Operative or endovascular treatment of ruptured intracranial vertebral artery aneurysms?

A Nationwide Analysis of Aneurysmal Subarachnoid Hemorrhage Mortality, Complications, and Health Economics in the USA

Aneurysmal subarachnoid hemorrhage (aSAH) is a devastating neurological condition. Endovascular coiling or surgical clipping have equivocal success rates, but relatively little is known regarding the health economics and complications of these procedures at the population level. We aimed to analyze the complication profiles and healthcare resource utilization (HRCU) associated with the treatment of aSAH in the USA. We performed a retrospective analysis utilizing the IBM MarketScan database between 2008 and 2015. Primary outcomes included economic analysis stratified by post-operative complication; determination of the effect of several factors on total cost by multivariable regression; and analysis of the incidence, timing, and associated HCRU of aSAH-related post-operative complications. Of the 2374 patients meeting inclusion criteria for economic analysis, 1783 (75.1%) patients had at least one of the ten complications. The most common complications included hydrocephalus (43.8%), transient cerebral ischemia (including vasospasm) (30.6%), ischemic stroke (29.1%), syndrome of inappropriate antidiuretic hormone (SIADH)/hyposmolarity/hyponatremia (22.1%), and seizures (14.9%). Patients who experienced complications had higher median 90-day total costs [$161,127 (Q1 to Q3, $101,411 to $257,662)] than those who did not [$97,376 (Q1 to Q3, $55,692 to $147,447)]. Length of stay was longest for those with pulmonary embolism and pneumonia (27 days) and shortest for those with SIADH/hyposmolarity/hyponatremia (16 days). Brain compression/herniation had the highest mortality rate (19.5%). In total, 14.6% of all patients experienced a readmission within 30 days. In conclusion, patients with aSAH have high post-operative complication rates and costs. Development of novel interventions to reduce complications and improve outcomes is crucial.

Clipping versus coiling for aneurysmal subarachnoid hemorrhage: a systematic review and meta-analysis of prospective studies

Neurosurgical clipping and endovascular coiling are both standard therapies to prevent rebleeding after aneurysmal subarachnoid hemorrhage (aSAH). However, controversy still exists about which is the optimal treatment. This meta-analysis aims to assess the effectiveness and safety of two treatments with high-quality evidence. Web of Science, Cochrane Library, EMBASE, Pubmed, Sinomed, China National Knowledge Infrastructure, and Wanfang Data databases were systematically searched on August 5, 2021. Randomized controlled trials (RCTs) and prospective cohort studies that evaluated the effectiveness and safety of clipping versus coiling in aSAH patients at discharge or within 1-year follow-up period were eligible. No restriction was set on the publication date. Meta-analyses were conducted to calculate the pooled estimates and 95% confidence intervals (CI) of relative risk (RR). Eight RCTs and 20 prospective cohort studies were identified. Compared to coiling, clipping was associated with a lower rebleeding rate at discharge (RR: 0.52, 95% CI: 0.29––0.94) and a higher aneurysmal occlusion rate (RR: 1.33, 95% CI: 1.19–1.48) at 1-year follow-up. In contrast, coiling reduced the vasospasm rate at discharge (RR: 1.45, 95% CI: 1.23–1.71) and 1-year poor outcome rate (RR: 1.27, 95% CI: 1.16–1.39). Subgroup analyses presented that among patients with a poor neurological condition at admission, no statistically significant outcome difference existed between the two treatments. The overall prognosis was better among patients who received coiling, but this advantage was not significant among patients with a poor neurological condition at admission. Therefore, the selection of treatment modality for aSAH patients should be considered comprehensively.

Transcondylar Fossa Approach to Unruptured Vertebral Artery and Vertebral Artery-Posterior Inferior Cerebellar Artery Aneurysms: Surgical Outcome

OBJECTIVE

Surgical treatment of vertebral artery (VA) and VA-proximal posterior inferior cerebellar artery (PICA) aneurysms poses a special challenge to the operating surgeon because of the complex anatomy of the neck and the location of the aneurysm. We report our surgical results of unruptured VA and VA-PICA aneurysms operated on through the transcondylar fossa approach.

METHODS

We retrospectively analyzed the data of 20 patients with unruptured VA and VA-PICA aneurysms who were treated by the transcondylar fossa approach in a single institution from November 2014 to March 2018. Data including clinical profile, radiology, complications, and outcome were analyzed.

RESULTS

Five patients had VA aneurysms and 15 had VA-PICA aneurysms. All were unruptured aneurysms, and 4 patients were symptomatic. All underwent surgical treatment through the transcondylar fossa approach. Proximal VA occlusion alone for 4 patients along with revascularization for 3 patients was performed. Twelve patients underwent clipping and 1 underwent wrapping of the aneurysm. The transcondylar fossa approach was adequate to expose the aneurysms successfully. There were no intraoperative complications encountered. Only 3 patients had transient postoperative complications. Follow-up imaging showed complete occlusion of all clipped aneurysms and complete thrombosis of the sac in all patients with proximal VA occlusion with or without revascularization.

CONCLUSIONS

Although the incidence of rupture of asymptomatic unruptured VA and VA-PICA aneurysms is low, they should be considered for surgical treatment because they carry higher early mortality and morbidity after rupture. The transcondylar fossa approach provides adequate exposure of the aneurysm without permanent lower cranial nerve morbidity.

Coiling Is Not Superior to Clipping in Patients with High-Grade Aneurysmal Subarachnoid Hemorrhage: Systematic Review and Meta-Analysis

BACKGROUND

Outcomes of coiling embolization versus clipping for patients with high-grade aneurysmal subarachnoid hemorrhage (aSAH) have not been previously compared. We reviewed current evidence regarding the safety and efficacy of clipping versus coiling for high-grade aSAH.

METHODS

We conducted a meta-analysis of studies that compared clipping with coiling in patients with high-grade aSAH published from January 1999 to February 2016 in Medline, Embase, and Cochrane databases based on PRISMA inclusion and exclusion criteria. Binary outcome comparisons between clipping and coiling were described using odds ratios (ORs).

RESULTS

Three randomized controlled trials (RCTs) and 16 observational studies were included. There was no statistical difference in good outcome rates between the clipping and coiling groups (OR, 1.44; 95% confidence interval [CI], 0.97-2.13). Subgroup analysis showed no significant difference between the 2 treatments in non-RCTs (OR, 1.49; 95% CI, 0.95-2.36) and RCTs (OR, 1.15; 95% CI, 0.59-2.25). Coiling was associated with higher mortality (OR, 0.55; 95% CI, 0.41-0.75). Lower mortality was associated with clipping in non-RCTs (OR, 0.54; 95% CI, 0.40-0.74), but there was no difference in the RCTs (OR, 0.79; 95% CI, 0.19-3.39). Coiling was not associated with lower rates of complications including rebleeding (OR, 0.62; 95% CI, 0.30-1.29), ischemic infarct (OR, 0.89; 95% CI, 0.53-1.49), symptomatic vasospasm (OR, 0.76; 95% CI, 0.45-1.29), or shunt-dependent hydrocephalus (OR, 1.33; 95% CI, 0.52-3.40).

CONCLUSION

The outcome with coiling is not superior to clipping in patients with high-grade aSAH; moreover, coiling has a greater risk of mortality.

Intracranial Vertebral Artery Aneurysms: Clinical Features and Outcome of 190 Patients

BACKGROUND

Vertebral artery (VA) aneurysms comprise approximately one-third of posterior circulation aneurysms. They are morphologically variable, and located critically close to the cranial nerves and the brainstem. We aim to represent the characteristics of these aneurysms and their treatment, and to analyze the outcome.

METHODS

We reviewed retrospectively 9709 patients with intracranial aneurysms. Of these, we included 190 with aneurysms at the VA or VA-posterior inferior cerebellar artery junction. These patients were treated in the Department of Neurosurgery, Helsinki, Finland, between 1934 and 2011.

RESULTS

The 190 patients had 193 VA aneurysms, among which 131 (68%) were ruptured. The VA aneurysm caused a mass effect in 7 and ischemia in 2 patients. Compared to 4387 patients with a ruptured aneurysm in other locations, those with a VA aneurysm were older, their aneurysms were more often fusiform, and more often caused intraventricular hemorrhages. Among surgically treated aneurysms, clipping was the treatment in 91 (88%) saccular and 11 (50%) fusiform aneurysms. Treatment was endovascular in 13 (9%), and multimodal in 6 (4%) aneurysms. Within a year after aneurysm diagnosis, 53 (28%) patients died. Among the survivors, 104 (93%) returned to an independent or to their previous state of life; only 2 (2%) were unable to return home.

CONCLUSIONS

Microsurgery is a feasible treatment for VA aneurysms, although cranial nerve deficits are more common than in endovascular surgery. Despite the challenge of an often severe hemorrhage, of challenging morphology, and risk for laryngeal palsy, most patients surviving the initial stage return to normalcy.

Endovascular treatment of proximal and distal posterior inferior cerebellar artery aneurysms

Object

Surgical clipping of posterior inferior cerebellar artery (PICA) aneurysms can be challenging and carries a potentially significant risk of morbidity and mortality. Experience with endovascular therapy has been limited to a few studies. The authors assess the feasibility, safety, and efficacy of endovascular therapy in the largest series of proximal and distal PICA aneurysms to date.

Methods

A total of 76 patients, 54 with proximal and 22 with distal PICA aneurysms, underwent endovascular treatment at Jefferson Hospital for Neuroscience between 2001 and 2011.

Results

Endovascular treatment was successful in 52 patients (96.3%) with proximal aneurysms and 19 patients (86.4%) with distal aneurysms. Treatment consisted of selective aneurysm coiling in 60 patients (84.5%) (including 4 with stent assistance and 4 with balloon assistance) and parent vessel trapping in 11 patients (15.5%). Specifically, a deconstructive procedure was necessary in 9.6% of proximal aneurysms (5 of 52) and 31.6% of distal aneurysms (6 of 19). There were 9 overall procedural complications (12.7%), 6 infarcts (8.5%; 4 occurring after deliberate occlusion of the PICA), and 3 intraprocedural ruptures (4.2%). The rate of procedure-related permanent morbidity was 2.8%. Complete aneurysm occlusion was achieved in 63.4% of patients (45 of 71). One patient (1.4%) treated with selective aneurysm coiling suffered a rehemorrhage on postoperative Day 15. The mean angiographic follow-up time was 17.2 months. Recurrence and re-treatment rates were, respectively, 20% and 17.1% for proximal aneurysms compared with 30.8% and 23.1% for distal aneurysms. Favorable outcomes (moderate, mild, or no disability) at follow-up were seen in 93% of patients with unruptured aneurysms and in 78.7% of those with ruptured aneurysms.

Conclusions

Endovascular therapy is a feasible, safe, and effective treatment in patients with proximal and distal PICA aneurysms, providing excellent patient outcomes and adequate protection against rehemorrhage. The long-term incidence of aneurysm recanalization appears to be high, especially in distal aneurysms, and requires careful angiographic follow-up.

Long-term Economic Impact of Coiling vs Clipping for Unruptured Intracranial Aneurysms

BACKGROUND:

Treatment of unruptured intracranial aneurysms (UIAs) involves endovascular coiling or aneurysm clipping. While many studies have compared these treatment modalities with respect to various clinical outcomes, few studies have investigated the economic costs associated with each procedure.

OBJECTIVE:

To determine the reoperation rate, postoperative complications, and inpatient and outpatient costs associated with surgical or endovascular treatment of patients with UIAs in the United States.

METHODS:

We utilized the MarketScan database to examine patients who underwent surgical clipping or endovascular coiling procedures for UIAs from 2000 to 2009, comparing reoperation rates, complications, and angiogram and healthcare resource use. Propensity score matching techniques were used to match patients.

RESULTS:

We identified 4,504 patients with surgically treated UIAs, with propensity score matching of 3,436 patients. Reoperation rates were significantly lower in the clipping group compared to the coiling group at 1- (P < .001), 2- (P < .001), and 5 years (P < .001) following the procedure. However, postoperative complications (immediate, 30 and 90 days) were significantly higher in those undergoing surgical clipping. Although hospital length of stay and costs were higher in the clipping group for the index procedure, the number of postoperative angiograms and outpatient services used at 1, 2, and 5 years were significantly higher in the coiling group.

CONCLUSION:

Though surgical clipping resulted in lower reoperation rates, it was associated with higher complication rates and initial costs. However, overall costs at 2 and 5 years were similar to endovascular coiling due to the significantly higher number of follow-up angiograms and outpatient costs in these patients.

The effect of coiling versus clipping of ruptured and unruptured cerebral aneurysms on length of stay, hospital cost, hospital reimbursement, and surgeon reimbursement at the university of Florida

OBJECTIVE

There are few studies comparing the economic costs and reimbursements for aneurysm clipping versus coiling, and none are from the United States. Our hypothesis predicted that coiling would result in shorter lengths of hospitalization than clipping in patients with unruptured aneurysms and would therefore result in lower hospital charges. However, because of the severity of subarachnoid hemorrhage, there would be no difference in length of hospitalization or hospital charges in patients with ruptured aneurysms.

METHODS

We compared aneurysm coiling with aneurysm clipping in patients with unruptured and ruptured aneurysms treated at the University of Florida from January 2005 to June 2007 for differences in length of hospitalization, hospital costs, hospital collections, and surgeon collections. Patient demographic and aneurysm characteristic data were obtained from a clinical database. Length of hospitalization, cost, billing, and collection data were obtained from the hospital cost accounting database. Multivariate statistical analyses of length of hospitalization, hospital costs, hospital collections, and surgeon collections were performed using factors including patient age, sex, aneurysm size, aneurysm location, aneurysm treatment, presence of subarachnoid hemorrhage, clinical grade, payor, hospital billing, and surgeon billing.

RESULTS

There were 565 patients with cerebral aneurysms treated either surgically (306 patients, 54%) or endovascularly (259 patients, 46%). In patients without subarachnoid hemorrhage (unruptured aneurysms) (n = 367), surgery, compared with endovascular treatment, was associated with longer hospitalization (P < 0.001), but lower hospital costs (P < 0.001), higher surgeon collections (P = 0.003), and similar hospital collections. In patients with subarachnoid hemorrhage (ruptured aneurysms) (n = 198), surgery was associated with lower hospital costs (P = 0.011), but similar length of stay, surgeon collections, and hospital collections. Larger aneurysm size was significantly associated with longer hospitalization in the patients with unruptured aneurysms (P < 0.001) and higher hospital costs for both patients with unruptured (P < 0.001) and ruptured (P = 0.015) aneurysms. The payor was significantly associated with hospital costs in patients with ruptured aneurysms (P = 0.034) and length of stay (unruptured aneurysms, P < 0.001; ruptured aneurysms, P < 0.001), hospital collections (unruptured aneurysms, P < 0.001; ruptured aneurysms, P < 0.001), and surgeon collections (unruptured aneurysms, P < 0.001; ruptured aneurysms, P < 0.001) in both patients with unruptured and ruptured aneurysms. A worse clinical grade was significantly associated with higher hospital costs (P < 0.001).

CONCLUSION

Despite a shorter length of hospitalization in patients with unruptured aneurysms, coiling was associated with higher hospital costs in both patients with unruptured and ruptured aneurysms. This is likely attributable to the higher device cost of coils than clips. The advantages of coiling over clipping would be better realized if the cost of coils could be comparably reduced to that of clips.

The endovascular management of saccular posterior inferior cerebellar artery aneurysms

Objective

The purpose of this retrospective study was to report the outcome of the endovascular treatment of eight patients with eight saccular posterior inferior cerebellar artery (PICA) aneurysms.

Materials and Methods

Over the last seven years (1999-2006), eight consecutive patients with saccular PICA aneurysms were treated by endovascular methods. Five of the aneurysms were presented with subarachnoid hemorrhaging, whereas three were discovered incidentally. Four of the aneurysms (3 ruptured and 1 incidental) were treated by intrasaccular coiling, whereas the remaining four (1 ruptured and 3 incidental) were treated by vertebral artery (VA) occlusion.

Results

Of the four aneurysms treated by intrasaccular coiling, three were completely packed with coils and one was partially packed. In three of four patients who underwent vertebral artery occlusions, follow-up digital subtraction angiographies demonstrated thrombosed aneurysms and PICA. No procedure-related morbidity occurred and no re-bleed was encountered during a follow-up examination (mean; 31 months).

Conclusion

As a result of this study, we found that the endovascular management of saccular PICA aneurysms should be considered as safe and effective.

Endovascular Surgery for Proximal Posterior Inferior Cerebellar Artery Aneurysms: An Analysis of Glasgow Outcome Score by Hunt-Hess Grades

OBJECTIVE:

Proximal posterior inferior cerebellar artery (PICA) aneurysms represent a subset of posterior circulation aneurysms that can be routinely treated with either clipping or coiling. The literature contains limited numbers of patients with proximal PICA aneurysms treated with endovascular surgery. We report our experience with endovascular surgery of proximal PICA aneurysms with emphasis on patients with poor Hunt-Hess grades.

METHODS:

We reviewed 31 consecutive patients with proximal PICA aneurysms who were treated with endovascular surgery. The following data were analyzed: age, sex, size of aneurysm, Hunt-Hess grade at presentation, Fisher grade at presentation, angiographic result after embolization, complications, number of days hospitalized, duration of follow-up, angiographic follow-up results, and Glasgow Outcome Score at follow-up.

RESULTS:

Excellent angiographic occlusion was achieved in 30 of 31 (97%) patients. Clinical follow-up with Glasgow Outcome Score was performed on every patient an average of 10 months later. Twenty-one of 31 (68%) patients had good outcomes (Glasgow Outcome Score I or II) at follow-up. Of the patients who presented with a favorable clinical grade (Hunt-Hess 0–III), 13 of 15 (87%) had good outcomes at follow-up. Of the patients who presented with a poor clinical grade (Hunt-Hess Grade IV or higher), 8 of 16 (50%) had good outcomes at follow-up.

CONCLUSION:

This series demonstrates the safety and efficacy of endovascular surgery for proximal PICA aneurysms. Many patients with poor Hunt-Hess grades from ruptured PICA aneurysms ultimately had a good outcome. This could be secondary to early, aggressive treatment of hydrocephalus and the minimally invasive nature of the endovascular approach.

Cardiac Injury after Subarachnoid Hemorrhage Is Independent of the Type of Aneurysm Therapy

OBJECTIVE:

Subarachnoid hemorrhage (SAH) is associated with cardiac injury and dysfunction. Whether aneurysm clipping versus coiling has a differential effect on the risk of troponin release and left ventricular (LV) dysfunction after SAH is unknown. It is hypothesized that aneurysm treatment does not affect the risk of developing cardiac injury and dysfunction.

METHODS:

The study included 172 consecutive SAH patients who underwent clipping (n = 109) or coiling (n = 63) aneurysm therapy. Hemodynamic data were collected, cardiac troponin I was measured, and echocardiography was performed on the 1st, 3rd, and 6th days after enrollment. A cardiac troponin I measurement of more than 1.0 μg/L was considered abnormal. For each echocardiographic examination, a blinded observer measured LV ejection fraction (abnormal if &lt;50%) and quantified LV regional wall motion abnormalities. The incidence of cardiac outcomes in the treatment groups was compared using odds ratios (ORs).

RESULTS:

The coiled patients were older than the clipped patients (mean age, 59 ± 13 yr versus 53 ± 12 yr; t test, P &lt; 0.001) and were more likely to have posterior aneurysms (33% versus 18%; χ2 test, P = 0.019). There were no significant between-group differences in the risk of cardiac troponin I release (coil 21% versus clip 19%; OR = 0.89, P = 0.789), regional wall motion abnormalities (33% versus 28%; OR = 0.76, P = 0.422), or LV ejection fraction lower than 50% (16% versus 17%; OR = 1.06, P = 0.892). No patient died of cardiac causes (heart failure, myocardial infarction, or arrhythmia).

CONCLUSION:

Surgical and endovascular aneurysm therapies were associated with similar risks of cardiac injury and dysfunction after SAH. The presence of neurocardiogenic injury should not affect aneurysm treatment decisions.

Three-dimensional pulsatile flow simulation before and after endovascular coil embolization of a terminal cerebral aneurysm

The effect of different percentages of coil mesh in a cerebral aneurysm on the pulsatile flow and pressure in the parent vessel and aneurysm lumen was evaluated. Geometric data on a basilar tip aneurysm and vertebrobasilar arteries after subarachnoid hemorrhage was obtained by computer tomographic angiography. Intraarterial pressure was measured at four vertebrobasilar points before and after treatment with detachable coils. Pulsatile flow was documented by transcranial ultrasonography. A three-dimensional computer simulation was created using a commercial fluid dynamics solver for four aneurysm conditions: (1) before intervention; (2) with a 20% filling showing a complete cessation of the inflow through the aneurysm neck; (3) with a 12% filling showing an incomplete deceleration of inflow through the aneurysm neck, with a remaining flow around the embedded platinum coils; and (4) with a 12% filling and simulation of clotted aneurysm dome, which did not inhibit persisting flow phenomena. The relative pressure amplitudes neither increased nor decreased under the different simulated aneurysm filling conditions. Inserted platinum coils can immediately and decisively relieve the influx of pulsating blood and allow for initial clotting. To reach this effect, a volume density of 20% platinum coil mesh in the aneurysm neck is needed.