. The CPGs are not the absolute standard but are the present reference as the evidence is still incomplete, each environment of clinical practice is different, and there is a high probability of variation in the current recommendations. The CPGs will be useful in the fields of clinical practice and research.
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Affiliation(s)
- Won-Sang Cho
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Jeong Eun Kim
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Sukh Que Park
- Department of Neurosurgery, Soonchunhyang University School of Medicine, Seoul, Korea
| | - Jun Kyeung Ko
- Departments of Neurosurgery, Medical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Dae-Won Kim
- Department of Neurosurgery, Institute of Wonkwang Medical Science, Wonkwang University School of Medicine, Iksan, Korea
| | - Jung Cheol Park
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Je Young Yeon
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seung Young Chung
- Department of Neurosurgery, Eulji University Hospital, Daejeon, Korea
| | - Joonho Chung
- Department of Neurosurgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Sung-Pil Joo
- Department of Neurosurgery, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
| | - Gyojun Hwang
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Deog Young Kim
- Department of Rehabilitation Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Won Hyuk Chang
- Department of Physical and Rehabilitation Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kyu-Sun Choi
- Department of Neurosurgery, Hanyang University Medical Center, Seoul, Korea
| | - Sung Ho Lee
- Department of Neurosurgery, Kyung Hee University School of Medicine, Seoul, Korea
| | - Seung Hun Sheen
- Department of Neurosurgery, Bundang Jesaeng General Hospital, Seongnam, Korea
| | - Hyun-Seung Kang
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Byung Moon Kim
- Department of Radiology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Hee-Joon Bae
- Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Chang Wan Oh
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Hyeon Seon Park
- Department of Neurosurgery, Inha University School of Medicine, Incheon, Korea
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14
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Zhang X, Li L, Hong B, Xu Y, Liu Y, Huang Q, Liu J. A Systematic Review and Meta-Analysis on Economic Comparison Between Endovascular Coiling Versus Neurosurgical Clipping for Ruptured Intracranial Aneurysms. World Neurosurg 2018; 113:269-275. [PMID: 29476995 DOI: 10.1016/j.wneu.2018.02.078] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2018] [Revised: 02/10/2018] [Accepted: 02/12/2018] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Healthcare expenditures and cost reduction have been under critical surveillance in all countries and are critical for policymakers. This review aims at qualitatively and quantitatively analyzing the difference of hospital costs and length of stay between endovascular coiling versus neurosurgical clipping in ruptured intracranial aneurysms (RAs). METHODS MEDLINE, the Cochrane database, Embase, and the Web of Science database were searched and evaluated independently by 2 authors according to the Newcastle-Ottawa Scale for cohort studies describing economic hospital cost or length of stay in patients with RAs. RESULTS A total of 8 studies were included, describing 24,219 RAs treated with neurosurgical clipping and 24,962 RAs with endovascular coiling. Meta-analysis revealed that the total hospital costs (THCs) were similar between coiling versus clipping in RAs (standard mean difference [SMD], -0.05; 95% confidence interval [CI], -0.12 to 0.22; I2 = 99%; P = 0.50). Subgroup analysis showed that THCs of clipping and coiling were similar in ruptured aneurysms in the United States. However, in South Korea, the THCs of coiling were significantly higher than clipping. In the long run, 1-year medical costs of endovascular treatment were significantly lower than that of clipping in RAs (SMD, 0.15; 95% CI, 0.05-0.25; I2 = 66%; P = 0.005). In addition, the length of stay of coiled patients was significantly shorter than clipped patients (SMD, 0.29; 95% CI, 0.13-0.45; I2 = 96%; P < 0.001). CONCLUSIONS Medical costs were region-specified. In the United States, total hospital costs and 1-year medical costs were similar in RA patients treated with endovascular coiling and neurosurgical clipping. However, in countries like South Korea and China, coiling was more expensive. The length of stay was much shorter in coiled patients in all countries.
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Affiliation(s)
- Xiaoxi Zhang
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Li Li
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Bo Hong
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Yi Xu
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Yuan Liu
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Qinghai Huang
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Jianmin Liu
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, China.
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15
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Stienen MN, Germans M, Burkhardt JK, Neidert MC, Fung C, Bervini D, Zumofen D, Röthlisberger M, Marbacher S, Maduri R, Robert T, Seule MA, Bijlenga P, Schaller K, Fandino J, Smoll NR, Maldaner N, Finkenstädt S, Esposito G, Schatlo B, Keller E, Bozinov O, Regli L. Predictors of In-Hospital Death After Aneurysmal Subarachnoid Hemorrhage: Analysis of a Nationwide Database (Swiss SOS [Swiss Study on Aneurysmal Subarachnoid Hemorrhage]). Stroke 2018; 49:333-340. [PMID: 29335333 DOI: 10.1161/strokeaha.117.019328] [Citation(s) in RCA: 90] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Revised: 12/10/2017] [Accepted: 12/12/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE To identify predictors of in-hospital mortality in patients with aneurysmal subarachnoid hemorrhage and to estimate their impact. METHODS Retrospective analysis of prospective data from a nationwide multicenter registry on all aneurysmal subarachnoid hemorrhage cases admitted to a tertiary neurosurgical department in Switzerland (Swiss SOS [Swiss Study on Aneurysmal Subarachnoid Hemorrhage]; 2009-2015). Both clinical and radiological independent predictors of in-hospital mortality were identified, and their effect size was determined by calculating adjusted odds ratios (aORs) using multivariate logistic regression. Survival was displayed using Kaplan-Meier curves. RESULTS Data of n=1866 aneurysmal subarachnoid hemorrhage patients in the Swiss SOS database were available. In-hospital mortality was 20% (n=373). In n=197 patients (10.6%), active treatment was discontinued after hospital admission (no aneurysm occlusion attempted), and this cohort was excluded from analysis of the main statistical model. In the remaining n=1669 patients, the rate of in-hospital mortality was 13.9% (n=232). Strong independent predictors of in-hospital mortality were rebleeding (aOR, 7.69; 95% confidence interval, 3.00-19.71; P<0.001), cerebral infarction attributable to delayed cerebral ischemia (aOR, 3.66; 95% confidence interval, 1.94-6.89; P<0.001), intraventricular hemorrhage (aOR, 2.65; 95% confidence interval, 1.38-5.09; P=0.003), and new infarction post-treatment (aOR, 2.57; 95% confidence interval, 1.43-4.62; P=0.002). CONCLUSIONS Several-and among them modifiable-factors seem to be associated with in-hospital mortality after aneurysmal subarachnoid hemorrhage. Our data suggest that strategies aiming to reduce the risk of rebleeding are most promising in patients where active treatment is initially pursued. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT03245866.
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Affiliation(s)
- Martin Nikolaus Stienen
- From the Department of Neurosurgery, University Hospital Zurich and Clinical Neuroscience Center, University of Zurich, Switzerland (M.N.S., M.G., J.-K.B., M.C.N., N.M., S.F., G.E., E.K., O.B., L.R.); Department of Neurosurgery, Inselspital Bern, Switzerland (C.F., D.B.); Department of Neurosurgery, University Hospital Basel, Switzerland (D.Z., M.R.); Department of Neurosurgery, Kantonsspital Aarau, Switzerland (S.M., J.F.); Department of Neurosurgery, University Hospital Lausanne, Switzerland (R.M.); Department of Neurosurgery, Ospedale Regionale di Lugano, Switzerland (T.R.); Department of Neurosurgery, Kantonsspital St.Gallen, Switzerland (M.A.S.); Department of Neurosurgery, Hôpitaux Universitaires de Genève, Switzerland (P.B., K.S., N.R.S.); and Department of Neurosurgery, University Hospital Göttingen, Germany (B.S.).
| | - Menno Germans
- From the Department of Neurosurgery, University Hospital Zurich and Clinical Neuroscience Center, University of Zurich, Switzerland (M.N.S., M.G., J.-K.B., M.C.N., N.M., S.F., G.E., E.K., O.B., L.R.); Department of Neurosurgery, Inselspital Bern, Switzerland (C.F., D.B.); Department of Neurosurgery, University Hospital Basel, Switzerland (D.Z., M.R.); Department of Neurosurgery, Kantonsspital Aarau, Switzerland (S.M., J.F.); Department of Neurosurgery, University Hospital Lausanne, Switzerland (R.M.); Department of Neurosurgery, Ospedale Regionale di Lugano, Switzerland (T.R.); Department of Neurosurgery, Kantonsspital St.Gallen, Switzerland (M.A.S.); Department of Neurosurgery, Hôpitaux Universitaires de Genève, Switzerland (P.B., K.S., N.R.S.); and Department of Neurosurgery, University Hospital Göttingen, Germany (B.S.)
| | - Jan-Karl Burkhardt
- From the Department of Neurosurgery, University Hospital Zurich and Clinical Neuroscience Center, University of Zurich, Switzerland (M.N.S., M.G., J.-K.B., M.C.N., N.M., S.F., G.E., E.K., O.B., L.R.); Department of Neurosurgery, Inselspital Bern, Switzerland (C.F., D.B.); Department of Neurosurgery, University Hospital Basel, Switzerland (D.Z., M.R.); Department of Neurosurgery, Kantonsspital Aarau, Switzerland (S.M., J.F.); Department of Neurosurgery, University Hospital Lausanne, Switzerland (R.M.); Department of Neurosurgery, Ospedale Regionale di Lugano, Switzerland (T.R.); Department of Neurosurgery, Kantonsspital St.Gallen, Switzerland (M.A.S.); Department of Neurosurgery, Hôpitaux Universitaires de Genève, Switzerland (P.B., K.S., N.R.S.); and Department of Neurosurgery, University Hospital Göttingen, Germany (B.S.)
| | - Marian C Neidert
- From the Department of Neurosurgery, University Hospital Zurich and Clinical Neuroscience Center, University of Zurich, Switzerland (M.N.S., M.G., J.-K.B., M.C.N., N.M., S.F., G.E., E.K., O.B., L.R.); Department of Neurosurgery, Inselspital Bern, Switzerland (C.F., D.B.); Department of Neurosurgery, University Hospital Basel, Switzerland (D.Z., M.R.); Department of Neurosurgery, Kantonsspital Aarau, Switzerland (S.M., J.F.); Department of Neurosurgery, University Hospital Lausanne, Switzerland (R.M.); Department of Neurosurgery, Ospedale Regionale di Lugano, Switzerland (T.R.); Department of Neurosurgery, Kantonsspital St.Gallen, Switzerland (M.A.S.); Department of Neurosurgery, Hôpitaux Universitaires de Genève, Switzerland (P.B., K.S., N.R.S.); and Department of Neurosurgery, University Hospital Göttingen, Germany (B.S.)
| | - Christian Fung
- From the Department of Neurosurgery, University Hospital Zurich and Clinical Neuroscience Center, University of Zurich, Switzerland (M.N.S., M.G., J.-K.B., M.C.N., N.M., S.F., G.E., E.K., O.B., L.R.); Department of Neurosurgery, Inselspital Bern, Switzerland (C.F., D.B.); Department of Neurosurgery, University Hospital Basel, Switzerland (D.Z., M.R.); Department of Neurosurgery, Kantonsspital Aarau, Switzerland (S.M., J.F.); Department of Neurosurgery, University Hospital Lausanne, Switzerland (R.M.); Department of Neurosurgery, Ospedale Regionale di Lugano, Switzerland (T.R.); Department of Neurosurgery, Kantonsspital St.Gallen, Switzerland (M.A.S.); Department of Neurosurgery, Hôpitaux Universitaires de Genève, Switzerland (P.B., K.S., N.R.S.); and Department of Neurosurgery, University Hospital Göttingen, Germany (B.S.)
| | - David Bervini
- From the Department of Neurosurgery, University Hospital Zurich and Clinical Neuroscience Center, University of Zurich, Switzerland (M.N.S., M.G., J.-K.B., M.C.N., N.M., S.F., G.E., E.K., O.B., L.R.); Department of Neurosurgery, Inselspital Bern, Switzerland (C.F., D.B.); Department of Neurosurgery, University Hospital Basel, Switzerland (D.Z., M.R.); Department of Neurosurgery, Kantonsspital Aarau, Switzerland (S.M., J.F.); Department of Neurosurgery, University Hospital Lausanne, Switzerland (R.M.); Department of Neurosurgery, Ospedale Regionale di Lugano, Switzerland (T.R.); Department of Neurosurgery, Kantonsspital St.Gallen, Switzerland (M.A.S.); Department of Neurosurgery, Hôpitaux Universitaires de Genève, Switzerland (P.B., K.S., N.R.S.); and Department of Neurosurgery, University Hospital Göttingen, Germany (B.S.)
| | - Daniel Zumofen
- From the Department of Neurosurgery, University Hospital Zurich and Clinical Neuroscience Center, University of Zurich, Switzerland (M.N.S., M.G., J.-K.B., M.C.N., N.M., S.F., G.E., E.K., O.B., L.R.); Department of Neurosurgery, Inselspital Bern, Switzerland (C.F., D.B.); Department of Neurosurgery, University Hospital Basel, Switzerland (D.Z., M.R.); Department of Neurosurgery, Kantonsspital Aarau, Switzerland (S.M., J.F.); Department of Neurosurgery, University Hospital Lausanne, Switzerland (R.M.); Department of Neurosurgery, Ospedale Regionale di Lugano, Switzerland (T.R.); Department of Neurosurgery, Kantonsspital St.Gallen, Switzerland (M.A.S.); Department of Neurosurgery, Hôpitaux Universitaires de Genève, Switzerland (P.B., K.S., N.R.S.); and Department of Neurosurgery, University Hospital Göttingen, Germany (B.S.)
| | - Michel Röthlisberger
- From the Department of Neurosurgery, University Hospital Zurich and Clinical Neuroscience Center, University of Zurich, Switzerland (M.N.S., M.G., J.-K.B., M.C.N., N.M., S.F., G.E., E.K., O.B., L.R.); Department of Neurosurgery, Inselspital Bern, Switzerland (C.F., D.B.); Department of Neurosurgery, University Hospital Basel, Switzerland (D.Z., M.R.); Department of Neurosurgery, Kantonsspital Aarau, Switzerland (S.M., J.F.); Department of Neurosurgery, University Hospital Lausanne, Switzerland (R.M.); Department of Neurosurgery, Ospedale Regionale di Lugano, Switzerland (T.R.); Department of Neurosurgery, Kantonsspital St.Gallen, Switzerland (M.A.S.); Department of Neurosurgery, Hôpitaux Universitaires de Genève, Switzerland (P.B., K.S., N.R.S.); and Department of Neurosurgery, University Hospital Göttingen, Germany (B.S.)
| | - Serge Marbacher
- From the Department of Neurosurgery, University Hospital Zurich and Clinical Neuroscience Center, University of Zurich, Switzerland (M.N.S., M.G., J.-K.B., M.C.N., N.M., S.F., G.E., E.K., O.B., L.R.); Department of Neurosurgery, Inselspital Bern, Switzerland (C.F., D.B.); Department of Neurosurgery, University Hospital Basel, Switzerland (D.Z., M.R.); Department of Neurosurgery, Kantonsspital Aarau, Switzerland (S.M., J.F.); Department of Neurosurgery, University Hospital Lausanne, Switzerland (R.M.); Department of Neurosurgery, Ospedale Regionale di Lugano, Switzerland (T.R.); Department of Neurosurgery, Kantonsspital St.Gallen, Switzerland (M.A.S.); Department of Neurosurgery, Hôpitaux Universitaires de Genève, Switzerland (P.B., K.S., N.R.S.); and Department of Neurosurgery, University Hospital Göttingen, Germany (B.S.)
| | - Rodolfo Maduri
- From the Department of Neurosurgery, University Hospital Zurich and Clinical Neuroscience Center, University of Zurich, Switzerland (M.N.S., M.G., J.-K.B., M.C.N., N.M., S.F., G.E., E.K., O.B., L.R.); Department of Neurosurgery, Inselspital Bern, Switzerland (C.F., D.B.); Department of Neurosurgery, University Hospital Basel, Switzerland (D.Z., M.R.); Department of Neurosurgery, Kantonsspital Aarau, Switzerland (S.M., J.F.); Department of Neurosurgery, University Hospital Lausanne, Switzerland (R.M.); Department of Neurosurgery, Ospedale Regionale di Lugano, Switzerland (T.R.); Department of Neurosurgery, Kantonsspital St.Gallen, Switzerland (M.A.S.); Department of Neurosurgery, Hôpitaux Universitaires de Genève, Switzerland (P.B., K.S., N.R.S.); and Department of Neurosurgery, University Hospital Göttingen, Germany (B.S.)
| | - Thomas Robert
- From the Department of Neurosurgery, University Hospital Zurich and Clinical Neuroscience Center, University of Zurich, Switzerland (M.N.S., M.G., J.-K.B., M.C.N., N.M., S.F., G.E., E.K., O.B., L.R.); Department of Neurosurgery, Inselspital Bern, Switzerland (C.F., D.B.); Department of Neurosurgery, University Hospital Basel, Switzerland (D.Z., M.R.); Department of Neurosurgery, Kantonsspital Aarau, Switzerland (S.M., J.F.); Department of Neurosurgery, University Hospital Lausanne, Switzerland (R.M.); Department of Neurosurgery, Ospedale Regionale di Lugano, Switzerland (T.R.); Department of Neurosurgery, Kantonsspital St.Gallen, Switzerland (M.A.S.); Department of Neurosurgery, Hôpitaux Universitaires de Genève, Switzerland (P.B., K.S., N.R.S.); and Department of Neurosurgery, University Hospital Göttingen, Germany (B.S.)
| | - Martin A Seule
- From the Department of Neurosurgery, University Hospital Zurich and Clinical Neuroscience Center, University of Zurich, Switzerland (M.N.S., M.G., J.-K.B., M.C.N., N.M., S.F., G.E., E.K., O.B., L.R.); Department of Neurosurgery, Inselspital Bern, Switzerland (C.F., D.B.); Department of Neurosurgery, University Hospital Basel, Switzerland (D.Z., M.R.); Department of Neurosurgery, Kantonsspital Aarau, Switzerland (S.M., J.F.); Department of Neurosurgery, University Hospital Lausanne, Switzerland (R.M.); Department of Neurosurgery, Ospedale Regionale di Lugano, Switzerland (T.R.); Department of Neurosurgery, Kantonsspital St.Gallen, Switzerland (M.A.S.); Department of Neurosurgery, Hôpitaux Universitaires de Genève, Switzerland (P.B., K.S., N.R.S.); and Department of Neurosurgery, University Hospital Göttingen, Germany (B.S.)
| | - Philippe Bijlenga
- From the Department of Neurosurgery, University Hospital Zurich and Clinical Neuroscience Center, University of Zurich, Switzerland (M.N.S., M.G., J.-K.B., M.C.N., N.M., S.F., G.E., E.K., O.B., L.R.); Department of Neurosurgery, Inselspital Bern, Switzerland (C.F., D.B.); Department of Neurosurgery, University Hospital Basel, Switzerland (D.Z., M.R.); Department of Neurosurgery, Kantonsspital Aarau, Switzerland (S.M., J.F.); Department of Neurosurgery, University Hospital Lausanne, Switzerland (R.M.); Department of Neurosurgery, Ospedale Regionale di Lugano, Switzerland (T.R.); Department of Neurosurgery, Kantonsspital St.Gallen, Switzerland (M.A.S.); Department of Neurosurgery, Hôpitaux Universitaires de Genève, Switzerland (P.B., K.S., N.R.S.); and Department of Neurosurgery, University Hospital Göttingen, Germany (B.S.)
| | - Karl Schaller
- From the Department of Neurosurgery, University Hospital Zurich and Clinical Neuroscience Center, University of Zurich, Switzerland (M.N.S., M.G., J.-K.B., M.C.N., N.M., S.F., G.E., E.K., O.B., L.R.); Department of Neurosurgery, Inselspital Bern, Switzerland (C.F., D.B.); Department of Neurosurgery, University Hospital Basel, Switzerland (D.Z., M.R.); Department of Neurosurgery, Kantonsspital Aarau, Switzerland (S.M., J.F.); Department of Neurosurgery, University Hospital Lausanne, Switzerland (R.M.); Department of Neurosurgery, Ospedale Regionale di Lugano, Switzerland (T.R.); Department of Neurosurgery, Kantonsspital St.Gallen, Switzerland (M.A.S.); Department of Neurosurgery, Hôpitaux Universitaires de Genève, Switzerland (P.B., K.S., N.R.S.); and Department of Neurosurgery, University Hospital Göttingen, Germany (B.S.)
| | - Javier Fandino
- From the Department of Neurosurgery, University Hospital Zurich and Clinical Neuroscience Center, University of Zurich, Switzerland (M.N.S., M.G., J.-K.B., M.C.N., N.M., S.F., G.E., E.K., O.B., L.R.); Department of Neurosurgery, Inselspital Bern, Switzerland (C.F., D.B.); Department of Neurosurgery, University Hospital Basel, Switzerland (D.Z., M.R.); Department of Neurosurgery, Kantonsspital Aarau, Switzerland (S.M., J.F.); Department of Neurosurgery, University Hospital Lausanne, Switzerland (R.M.); Department of Neurosurgery, Ospedale Regionale di Lugano, Switzerland (T.R.); Department of Neurosurgery, Kantonsspital St.Gallen, Switzerland (M.A.S.); Department of Neurosurgery, Hôpitaux Universitaires de Genève, Switzerland (P.B., K.S., N.R.S.); and Department of Neurosurgery, University Hospital Göttingen, Germany (B.S.)
| | - Nicolas R Smoll
- From the Department of Neurosurgery, University Hospital Zurich and Clinical Neuroscience Center, University of Zurich, Switzerland (M.N.S., M.G., J.-K.B., M.C.N., N.M., S.F., G.E., E.K., O.B., L.R.); Department of Neurosurgery, Inselspital Bern, Switzerland (C.F., D.B.); Department of Neurosurgery, University Hospital Basel, Switzerland (D.Z., M.R.); Department of Neurosurgery, Kantonsspital Aarau, Switzerland (S.M., J.F.); Department of Neurosurgery, University Hospital Lausanne, Switzerland (R.M.); Department of Neurosurgery, Ospedale Regionale di Lugano, Switzerland (T.R.); Department of Neurosurgery, Kantonsspital St.Gallen, Switzerland (M.A.S.); Department of Neurosurgery, Hôpitaux Universitaires de Genève, Switzerland (P.B., K.S., N.R.S.); and Department of Neurosurgery, University Hospital Göttingen, Germany (B.S.)
| | - Nicolai Maldaner
- From the Department of Neurosurgery, University Hospital Zurich and Clinical Neuroscience Center, University of Zurich, Switzerland (M.N.S., M.G., J.-K.B., M.C.N., N.M., S.F., G.E., E.K., O.B., L.R.); Department of Neurosurgery, Inselspital Bern, Switzerland (C.F., D.B.); Department of Neurosurgery, University Hospital Basel, Switzerland (D.Z., M.R.); Department of Neurosurgery, Kantonsspital Aarau, Switzerland (S.M., J.F.); Department of Neurosurgery, University Hospital Lausanne, Switzerland (R.M.); Department of Neurosurgery, Ospedale Regionale di Lugano, Switzerland (T.R.); Department of Neurosurgery, Kantonsspital St.Gallen, Switzerland (M.A.S.); Department of Neurosurgery, Hôpitaux Universitaires de Genève, Switzerland (P.B., K.S., N.R.S.); and Department of Neurosurgery, University Hospital Göttingen, Germany (B.S.)
| | - Sina Finkenstädt
- From the Department of Neurosurgery, University Hospital Zurich and Clinical Neuroscience Center, University of Zurich, Switzerland (M.N.S., M.G., J.-K.B., M.C.N., N.M., S.F., G.E., E.K., O.B., L.R.); Department of Neurosurgery, Inselspital Bern, Switzerland (C.F., D.B.); Department of Neurosurgery, University Hospital Basel, Switzerland (D.Z., M.R.); Department of Neurosurgery, Kantonsspital Aarau, Switzerland (S.M., J.F.); Department of Neurosurgery, University Hospital Lausanne, Switzerland (R.M.); Department of Neurosurgery, Ospedale Regionale di Lugano, Switzerland (T.R.); Department of Neurosurgery, Kantonsspital St.Gallen, Switzerland (M.A.S.); Department of Neurosurgery, Hôpitaux Universitaires de Genève, Switzerland (P.B., K.S., N.R.S.); and Department of Neurosurgery, University Hospital Göttingen, Germany (B.S.)
| | - Giuseppe Esposito
- From the Department of Neurosurgery, University Hospital Zurich and Clinical Neuroscience Center, University of Zurich, Switzerland (M.N.S., M.G., J.-K.B., M.C.N., N.M., S.F., G.E., E.K., O.B., L.R.); Department of Neurosurgery, Inselspital Bern, Switzerland (C.F., D.B.); Department of Neurosurgery, University Hospital Basel, Switzerland (D.Z., M.R.); Department of Neurosurgery, Kantonsspital Aarau, Switzerland (S.M., J.F.); Department of Neurosurgery, University Hospital Lausanne, Switzerland (R.M.); Department of Neurosurgery, Ospedale Regionale di Lugano, Switzerland (T.R.); Department of Neurosurgery, Kantonsspital St.Gallen, Switzerland (M.A.S.); Department of Neurosurgery, Hôpitaux Universitaires de Genève, Switzerland (P.B., K.S., N.R.S.); and Department of Neurosurgery, University Hospital Göttingen, Germany (B.S.)
| | - Bawarjan Schatlo
- From the Department of Neurosurgery, University Hospital Zurich and Clinical Neuroscience Center, University of Zurich, Switzerland (M.N.S., M.G., J.-K.B., M.C.N., N.M., S.F., G.E., E.K., O.B., L.R.); Department of Neurosurgery, Inselspital Bern, Switzerland (C.F., D.B.); Department of Neurosurgery, University Hospital Basel, Switzerland (D.Z., M.R.); Department of Neurosurgery, Kantonsspital Aarau, Switzerland (S.M., J.F.); Department of Neurosurgery, University Hospital Lausanne, Switzerland (R.M.); Department of Neurosurgery, Ospedale Regionale di Lugano, Switzerland (T.R.); Department of Neurosurgery, Kantonsspital St.Gallen, Switzerland (M.A.S.); Department of Neurosurgery, Hôpitaux Universitaires de Genève, Switzerland (P.B., K.S., N.R.S.); and Department of Neurosurgery, University Hospital Göttingen, Germany (B.S.)
| | - Emanuela Keller
- From the Department of Neurosurgery, University Hospital Zurich and Clinical Neuroscience Center, University of Zurich, Switzerland (M.N.S., M.G., J.-K.B., M.C.N., N.M., S.F., G.E., E.K., O.B., L.R.); Department of Neurosurgery, Inselspital Bern, Switzerland (C.F., D.B.); Department of Neurosurgery, University Hospital Basel, Switzerland (D.Z., M.R.); Department of Neurosurgery, Kantonsspital Aarau, Switzerland (S.M., J.F.); Department of Neurosurgery, University Hospital Lausanne, Switzerland (R.M.); Department of Neurosurgery, Ospedale Regionale di Lugano, Switzerland (T.R.); Department of Neurosurgery, Kantonsspital St.Gallen, Switzerland (M.A.S.); Department of Neurosurgery, Hôpitaux Universitaires de Genève, Switzerland (P.B., K.S., N.R.S.); and Department of Neurosurgery, University Hospital Göttingen, Germany (B.S.)
| | - Oliver Bozinov
- From the Department of Neurosurgery, University Hospital Zurich and Clinical Neuroscience Center, University of Zurich, Switzerland (M.N.S., M.G., J.-K.B., M.C.N., N.M., S.F., G.E., E.K., O.B., L.R.); Department of Neurosurgery, Inselspital Bern, Switzerland (C.F., D.B.); Department of Neurosurgery, University Hospital Basel, Switzerland (D.Z., M.R.); Department of Neurosurgery, Kantonsspital Aarau, Switzerland (S.M., J.F.); Department of Neurosurgery, University Hospital Lausanne, Switzerland (R.M.); Department of Neurosurgery, Ospedale Regionale di Lugano, Switzerland (T.R.); Department of Neurosurgery, Kantonsspital St.Gallen, Switzerland (M.A.S.); Department of Neurosurgery, Hôpitaux Universitaires de Genève, Switzerland (P.B., K.S., N.R.S.); and Department of Neurosurgery, University Hospital Göttingen, Germany (B.S.)
| | - Luca Regli
- From the Department of Neurosurgery, University Hospital Zurich and Clinical Neuroscience Center, University of Zurich, Switzerland (M.N.S., M.G., J.-K.B., M.C.N., N.M., S.F., G.E., E.K., O.B., L.R.); Department of Neurosurgery, Inselspital Bern, Switzerland (C.F., D.B.); Department of Neurosurgery, University Hospital Basel, Switzerland (D.Z., M.R.); Department of Neurosurgery, Kantonsspital Aarau, Switzerland (S.M., J.F.); Department of Neurosurgery, University Hospital Lausanne, Switzerland (R.M.); Department of Neurosurgery, Ospedale Regionale di Lugano, Switzerland (T.R.); Department of Neurosurgery, Kantonsspital St.Gallen, Switzerland (M.A.S.); Department of Neurosurgery, Hôpitaux Universitaires de Genève, Switzerland (P.B., K.S., N.R.S.); and Department of Neurosurgery, University Hospital Göttingen, Germany (B.S.)
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16
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Tykocki T, Czyż M, Machaj M, Szydlarska D, Kostkiewicz B. Comparison of the timing of intervention and treatment modality of poor-grade aneurysmal subarachnoid hemorrhage. Br J Neurosurg 2017; 31:430-433. [PMID: 28436243 DOI: 10.1080/02688697.2017.1319906] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVES The timing and modality of intervention in the treatment of poor-grade aneurysmal subarachnoid haemorrhage (aSAH) has not been defined. The purpose of the study is to analyse whether early treatment and type of intervention influence the clinical outcomes of poor-grade aSAH patients. MATERIAL AND METHODS Patients with poor-grade aSAH were retrieved. Demographics, Fisher grade, radiological characteristics and clinical outcomes were recorded. Outcomes were compared using the modified Rankin Scale (mRS), for groups treated early within 24 hours of aSAH or later and by clipping or endovascular therapy. Multivariate multiple regression model and logistic regression were used to assess factors affecting outcomes at discharge in mRS and length of stay. RESULTS The study was conducted on 79 patients. 47 (59%) were treated by clipping, 38 (48%) received intervention within 24 hours of aSAH. Patients treated <24h had significantly lower mortality (n = 5; 13% vs. n = 14; 37%; p < .023), higher rate of 0-3 mRS (n = 22;58% vs. n = 9; 22%; p < .039) and were younger (49.5 ± 6.1 vs. 65.8 ± 7.4 years; p < .038). There were no significant differences in mRS between clipping and endovascular therapy. Predictors of length of stay were ICH, MLS, endovascular therapy, location in posterior circulation, Fisher grade and time to intervention <24h. Early intervention, <24h significantly influenced the favourable results in mRS (0-3); (OR 4,14; Cl95% 3.82-4.35). Posterior circulation aneurysms, midline shift and intracerebral hematoma were correlated with poor outcomes. CONCLUSIONS Early treatment, within 24 h, of poor-grade aSAH confirmed better clinical outcome compared to later aneurysm securement. There was no significant difference between clipping and endovascular treatment.
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Affiliation(s)
- Tomasz Tykocki
- a Department of Neurosurgery , Institute of Psychiatry and Neurology in Warsaw , Warsaw , Poland
| | - Marcin Czyż
- b The Centre for Spinal Studies and Surgery , Queens Medical Centre , Nottingham , UK
| | - Małgorzata Machaj
- c Department of Human Resource , Central Clinical Hospital of the Ministry of the Interior in Warsaw , Warsaw , Poland
| | - Dorota Szydlarska
- d Family Medicine Outpatient Clinic with Vaccination Centre , Central Clinical Hospital of the Ministry of the Interior in Warsaw , Warsaw , Poland
| | - Bogusław Kostkiewicz
- e Department of Neurosurgery , Central Clinical Hospital of the Ministry of the Interior in Warsaw , Warsaw , Poland
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17
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Rawal S, Alcaide-Leon P, Macdonald RL, Rinkel GJE, Victor JC, Krings T, Kapral MK, Laupacis A. Meta-analysis of timing of endovascular aneurysm treatment in subarachnoid haemorrhage: inconsistent results of early treatment within 1 day. J Neurol Neurosurg Psychiatry 2017; 88:241-248. [PMID: 28100721 DOI: 10.1136/jnnp-2016-314596] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Revised: 12/06/2016] [Accepted: 12/19/2016] [Indexed: 11/04/2022]
Abstract
BACKGROUND AND PURPOSE To systematically review and meta-analyse the data on impact of timing of endovascular treatment in aneurysmal subarachnoid haemorrhage (SAH) to determine if earlier treatment is associated with improved clinical outcomes and reduced case fatality. METHODS We searched MEDLINE, Cochrane database, EMBASE and Web of Science to identify studies for inclusion. The measures of effect utilised were unadjusted/adjusted ORs. Effect estimates were combined using random effects models for each outcome (poor outcome, case fatality); heterogeneity was assessed using the I2 index. Subgroup and sensitivity analyses were performed to account for heterogeneity and risk of bias. RESULTS 16 studies met the inclusion criteria. Treatment <1 day was associated with a reduced odds of poor outcome compared with treatment >1 day (OR=0.40 (95% CI 0.28 to 0.56; I2=0%)) but not when compared with treatment at 1-3 days (OR=1.16 (95% CI 0.47 to 2.90; I2=81%)). Treatment at <2 days and at <3 days were associated with similar odds of poor outcome compared with later treatment (OR=1.20 (95% CI 0.70 to 2.05; I2=73%; OR=0.71 (95% CI 0.36 to 1.37; I2=71%)). Early treatment was associated with similar odds of case fatality compared with later treatment, regardless of how early/late treatment were defined (OR=1.80 (95% CI 0.88 to 3.67; I2=34%) for treatment <1 day vs days 1-3; OR=1.71 (95% CI 0.72 to 4.03; I2=54%) for treatment <2 days vs later; OR=0.90 (95% CI 0.31 to 2.68; I2=48%) for treatment <3 days vs later). CONCLUSIONS In only 1 of the analyses was there a statistically significant result, which favoured treatment <1 day. The inconsistent results and heterogeneity within most analyses highlight the lack of evidence for best timing of endovascular treatment in SAH patients.
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Affiliation(s)
- Sapna Rawal
- Division of Neuroradiology, Joint Department of Medical Imaging, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Paula Alcaide-Leon
- Division of Neuroradiology, Department of Medical Imaging, St Michael's Hospital, Toronto, Ontario, Canada
| | - R Loch Macdonald
- Division of Neurosurgery, Department of Surgery, St Michael's Hospital, Labatt Family Centre of Excellence in Brain Injury and Trauma Research, Keenan Research Centre for Biomedical Research and Li Ka Shing Knowledge Institute, Toronto, Ontario, Canada
| | - Gabriel J E Rinkel
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center, Utrecht, The Netherlands
| | - J Charles Victor
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Timo Krings
- Division of Neuroradiology, Joint Department of Medical Imaging, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Moira K Kapral
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.,Division of General Internal Medicine, Toronto General Research Institute, University Health Network, Toronto, Ontario, Canada
| | - Andreas Laupacis
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.,Department of Medicine, St Michael's Hospital, Li Ka Shing Knowledge Institute, Toronto, Ontario, Canada
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18
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Zhao B, Yang H, Zheng K, Li Z, Xiong Y, Tan X, Zhong M. Preoperative and postoperative predictors of long-term outcome after endovascular treatment of poor-grade aneurysmal subarachnoid hemorrhage. J Neurosurg 2016; 126:1764-1771. [PMID: 27367238 DOI: 10.3171/2016.4.jns152587] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE An increasing number of patients with poor-grade aneurysmal subarachnoid hemorrhage (aSAH) have received endovascular treatment. Endovascular treatment of poor-grade aSAH, however, is based on single-center retrospective studies, and predictors of long-term outcome have not been well defined. Using results from a multicenter prospective registry, the authors aimed to develop preoperative and postoperative prognostic models to predict poor outcome after endovascular treatment of poor-grade aSAH. METHODS A Multicenter Poor-grade Aneurysm Study (AMPAS) was a prospective and observational registry of consecutive patients with poor-grade aSAH. From October 2010 to March 2012, 366 patients were enrolled in the registry, and 136 patients receiving endovascular treatment were included in this study. Outcome was assessed by modified Rankin Scale (mRS) score at 12 months, and poor outcome was defined as an mRS score of 4, 5, or 6. Prognostic models were developed in multivariate logistic regression models. The area under receiver operating characteristic curves (AUC) was used to assess the model's discriminatory ability, and Hosmer-Lemeshow goodness-of-fit tests were used to assess the calibration. RESULTS At 12 months, 64 patients (47.0%) had a poor outcome: 9 (6.6%) had an mRS score of 4, 6 (4.4%) had an mRS score of 5, and 49 (36.0%) had died. Univariate analyses showed that older age (p = 0.001), female sex (p = 0.044), lower Glasgow Coma Scale score (p < 0.001), a World Federation of Neurosurgical Societies (WFNS) grade of V (p < 0.001), higher Fisher grade (p < 0.001), modified Fisher grade (p < 0.001), and wider neck aneurysm (p = 0.026) were associated with a poor outcome. There was a trend toward a worse outcome in patients with anterior communicating artery aneurysms (p = 0.080) and in those with incompletely occluded aneurysms (p = 0.063). After endovascular treatment, the presence of cerebral infarction (p = 0.039), symptomatic vasospasm (p = 0.039), and pneumonia (p = 0.006) were associated with a poor outcome. Multivariate analyses showed that the preoperative prognostic model including age, a WFNS grade of V, modified Fisher grade, and aneurysm neck size had excellent discrimination with an AUC of 0.86 (95% CI 0.80-0.92, p < 0.001), and a postoperative model that included these predictors as well as postoperative pneumonia had excellent discrimination (AUC = 0.87, 95% CI 0.81-0.93, p < 0.001). Both models had good calibration (p = 0.941 and p = 0.653, respectively). CONCLUSIONS Older age, WFNS Grade V, higher modified Fisher grade, wider neck aneurysm, and postoperative pneumonia were independent predictors of poor outcome after endovascular treatment of poor-grade aSAH. The preoperative model had almost the same discrimination as the postoperative model. Endovascular treatment should be carefully considered in patients with poor-grade aSAH with ruptured wide-neck aneurysms. ▪ CLASSIFICATION OF EVIDENCE Type of question: prognostic; study design: retrospective cohort trial; evidence: Class I.
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Affiliation(s)
- Bing Zhao
- Department of Neurosurgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China.,Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota; and
| | - Hua Yang
- Department of Neurosurgery, The Affiliated Hospital of Guizhou Medical University, Guiyang, China
| | - Kuang Zheng
- Department of Neurosurgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Zequn Li
- Department of Neurosurgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Ye Xiong
- Department of Neurosurgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Xianxi Tan
- Department of Neurosurgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Ming Zhong
- Department of Neurosurgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
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19
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Brinjikji W, Piano M, Fang S, Pero G, Kallmes DF, Quilici L, Valvassori L, Lozupone E, Cloft HJ, Boccardi E, Lanzino G. Treatment of ruptured complex and large/giant ruptured cerebral aneurysms by acute coiling followed by staged flow diversion. J Neurosurg 2016; 125:120-7. [DOI: 10.3171/2015.6.jns151038] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT
Flow-diversion treatment has been shown to be associated with high rates of angiographic obliteration; however, the treatment is relatively contraindicated in the acute phase following subarachnoid hemorrhage (SAH) as these patients require periprocedural dual antiplatelet therapy. Acute coiling followed by flow diversion has emerged as an intriguing and feasible treatment option for ruptured complex and giant aneurysms. In this study the authors report outcomes and complications of patients with ruptured aneurysms undergoing coiling in the acute phase followed by planned delayed flow diversion.
METHODS
This case series includes patients from 2 institutions. All patients underwent standard endovascular coiling in the acute phase after SAH with the intention and plan to proceed with flow diversion at a later date. Outcomes studied included angiographic occlusion, procedure-related complications, and long-term clinical outcome as measured using the modified Rankin Scale.
RESULTS
A total of 31 patients underwent coiling in the acute phase with the intention to undergo flow diversion at a later date. The mean aneurysm size was 15.8 ± 7.9 mm. Of the 31 patients undergoing coiling, 4 patients could not undergo further flow-diverter therapy: 3 patients (9.7%) died of complications of subarachnoid hemorrhage and 1 patient had permanent morbidity as a result of perioperative ischemic stroke (3.1%). Twenty-seven patients underwent staged placement of flow diverters after adequate recovery. The median time to treatment was 16 weeks. There was one case of aneurysm rebleeding following coil treatment. There were no cases of permanent morbidity or mortality resulting from flow-diverter treatment. Twenty-four patients underwent imaging follow-up; 18 of these patients had aneurysms that were completely or nearly completely occluded (58.1% on an intent-to-treat basis). At last follow-up (mean 18.3 months), 25 patients had mRS scores ≤ 2 (80.6% on an intent-to-treat basis).
CONCLUSIONS
Staged treatment of ruptured complex and giant intracranial aneurysms with coiling in the acute phase and flow-diverter treatment following recovery from SAH is both safe and effective. In this series, no cases of rebleeding occurred during the interval between coiling and flow diversion. This strategy should be considered as a valid option in patients presenting with these challenging ruptured aneurysms.
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Affiliation(s)
| | | | - Shanna Fang
- 2Mayo Medical School, Mayo Clinic, Rochester, Minnesota, Mayo Clinic, Rochester, Minnesota
| | | | | | - Luca Quilici
- 4Department of Radiology, Hospital Niguarda, Milan; and
| | | | - Emilio Lozupone
- 5Department of Radiodiagnostics, Gemelli Hospital, Rome, Italy
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20
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Inamasu J, Sadato A, Oheda M, Hayakawa M, Nakae S, Ohmi T, Adachi K, Nakahara I, Hirose Y. Improvement in patient outcomes following endovascular treatment of WFNS grade V subarachnoid haemorrhage from 2000 to 2014. J Clin Neurosci 2016; 27:114-8. [PMID: 26778358 DOI: 10.1016/j.jocn.2015.08.043] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Revised: 08/04/2015] [Accepted: 08/14/2015] [Indexed: 02/05/2023]
Abstract
Patient outcomes following grade V subarachnoid haemorrhage (SAH) have been dismal, although they may have improved following recent technological advances in endovascular treatment (EVT). A single-centre, retrospective study was conducted to evaluate whether outcomes have improved from 2000 to 2014 for patients with World Federation of Neurosurgical Societies (WFNS) grade V SAH. Coiling has been the preferred first-line treatment for grade V SAH patients in our institution since 2000. Patients who underwent EVT (n=115) were grouped on the basis of their hospital admission year: 2000-2004 (n=44), 2005-2009 (n=37) and 2010-2014 (n=34). Patient demographics, outcomes and in-hospital mortality rates were compared between the groups. Patient outcomes at discharge were evaluated using the Glasgow Outcome Scale (GOS), with GOS scores of 4-5 defined as favourable outcomes. There were no significant intergroup differences in patient demographics. In addition, there were no significant differences in the frequencies of favourable outcomes (14% in 2000-2004, 16% in 2005-2009 and 26% in 2010-2014). Mortality rates were 52% in 2000-2004, 43% in 2005-2009 and 24% in 2010-2014, with a significantly lower mortality rate in 2010-2014 than in 2000-2004 (p=0.01). Both perioperative rebleeding and delayed cerebral ischaemia decreased over time; however, multivariate regression analysis showed that the former contributed more to the decrease in mortality. Age was the only variable associated with favourable outcomes. The results of this study indicate that EVT is an appropriate therapeutic option for grade V SAH patients. However, multi-centre, prospective trials are required to provide evidence-based verification of the efficacy of EVT.
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Affiliation(s)
- Joji Inamasu
- Department of Neurosurgery, Fujita Health University Hospital, 1-98 Dengakugakubo, Toyoake 470-1192, Japan.
| | - Akiyo Sadato
- Department of Neurosurgery, Fujita Health University Hospital, 1-98 Dengakugakubo, Toyoake 470-1192, Japan
| | - Motoki Oheda
- Department of Neurosurgery, Fujita Health University Hospital, 1-98 Dengakugakubo, Toyoake 470-1192, Japan
| | - Motoharu Hayakawa
- Department of Neurosurgery, Fujita Health University Hospital, 1-98 Dengakugakubo, Toyoake 470-1192, Japan
| | - Shunsuke Nakae
- Department of Neurosurgery, Fujita Health University Hospital, 1-98 Dengakugakubo, Toyoake 470-1192, Japan
| | - Tatsuo Ohmi
- Department of Neurosurgery, Fujita Health University Hospital, 1-98 Dengakugakubo, Toyoake 470-1192, Japan
| | - Kazuhide Adachi
- Department of Neurosurgery, Fujita Health University Hospital, 1-98 Dengakugakubo, Toyoake 470-1192, Japan
| | - Ichiro Nakahara
- Department of Neurosurgery, Fujita Health University Hospital, 1-98 Dengakugakubo, Toyoake 470-1192, Japan
| | - Yuichi Hirose
- Department of Neurosurgery, Fujita Health University Hospital, 1-98 Dengakugakubo, Toyoake 470-1192, Japan
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