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Padmanaban V, Benjamin WJ, Cohrs A, Jareczek FJ, Hazard SW, Zacko JC, Church EW, Simon SD, Cockroft KM, Leslie DL, Wilkinson DA. Nationwide trends in intensive care unit utilization in the elective endovascular treatment of unruptured intracranial aneurysms. Interv Neuroradiol 2024:15910199241233028. [PMID: 38454799 DOI: 10.1177/15910199241233028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2024] Open
Abstract
OBJECTIVE Multiple studies suggest routine post-operative intensive care unit (ICU) stays after endovascular treatment (EVT) of unruptured intracranial aneurysms (UIAs) is unnecessary, though rates of ICU utilization nationwide are unknown. We aim to evaluate rates and characteristics of ICU utilization in patients undergoing elective endovascular repair of UIAs. METHODS This is a retrospective cohort study utilizing a nationwide private-payer database in the United States to evaluate the ICU utilization in patients undergoing elective endovascular repair of UIAs between 2005 and 2019. Demographics and pre-operative comorbidities as well as post-procedural complications and discharge status were compared. An analysis of charges and costs was also performed. RESULTS Among 6218 patients who underwent elective EVT of a UIA, 4890 (78.6%) were admitted to the ICU post-operatively. There were no differences in age, sex, or Charlson comorbidity scores in patients admitted to the ICU post-operatively compared to those admitted elsewhere. ICU utilization was more common in urban locations compared to rural. 12.7% of patients had ICU-specific needs sufficient to be billed by a critical care provider. Total provider costs were significantly higher in patients utilizing the ICU post-operatively, even among uncomplicated patients with routine discharges. CONCLUSION Most patients undergoing elective endovascular UIA repair in the United States are admitted to the ICU postoperatively. Only 12.7% have ICU needs, and these patients are predictable from pre-operative characteristics or peri-operative complications. Reducing ICU use in this subgroup of patients may be an important target to improve healthcare value in this patient population.
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Affiliation(s)
- Varun Padmanaban
- Department of Neurosurgery, Pennsylvania State University College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
| | | | - Austin Cohrs
- Center for Applied Studies in Health Economics, Pennsylvania State University College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Francis J Jareczek
- Department of Neurosurgery, Pennsylvania State University College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Sprague W Hazard
- Department of Neurosurgery, Pennsylvania State University College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
- Department of Anesthesia and Perioperative Services, Pennsylvania State University College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Joseph Christopher Zacko
- Department of Neurosurgery, Pennsylvania State University College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Ephraim W Church
- Department of Neurosurgery, Pennsylvania State University College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Scott D Simon
- Department of Neurosurgery, Pennsylvania State University College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Kevin M Cockroft
- Department of Neurosurgery, Pennsylvania State University College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
- Department of Anesthesia and Perioperative Services, Pennsylvania State University College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
- Department of Radiology, Pennsylvania State University College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Douglas L Leslie
- Center for Applied Studies in Health Economics, Pennsylvania State University College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
| | - David Andrew Wilkinson
- Department of Neurosurgery, Pennsylvania State University College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
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Saal-Zapata G, Durand-Castro W, Valer-Gonzales D, Flores-Quijaite JEM, Rodriguez-Varela R. Endovascular trends in the treatment of intracranial aneurysms in a Peruvian reference center. J Neurosci Rural Pract 2023; 14:655-659. [PMID: 38059237 PMCID: PMC10696328 DOI: 10.25259/jnrp_282_2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Accepted: 07/01/2023] [Indexed: 12/08/2023] Open
Abstract
Objectives Endovascular treatment of intracranial aneurysms (IAs) has evolved in recent years and is currently the preferred treatment worldwide. We analyzed the trends in the number of patients, number of aneurysms, aneurysm characteristics, and techniques used in a pure endovascular cohort of patients treated in a reference center. Materials and Methods Between 2010 and 2020, a retrospective data collection of patients who underwent endovascular intervention of IAs was performed. We used the Mann-Kendal test to evaluate the trends. In addition, the moving-average technique was used to assess smoother curves. Results Eight hundred and forty-five aneurysms were treated in 765 patients, the mean age was 53.9 ± 14.6 years and 81% were women. The number of patients (P = 0.016) and aneurysms (P = 0.003) increased significantly. Unruptured (P = 0.029) and posterior communicating artery aneurysms increased their frequency of treatment (P = 0.042). Balloon remodeling (P = 0.01) and the use of flow diverters showed a positive trend (P = 0.016). Conclusion There have been an increased number of patients and aneurysms treated endovascularly at our institution, including unruptured and posterior communicating aneurysms. Advanced endovascular techniques also increased. Comparative studies including surgical cases must be done in our region to determine the best approach.
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Affiliation(s)
- Giancarlo Saal-Zapata
- Department of Neurosurgery, Hospital Nacional Guillermo Almenara Irigoyen, La Victoria, Lima, Peru
| | - Walter Durand-Castro
- Department of Neurosurgery, Hospital Nacional Guillermo Almenara Irigoyen, La Victoria, Lima, Peru
| | - Dante Valer-Gonzales
- Department of Neurosurgery, Hospital Nacional Guillermo Almenara Irigoyen, La Victoria, Lima, Peru
| | | | - Rodolfo Rodriguez-Varela
- Department of Neurosurgery, Hospital Nacional Guillermo Almenara Irigoyen, La Victoria, Lima, Peru
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Cras TY, Hunink MMG, Dammers R, van Es ACGM, Volovici V, Burke JF, Kremers FCC, Dippel DWJ, Roozenbeek B. Surveillance of Unruptured Intracranial Aneurysms: Cost-Effectiveness Analysis for 3 Countries. Neurology 2022; 99:e890-e903. [PMID: 35654593 DOI: 10.1212/wnl.0000000000200785] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Accepted: 04/11/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVES No consensus exists on adequate surveillance of conservatively managed unruptured intracranial aneurysms (UIAs). We aimed to determine optimal MRI surveillance strategies for the growth of UIAs using cost-effectiveness analysis. A secondary aim was to develop a clinical tool for personalizing UIA surveillance. METHODS We designed a microsimulation model from a health care perspective simulating 100,000 55-year-old women to estimate costs and quality-adjusted life years (QALYs) over a lifetime horizon in the United States, the United Kingdom, and the Netherlands, using literature-derived model parameters. Country-specific costs and willingness-to-pay thresholds ($100,000/QALY for the United States, £30,000/QALY for the United Kingdom, and €80,000/QALY for the Netherlands) were used. Lifetime costs and QALYs were annually discounted at 3% for the United States, 3.5% for the United Kingdom, or 4% (costs) and 1.5% (QALYs) for the Netherlands. Strategies were no follow-up surveillance, follow-up with MRI in the first and fifth year after UIA discovery, every 5 years, every 2 years, or annually, or immediate intervention (i.e., clipping or coiling). Using the microsimulation model, we developed a tool for personalizing UIA surveillance for men and women, with different ages and varying aneurysm characteristics. Uncertainty in the input parameters was modeled with probabilistic sensitivity analysis. RESULTS Among 55-year-old women, 2,222 individuals in the United States, 1,910 in the United Kingdom, and 2,040 in the Netherlands needed to undergo an annual MRI scan to prevent 1 case of subarachnoid hemorrhage per year. No surveillance MRI was most cost-effective in the United States (in 47% of the simulations) and United Kingdom (in 54% of simulations), whereas annual MRI was most cost-effective in the Netherlands (in 53% of simulations). In the United States and United Kingdom, annual surveillance or surveillance in the first and fifth year after discovery was cost-effective in patients <60 years and at increased risk of aneurysm growth. The optimal, personalized, surveillance strategies were summarized in a look-up table for use in clinical practice. DISCUSSION Generally, the US and UK physicians should refrain from assigning patients, particularly older patients and those with few risk factors for aneurysm growth or rupture, to frequent MRI surveillance. In the Netherlands, annual follow-up is generally most cost-effective.
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Affiliation(s)
- Tim Yannick Cras
- From the Departments of Neurology (T.Y.C., F.C.C.K., D.W.J.D., B.R.), Epidemiology (M.M.G.H.), Radiology & Nuclear Medicine (M.M.G.H., B.R.), Neurosurgery (R.D., V.V.), and Erasmus MC University Medical Center (T.Y.C., F.C.C.K., D.W.J.D., B.R., R.D.), Rotterdam, the Netherlands; Centre for Health Decision Sciences (M.M.G.H.), Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA; Department of Radiology (A.C.G.M.v.E.), Leiden University Medical Center, the Netherlands; and Department of Neurology (J.F.B.), University of Michigan, Ann Arbor
| | - Myriam M G Hunink
- From the Departments of Neurology (T.Y.C., F.C.C.K., D.W.J.D., B.R.), Epidemiology (M.M.G.H.), Radiology & Nuclear Medicine (M.M.G.H., B.R.), Neurosurgery (R.D., V.V.), and Erasmus MC University Medical Center (T.Y.C., F.C.C.K., D.W.J.D., B.R., R.D.), Rotterdam, the Netherlands; Centre for Health Decision Sciences (M.M.G.H.), Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA; Department of Radiology (A.C.G.M.v.E.), Leiden University Medical Center, the Netherlands; and Department of Neurology (J.F.B.), University of Michigan, Ann Arbor
| | - Ruben Dammers
- From the Departments of Neurology (T.Y.C., F.C.C.K., D.W.J.D., B.R.), Epidemiology (M.M.G.H.), Radiology & Nuclear Medicine (M.M.G.H., B.R.), Neurosurgery (R.D., V.V.), and Erasmus MC University Medical Center (T.Y.C., F.C.C.K., D.W.J.D., B.R., R.D.), Rotterdam, the Netherlands; Centre for Health Decision Sciences (M.M.G.H.), Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA; Department of Radiology (A.C.G.M.v.E.), Leiden University Medical Center, the Netherlands; and Department of Neurology (J.F.B.), University of Michigan, Ann Arbor
| | - Adriaan C G M van Es
- From the Departments of Neurology (T.Y.C., F.C.C.K., D.W.J.D., B.R.), Epidemiology (M.M.G.H.), Radiology & Nuclear Medicine (M.M.G.H., B.R.), Neurosurgery (R.D., V.V.), and Erasmus MC University Medical Center (T.Y.C., F.C.C.K., D.W.J.D., B.R., R.D.), Rotterdam, the Netherlands; Centre for Health Decision Sciences (M.M.G.H.), Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA; Department of Radiology (A.C.G.M.v.E.), Leiden University Medical Center, the Netherlands; and Department of Neurology (J.F.B.), University of Michigan, Ann Arbor
| | - Victor Volovici
- From the Departments of Neurology (T.Y.C., F.C.C.K., D.W.J.D., B.R.), Epidemiology (M.M.G.H.), Radiology & Nuclear Medicine (M.M.G.H., B.R.), Neurosurgery (R.D., V.V.), and Erasmus MC University Medical Center (T.Y.C., F.C.C.K., D.W.J.D., B.R., R.D.), Rotterdam, the Netherlands; Centre for Health Decision Sciences (M.M.G.H.), Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA; Department of Radiology (A.C.G.M.v.E.), Leiden University Medical Center, the Netherlands; and Department of Neurology (J.F.B.), University of Michigan, Ann Arbor
| | - James F Burke
- From the Departments of Neurology (T.Y.C., F.C.C.K., D.W.J.D., B.R.), Epidemiology (M.M.G.H.), Radiology & Nuclear Medicine (M.M.G.H., B.R.), Neurosurgery (R.D., V.V.), and Erasmus MC University Medical Center (T.Y.C., F.C.C.K., D.W.J.D., B.R., R.D.), Rotterdam, the Netherlands; Centre for Health Decision Sciences (M.M.G.H.), Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA; Department of Radiology (A.C.G.M.v.E.), Leiden University Medical Center, the Netherlands; and Department of Neurology (J.F.B.), University of Michigan, Ann Arbor
| | - Femke C C Kremers
- From the Departments of Neurology (T.Y.C., F.C.C.K., D.W.J.D., B.R.), Epidemiology (M.M.G.H.), Radiology & Nuclear Medicine (M.M.G.H., B.R.), Neurosurgery (R.D., V.V.), and Erasmus MC University Medical Center (T.Y.C., F.C.C.K., D.W.J.D., B.R., R.D.), Rotterdam, the Netherlands; Centre for Health Decision Sciences (M.M.G.H.), Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA; Department of Radiology (A.C.G.M.v.E.), Leiden University Medical Center, the Netherlands; and Department of Neurology (J.F.B.), University of Michigan, Ann Arbor
| | - Diederik W J Dippel
- From the Departments of Neurology (T.Y.C., F.C.C.K., D.W.J.D., B.R.), Epidemiology (M.M.G.H.), Radiology & Nuclear Medicine (M.M.G.H., B.R.), Neurosurgery (R.D., V.V.), and Erasmus MC University Medical Center (T.Y.C., F.C.C.K., D.W.J.D., B.R., R.D.), Rotterdam, the Netherlands; Centre for Health Decision Sciences (M.M.G.H.), Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA; Department of Radiology (A.C.G.M.v.E.), Leiden University Medical Center, the Netherlands; and Department of Neurology (J.F.B.), University of Michigan, Ann Arbor
| | - Bob Roozenbeek
- From the Departments of Neurology (T.Y.C., F.C.C.K., D.W.J.D., B.R.), Epidemiology (M.M.G.H.), Radiology & Nuclear Medicine (M.M.G.H., B.R.), Neurosurgery (R.D., V.V.), and Erasmus MC University Medical Center (T.Y.C., F.C.C.K., D.W.J.D., B.R., R.D.), Rotterdam, the Netherlands; Centre for Health Decision Sciences (M.M.G.H.), Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA; Department of Radiology (A.C.G.M.v.E.), Leiden University Medical Center, the Netherlands; and Department of Neurology (J.F.B.), University of Michigan, Ann Arbor.
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Silva MA, Chen S, Starke RM. Unruptured cerebral aneurysm risk stratification: Background, current research, and future directions in aneurysm assessment. Surg Neurol Int 2022; 13:182. [PMID: 35509527 PMCID: PMC9062958 DOI: 10.25259/sni_1112_2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Accepted: 04/07/2022] [Indexed: 12/04/2022] Open
Abstract
Background: The optimal management of unruptured cerebral aneurysms is widely debated in the medical field. Rapid technology advances, evolving understanding of underlying pathophysiology, and shifting practice patterns have made the cerebrovascular field particularly dynamic in recent years. Despite progress, there remains a dearth of large randomized studies to help guide the management of these controversial patients. Methods: We review the existing literature on the natural history of unruptured cerebral aneurysms and highlight ongoing research aimed at improving our ability to stratify risk in these patients. Results: Landmark natural history studies demonstrated the significance of size, location, and other risk factors for aneurysm rupture, but prior studies have significant limitations. We have begun to understand the underlying pathophysiology behind aneurysm formation and rupture and are now applying new tools such as flow dynamics simulations and machine learning to individualize rupture risk stratification. Conclusion: Prior studies have identified several key risk factors for aneurysmal rupture, but have limitations. New technology and research methods have enabled us to better understanding individual rupture risk for patients with unruptured cerebral aneurysms.
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Abecassis IJ, Meyer RM, Levitt MR, Sheehan JP, Chen CJ, Gross BA, Lockerman A, Fox WC, Brinjikji W, Lanzino G, Starke RM, Chen SH, Potgieser ARE, van Dijk JMC, Durnford A, Bulters D, Satomi J, Tada Y, Kwasnicki A, Amin-Hanjani S, Alaraj A, Samaniego EA, Hayakawa M, Derdeyn CP, Winkler E, Abla A, Lai PMR, Du R, Guniganti R, Kansagra AP, Zipfel GJ, Kim LJ. Assessing the rate, natural history, and treatment trends of intracranial aneurysms in patients with intracranial dural arteriovenous fistulas: a Consortium for Dural Arteriovenous Fistula Outcomes Research (CONDOR) investigation. J Neurosurg 2021; 136:971-980. [PMID: 34507300 DOI: 10.3171/2021.1.jns202861] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Accepted: 01/20/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE There is a reported elevated risk of cerebral aneurysms in patients with intracranial dural arteriovenous fistulas (dAVFs). However, the natural history, rate of spontaneous regression, and ideal treatment regimen are not well characterized. In this study, the authors aimed to describe the characteristics of patients with dAVFs and intracranial aneurysms and propose a classification system. METHODS The Consortium for Dural Arteriovenous Fistula Outcomes Research (CONDOR) database from 12 centers was retrospectively reviewed. Analysis was performed to compare dAVF patients with (dAVF+ cohort) and without (dAVF-only cohort) concomitant aneurysm. Aneurysms were categorized based on location as a dAVF flow-related aneurysm (FRA) or a dAVF non-flow-related aneurysm (NFRA), with further classification as extra- or intradural. Patients with traumatic pseudoaneurysms or aneurysms with associated arteriovenous malformations were excluded from the analysis. Patient demographics, dAVF anatomical information, aneurysm information, and follow-up data were collected. RESULTS Of the 1077 patients, 1043 were eligible for inclusion, comprising 978 (93.8%) and 65 (6.2%) in the dAVF-only and dAVF+ cohorts, respectively. There were 96 aneurysms in the dAVF+ cohort; 10 patients (1%) harbored 12 FRAs, and 55 patients (5.3%) harbored 84 NFRAs. Dural AVF+ patients had higher rates of smoking (59.3% vs 35.2%, p < 0.001) and illicit drug use (5.8% vs 1.5%, p = 0.02). Sixteen dAVF+ patients (24.6%) presented with aneurysm rupture, which represented 16.7% of the total aneurysms. One patient (1.5%) had aneurysm rupture during follow-up. Patients with dAVF+ were more likely to have a dAVF located in nonconventional locations, less likely to have arterial supply to the dAVF from external carotid artery branches, and more likely to have supply from pial branches. Rates of cortical venous drainage and Borden type distributions were comparable between cohorts. A minority (12.5%) of aneurysms were FRAs. The majority of the aneurysms underwent treatment via either endovascular (36.5%) or microsurgical (15.6%) technique. A small proportion of aneurysms managed conservatively either with or without dAVF treatment spontaneously regressed (6.2%). CONCLUSIONS Patients with dAVF have a similar risk of harboring a concomitant intracranial aneurysm unrelated to the dAVF (5.3%) compared with the general population (approximately 2%-5%) and a rare risk (0.9%) of harboring an FRA. Only 50% of FRAs are intradural. Dural AVF+ patients have differences in dAVF angioarchitecture. A subset of dAVF+ patients harbor FRAs that may regress after dAVF treatment.
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Affiliation(s)
| | | | - Michael R Levitt
- Departments of1Neurological Surgery.,4Stroke and Applied Neuroscience Center, University of Washington, Seattle, Washington
| | - Jason P Sheehan
- 5Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Ching-Jen Chen
- 5Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Bradley A Gross
- 6Department of Neurological Surgery, University of Pittsburgh, Pennsylvania
| | - Ashley Lockerman
- 7Department of Neurosurgery, University of Florida, Gainesville, Florida
| | - W Christopher Fox
- 7Department of Neurosurgery, University of Florida, Gainesville, Florida
| | - Waleed Brinjikji
- Departments of8Neurosurgery and.,9Radiology, Mayo Clinic, Rochester, Minnesota
| | - Giuseppe Lanzino
- Departments of8Neurosurgery and.,9Radiology, Mayo Clinic, Rochester, Minnesota
| | - Robert M Starke
- 10Department of Neurological Surgery, University of Miami, Florida
| | - Stephanie H Chen
- 10Department of Neurological Surgery, University of Miami, Florida
| | - Adriaan R E Potgieser
- 11Department of Neurosurgery, University of Groningen, University Medical Center Groningen, The Netherlands
| | - J Marc C van Dijk
- 11Department of Neurosurgery, University of Groningen, University Medical Center Groningen, The Netherlands
| | - Andrew Durnford
- 12Department of Neurosurgery, University of Southampton, United Kingdom
| | - Diederik Bulters
- 12Department of Neurosurgery, University of Southampton, United Kingdom
| | - Junichiro Satomi
- 13Department of Neurosurgery, Tokushima University, Tokushima, Japan
| | - Yoshiteru Tada
- 13Department of Neurosurgery, Tokushima University, Tokushima, Japan
| | - Amanda Kwasnicki
- 14Department of Neurosurgery, University of Illinois at Chicago, Illinois
| | | | - Ali Alaraj
- 14Department of Neurosurgery, University of Illinois at Chicago, Illinois
| | - Edgar A Samaniego
- 15Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Minako Hayakawa
- 15Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Colin P Derdeyn
- 15Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Ethan Winkler
- 16Department of Neurological Surgery, University of California, San Francisco, California
| | - Adib Abla
- 16Department of Neurological Surgery, University of California, San Francisco, California
| | - Pui Man Rosalind Lai
- 17Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts; and
| | - Rose Du
- 17Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts; and
| | | | - Akash P Kansagra
- Departments of18Neurological Surgery.,20Neurology, Washington University School of Medicine, St. Louis, Missouri
| | | | - Louis J Kim
- Departments of1Neurological Surgery.,2Radiology, and.,4Stroke and Applied Neuroscience Center, University of Washington, Seattle, Washington
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Padmanaban V, Gigliotti M, Majid S, Jareczek FJ, Fritch C, Hazard SW, Zacko JC, Simon SD, Kalapos P, Church EW, Wilkinson DA, Cockroft KM. Risk Factors Associated with ICU-Specific Care in Patients Undergoing Endovascular Treatment of Unruptured Intracranial Aneurysms. Neurocrit Care 2021; 36:39-45. [PMID: 34309785 DOI: 10.1007/s12028-021-01306-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2021] [Accepted: 06/16/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Multiple studies suggest routine postoperative intensive care unit (ICUs) stays in presumed high-risk neurosurgical procedures may be unnecessary. Our objective was to evaluate the risk factors associated with ICU-specific needs in patients undergoing elective endovascular treatment of unruptured intracranial aneurysms. METHODS A retrospective review of consecutive patients undergoing elective endovascular treatment of unruptured aneurysms was performed between January 2010 and January 2020 in a single academic medical center. Patient demographic information, aneurysm and treatment characteristics, intraoperative and postoperative complications, as well as ICU-specific needs, were abstracted. The primary outcome was ICU-specific needs. RESULTS A total of 382 patient encounters in 344 unique patients were abstracted. 13.6% (52 of 382) of patient encounters had an ICU-specific need. Multivariate analysis revealed that age [adjusted odds ratio (OR) 1.04, 95% confidence interval (CI) 1.01-1.07, p = 0.03], procedure duration greater 200 min (adjusted OR 2.75, 95% CI 1.34-5.88, p = 0.007), and any intraoperative complication (adjusted OR 20.41, CI 7.97-56.57, p < 0.001) were independent predictors of postoperative ICU-specific needs. The majority of ICU-specific needs (94%, 49 of 52) occurred within 6 h of surgery. CONCLUSIONS Our results show that age, procedure duration greater than or equal to 200 min, and intraoperative complication were independent predictors of postoperative ICU-specific needs in patients presenting for elective endovascular treatment of unruptured intracranial aneurysms. The majority of ICU-specific needs and associated complications occurred in the immediate postoperative period. This data can be used to help decide the appropriate postoperative level of care in this patient population.
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Affiliation(s)
- Varun Padmanaban
- Department of Neurosurgery - EC110, 30 Hope Drive, Pennsylvania State University College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA, 17033, USA
| | - Michael Gigliotti
- Department of Neurosurgery - EC110, 30 Hope Drive, Pennsylvania State University College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA, 17033, USA
| | - Sonia Majid
- Department of Neurosurgery - EC110, 30 Hope Drive, Pennsylvania State University College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA, 17033, USA
| | - Francis J Jareczek
- Department of Neurosurgery - EC110, 30 Hope Drive, Pennsylvania State University College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA, 17033, USA
| | - Chanju Fritch
- Department of Neurosurgery - EC110, 30 Hope Drive, Pennsylvania State University College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA, 17033, USA
| | - Sprague W Hazard
- Department of Neurosurgery - EC110, 30 Hope Drive, Pennsylvania State University College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA, 17033, USA.,Department of Anesthesia and Perioperative Services, Pennsylvania State University College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
| | - J Christopher Zacko
- Department of Neurosurgery - EC110, 30 Hope Drive, Pennsylvania State University College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA, 17033, USA
| | - Scott D Simon
- Department of Neurosurgery - EC110, 30 Hope Drive, Pennsylvania State University College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA, 17033, USA
| | - Paul Kalapos
- Department of Radiology, Pennsylvania State University College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Ephraim W Church
- Department of Neurosurgery - EC110, 30 Hope Drive, Pennsylvania State University College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA, 17033, USA
| | - D Andrew Wilkinson
- Department of Neurosurgery - EC110, 30 Hope Drive, Pennsylvania State University College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA, 17033, USA
| | - Kevin M Cockroft
- Department of Neurosurgery - EC110, 30 Hope Drive, Pennsylvania State University College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA, 17033, USA. .,Department of Radiology, Pennsylvania State University College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA. .,Department of Public Health Services, Pennsylvania State University College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA.
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7
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Lopez C, Frechon P, Seizeur R, Emery E, Pelissou-Guyotat I, Proust F, Thines L, Gaberel T, Magro E. What is the role of neurosurgeons in the current management of intracranial aneurysm in France? An analysis of professional practices. Neurochirurgie 2021; 68:16-20. [PMID: 34246662 DOI: 10.1016/j.neuchi.2021.06.013] [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: 02/15/2021] [Revised: 06/27/2021] [Accepted: 06/29/2021] [Indexed: 10/20/2022]
Abstract
STUDY DESIGN Retrospective observational survey-based study. INTRODUCTION In France, intracranial aneurysm (IA) patients are managed by neurosurgeons and by interventional neuroradiologists. The growth of endovascular treatment led us to reflect on the role of neurosurgeons in the management of patients with IA. The present study aimed to highlight the current organization of IA management in France. METHOD A 60-question survey was sent to the neurosurgeons in 34 hospitals managing IA patients. Thirty-three questions dealt with standards of care, follow-up procedures and the involvement of the specific specialist. RESULTS Twenty-seven centers (79.4%) responded to the survey. A Vascular Multidisciplinary Discussion Team was organized, including both surgeons and neuroradiologists, in 92% of responding centers. There were department protocols in 66% of centers, a local registry in 33% and clinical trials in IA in 60%. Patients with unruptured IA were first seen by a neurosurgeon or by an interventional neuroradiologist, with different practices. For ruptured IA, the neurosurgeons were contacted first in 93% of cases, and were systematically involved in initial intensive care unit management. The patients were hospitalized in the neurosurgery department in 89% of the centers. The neurosurgeons took care of initial follow-up in 85% of the centers, and of lifetime follow-up in 36%. In most centers, radiological monitoring of IA was based on MRI angiography for patients who were embolized or under surveillance, and on CT angiography after microsurgery. CONCLUSION Despite the growth of endovascular treatments, the present survey and the literature highlight a major role of neurosurgeons in treatment, follow-up and care coordination.
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Affiliation(s)
- C Lopez
- Department of Neurosurgery, CHRU de la Cavale Blanche, Boulevard Tanguy-Prigent, 29609 Brest cedex, France.
| | - P Frechon
- CHU Caen, Department of Neurosurgery, Caen University Hospital, Avenue de la Côte de Nacre, 14033 Caen, France
| | - R Seizeur
- Department of Neurosurgery, CHRU de la Cavale Blanche, Boulevard Tanguy-Prigent, 29609 Brest cedex, France; Université de Bretagne Occidentale, INSERM, UMR 1101, LaTIM, Laboratoire de Traitement de l'Information Médicale, 29200 Brest, France
| | - E Emery
- CHU Caen, Department of Neurosurgery, Caen University Hospital, Avenue de la Côte de Nacre, 14033 Caen, France; Normandie Université, UNICAEN, INSERM, UMR-S U1237, Physiopathology and Imaging of Neurological Disorders (PhIND), GIP Cyceron, 14000 Caen, France
| | - I Pelissou-Guyotat
- Hospices Civils de Lyon, Hôpital Neurologique Pierre Wertheimer, Department of Neurosurgery, 59, Boulevard Pinel, 69667 Bron, France
| | - F Proust
- Department of Neurosurgery, Hautepierre Hospital Strasbourg, University Hospital, 67098 Strasbourg, France
| | - L Thines
- Neurosurgery Department, Besançon University Hospital, 3, Boulevard Alexandre Fleming, 25030 Besançon cedex, France
| | - T Gaberel
- CHU Caen, Department of Neurosurgery, Caen University Hospital, Avenue de la Côte de Nacre, 14033 Caen, France; Normandie Université, UNICAEN, INSERM, UMR-S U1237, Physiopathology and Imaging of Neurological Disorders (PhIND), GIP Cyceron, 14000 Caen, France
| | - E Magro
- Department of Neurosurgery, CHRU de la Cavale Blanche, Boulevard Tanguy-Prigent, 29609 Brest cedex, France; Université de Bretagne Occidentale, INSERM, UMR 1101, LaTIM, Laboratoire de Traitement de l'Information Médicale, 29200 Brest, France
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Mehta T, Desai N, Patel S, Male S, Khan A, Grande AW, Tummala RP, Jagadeesan BD. Readmission Trends Related to Unruptured Intracranial Aneurysm Treatment. Front Neurol 2021; 12:590751. [PMID: 34093383 PMCID: PMC8172776 DOI: 10.3389/fneur.2021.590751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Accepted: 04/14/2021] [Indexed: 11/13/2022] Open
Abstract
Background and Purpose: Aneurysmal subarachnoid hemorrhage (SAH) is associated with high mortality. Prophylactic treatment of the unruptured intracranial aneurysm (UIA) is considered in a select group of patients thought to be at high for aneurysmal rupture. Hospital readmission rates can serve as a surrogate marker for the safety and cost-effectiveness of treatment options for UIAs; we present an analysis of the 30-day rehospitalization rates and predictors of readmission following UIA treatment with surgical and endovascular approaches. Methods: We retrospectively analyzed data from the National Readmission Database (NRD) derived from the Healthcare Cost and Utilization Project for the year 2014. The cohort included patients with a primary discharge diagnosis of a treated unruptured aneurysm. The primary outcome variable was the 30-day readmission rate in open surgical vs. endovascularly treated groups. The secondary outcomes included predictors of readmissions, and causes of 30-day readmissions in these two groups. Results: The 30-day readmission rate for the surgical group was 8.37% compared to 4.87% for the endovascular group. The index hospitalization duration was longer in the surgical group. A larger proportion of the patients readmitted following surgical treatment were hypertensive (76.35, vs. 63.43%), but the prevalence of other medical comorbidities was comparable in the two treatment groups. Conclusions: There is a higher likelihood for 30-day readmission, longer duration of initial hospitalization and a lower likelihood of discharge home following surgical treatment of UIAs when compared to endovascular treatment. These findings, however, do not demonstrate long-term superiority of one specific treatment modality.
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Affiliation(s)
- Tapan Mehta
- Department of Neurology and Interventional Neuroradiology, Hartford Hospital, Hartford, CT, United States
| | - Ninad Desai
- Department of Neurology, NYU Langone Medical Center, New York, NY, United States
| | - Smit Patel
- Department of Neurology, University of Connecticut, Farmington, CT, United States
| | - Shailesh Male
- Department of Neurosurgery, Radiology and Neurology, University of Minnesota, Minneapolis, MN, United States
| | - Adam Khan
- Department of Neurosurgery, Radiology and Neurology, University of Minnesota, Minneapolis, MN, United States
| | - Andrew Walker Grande
- Department of Neurosurgery, Radiology and Neurology, University of Minnesota, Minneapolis, MN, United States
| | - Ramachandra Prasad Tummala
- Department of Neurosurgery, Radiology and Neurology, University of Minnesota, Minneapolis, MN, United States
| | - Bharathi Dasan Jagadeesan
- Department of Neurosurgery, Radiology and Neurology, University of Minnesota, Minneapolis, MN, United States
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Koo AB, Elsamadicy AA, Lin IH, David WB, Sujijantarat N, Santarosa C, Cord BJ, Zetchi A, Hebert R, Bahrassa F, Malhotra A, Matouk CC. Predictors of Extended Length of Stay Following Treatment of Unruptured Adult Cerebral Aneurysms: A Study of The National Inpatient Sample. J Stroke Cerebrovasc Dis 2020; 29:105230. [PMID: 33066916 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105230] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 07/26/2020] [Accepted: 07/30/2020] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND In an unprecedented era of soaring healthcare costs, payers and providers alike have started to place increased importance on measuring the quality of surgical procedures as a surrogate for operative success. One metric used is the length of hospital stay (LOS) during index admission. For the treatment of unruptured cerebral aneurysms, the determinants of extended length of stay are relatively unknown. The aim of this study was to identify the patient- and hospital-level factors associated with extended LOS following treatment for unruptured cerebral aneurysms. METHODS The National Inpatient Sample years 2010 - 2014 was queried. Adults (≥18 years) with unruptured aneurysms undergoing either clipping or coiling were selected using the International Classification of Diseases, Ninth Revision, Clinical Modification coding system. Extended LOS was defined as greater than 75th percentile for the entire cohort (>5 days). Weighted patient demographics, comorbidities, complications, LOS, disposition and total cost were recorded. Multivariate logistic regression was used to determine the odds ratio for risk-adjusted extended LOS. The primary outcome was the degree which patient comorbidities or postoperative complications correlated with extended LOS. RESULTS A total of 46,880 patients were identified for which 9,774 (20.8%) patients had extended LOS (Normal LOS: 37,106; Extended LOS: 9,774). Patients in the extended LOS cohort presented with a greater number of comorbidities compared to the normal LOS cohort. A greater proportion of the normal LOS cohort was coiled (Normal LOS: 63.0% vs. Extended LOS: 33.5%, P<0.001), while more patients in the extended LOS cohort were clipped (Normal LOS: 37.0% vs. Extended LOS: 66.5%, P<0.001). The overall complication rate was higher in the extended LOS cohort (Normal LOS: 7.3% vs. Extended LOS: 43.8%, P<0.001). On average, the extended LOS cohort incurred a total cost nearly twice as large (Normal LOS: $26,050 ± 13,430 vs. Extended LOS: $52,195 ± 37,252, P<0.001) and had more patients encounter non-routine discharges (Normal LOS: 8.5% vs. Extended LOS: 52.5%, P<0.001) compared to the normal LOS cohort. On weighted multivariate logistic regression, multiple patient-specific factors were associated with extended LOS. These included demographics, preadmission comorbidities, choice of procedure, and inpatient complications. The odds ratio for extended LOS was 5.14 (95% CI, 4.30 - 6.14) for patients with 1 complication and 19.58 (95% CI, 15.75 - 24.34) for patients with > 1 complication. CONCLUSIONS Our study demonstrates that extended LOS after treatment of unruptured aneurysms is influenced by a number of patient-level factors including demographics, preadmission comorbidities, type of aneurysm treatment (open surgical versus endovascular), and, importantly, inpatient complications. A better understanding of these independent predictors of prolonged length of hospital stay may help to improve patient outcomes and decrease overall healthcare costs.
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Affiliation(s)
- Andrew B Koo
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT
| | | | - I-Hsin Lin
- Yale Center for Analytical Sciences, New Haven, CT
| | - Wyatt B David
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT
| | | | - Corrado Santarosa
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT
| | - Branden J Cord
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT
| | - Akli Zetchi
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT
| | - Ryan Hebert
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT
| | - Farhad Bahrassa
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT
| | - Ajay Malhotra
- Department of Radiology & Biomedical Imaging, Yale University School of Medicine, New Haven, CT
| | - Charles C Matouk
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT; Department of Radiology & Biomedical Imaging, Yale University School of Medicine, New Haven, CT.
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Dharia A, Lacci JV, Mascitelli J, Seifi A. Impact of Ruptured Aneurysm Circulation on Mortality: A Nationwide Inpatient Sample Analysis. J Stroke Cerebrovasc Dis 2020; 29:105124. [PMID: 32912535 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105124] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 06/23/2020] [Accepted: 06/29/2020] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVE This study investigates the effect of aneurysm circulation on mortality and patient outcomes after aneurysmal subarachnoid hemorrhage (SAH) within the United States. METHODS A retrospective cohort study was conducted using the Nationwide Inpatient Sample (NIS), a part of the Healthcare Cost and Utilization Project (HCUP), with ICD-10 codes for non-traumatic SAH between 2015-2016. Aneurysms were stratified as either anterior or posterior circulation. Multivariate logistic regression was used to find the impact of selected variables on the odds of mortality. RESULTS The NIS reported 1,892 cases of non-traumatic SAH within the study period that were predominantly anterior circulation (82.6%), female (68.6%), white (57.7%), with mean age of 59.07 years, and in-hospital mortality of 21.4%. Anterior circulation aneurysms were associated with lower severity of initial illness (p = 0.014) but higher likelihood of vasospasm (p = 0.0006) than those of the posterior circulation. In a multivariate logistic regression analysis, mortality was associated with posterior circulation aneurysms (OR: 1.42; CI 95% 1.005-20.10, p = 0.047), increasing age (OR: 1.035; 95% CI 1.022-1.049; p < 0.0001), and shorter hospital stays (OR: 0.7838; 95% CI 0.758-0.811; p < 0.0001). Smoking history (OR: 0.825; 95% CI 0.573-1.187, p > 0.05) and vasospasm (OR: 1.005; 95% CI 0.648-1.558; p > 0.05) were not significantly associated with higher odds of mortality. CONCLUSIONS Mortality following aneurysmal SAH is associated with posterior circulation aneurysms, and increasing age, but not smoking history or vasospasm. These findings may be useful for prognostication and counseling patients and families.
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Affiliation(s)
- Anand Dharia
- Long School of Medicine, University of Texas Health at San Antonio, Texas, USA.
| | - John V Lacci
- Long School of Medicine, University of Texas Health at San Antonio, Texas, USA.
| | - Justin Mascitelli
- Department of Neurosurgery, University of Texas Health at San Antonio, Texas, USA.
| | - Ali Seifi
- Department of Neurosurgery, University of Texas Health at San Antonio, Texas, USA.
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Luther E, McCarthy DJ, Brunet MC, Sur S, Chen SH, Sheinberg D, Hasan D, Jabbour P, Yavagal DR, Peterson EC, Starke RM. Treatment and diagnosis of cerebral aneurysms in the post-International Subarachnoid Aneurysm Trial (ISAT) era: trends and outcomes. J Neurointerv Surg 2020; 12:682-687. [PMID: 31959634 DOI: 10.1136/neurintsurg-2019-015418] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Revised: 12/02/2019] [Accepted: 12/04/2019] [Indexed: 11/03/2022]
Abstract
BACKGROUND Following publication of the International Subarachnoid Aneurysm Trial (ISAT), treatment paradigms for cerebral aneurysms (CAs) shifted from open surgical clipping to endovascular embolization as primary therapy in a majority of cases. However, comprehensive analyses evaluating more recent CA diagnosis patterns, patient populations and outcomes as a function of treatment modality remain rare. METHODS The National Inpatient Sample from 2004 to 2014 was reviewed. Aneurysmal subarachnoid hemorrhages (aSAHs) and unruptured intracranial aneurysms (UIAs) with a treatment of surgical clipping or endovascular therapy (EVT) were identified. Time trend series plots were created. Linear and logistic regressions were utilized to quantify treatment changes. RESULTS 114 137 aSAHs and 122 916 UIAs were reviewed. aSAH (+732/year, p=0.014) and UIA (+2550/year, p<0.0001) discharges increased annually. The annual caseload of surgical clippings for aSAH decreased (-264/year, p=0.0002) while EVT increased (+366/year, p=0.0003). For UIAs, the annual caseload for surgical clipping remained stable but increased for EVT (+615/year, p<0.0001). The rate of incidentally diagnosed UIAs increased annually (+1987/year; p<0.0001). Inpatient mortality decreased for clipping (p<0.0001) and EVT in aSAH (p<0.0001) (2004 vs 2014-clipping 13% vs 11.7%, EVT 15.8% vs 12.7%). Mortality rates for clipped UIAs decreased over time (p<0.0001) and remained stable for EVT (2004 vs 2014-clipping 1.57% vs 0.40%, EVT 0.59% vs 0.52%). CONCLUSION Ruptured and unruptured CAs are increasingly being treated with EVT over clipping. Incidental unruptured aneurysm diagnoses are increasing dramatically. Mortality rates of ruptured aneurysms are improving regardless of treatment modality, whereas mortality in unruptured aneurysms is only improving for surgical clipping.
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Affiliation(s)
- Evan Luther
- Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - David J McCarthy
- Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA .,Neurosurgery, University of Miami School of Medicine, Miami, Florida, USA
| | - Marie-Christine Brunet
- Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Samir Sur
- Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Stephanie H Chen
- Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Dallas Sheinberg
- Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - David Hasan
- Neurological Surgery, University of Iowa, Iowa City, Iowa, USA
| | - Pascal Jabbour
- Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Dileep R Yavagal
- Neurology, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Eric C Peterson
- Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Robert M Starke
- Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
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