Cost-effectiveness of clipping vs coiling of intracranial aneurysms after subarachnoid hemorrhage in a developing country--a prospective study

Practical pearls for management of cranial injury in the developing world

Traumatic brain injury (TBI) remains a leading cause of morbidity and mortality, with approximately 69 million individuals affected globally each year, particularly in low- and middle-income countries (LMICs) where neurosurgical resources are limited. The neurocognitive consequences of TBI range from life-threatening conditions to more subtle impairments such as cognitive deficits, impulsivity, and behavioral changes, significantly impacting patients' reintegration into society. LMICs bear about 70% of the global trauma burden, with causes of TBI differing from high-income countries (HICs). The lack of equitable neurosurgical care in LMICs exacerbates these challenges. Improving TBI care in LMICs requires targeted resource allocation, neurotrauma registries, increased education, and multidisciplinary approaches within trauma centers. Reports from successful neurotrauma initiatives in low-resource settings provide valuable insights into safe, adaptable strategies for managing TBI when "gold standard" protocols are unfeasible. This review discusses common TBI scenarios in LMICs, highlighting key epidemiological factors, diagnostic challenges, and surgical techniques applicable to resource-limited settings. Specific cases, including epidural hematoma, subdural hematoma, subarachnoid hemorrhage, and cerebrospinal fluid leaks, are explored to provide actionable insights for improving neurosurgical outcomes in LMICs.

Surgical Aneurysm Repair of Aneurysmal Subarachnoid Hemorrhage in Sub-Saharan Africa: The State of Training and Management

BACKGROUND

In a resource-limited setting such as sub-Saharan African countries, neurosurgeons need training and fellowship for surgical repair of aneurysmal subarachnoid hemorrhage (aSAH). Surgical repair of ruptured aneurysms costs less and requires less instrumentation compared with endovascular procedures. The purpose of this study is to evaluate the state of training and management of aSAH in sub-Saharan Africa training centers.

METHODS

An e-survey was sent as a Google Form to neurosurgeons and neurosurgical trainees in neurosurgery training centers in sub-Saharan Africa; responses were accepted from September 9 to October 23, 2022. Statistical analysis was performed using Microsoft Excel and JAMOVI 3.2.

RESULTS

All 44 centers from 17 countries responded. Most of the respondents were neurosurgery residents (n = 30; 68.18%). The level of training on clipping was basic after completing the residency program (n = 18; 40.91%). Twenty respondents (45.45%) identified that fellowships on aneurysmal clipping and endovascular treatment are offered abroad. Thirteen participants (29.55%) indicated that endovascular treatment is available at their institutions. The most common challenges with lack of training for neurosurgical aneurysm clipping were scarce scholarship and collaboration with training centers from high-income countries (n = 33; 75%). The availability of intensive care unit beds also contributed to the presence of neurosurgical training of aneurysm clipping (12.1 ± 3.67 vs. 9.29 ± 5.82; P = 0.05).

CONCLUSIONS

In sub-Saharan African countries, the lack of collaborations with high-income countries for training through fellowships of young neurosurgeons for aneurysm repair seems to be the most important challenge that should be overcome.

Endovascular treatment and neurosurgical clipping in subarachnoid hemorrhage: a systematic review of economic evaluations

INTRODUCTION

There are two treatment modalities for aneurysmal subarachnoid hemorrhage: endovascular treatment (EVT) and neurosurgical clipping. Results of economic evaluations are needed to gain insight into the relationship between clinical effectiveness and costs of these treatment modalities. This important information can inform both clinical decision-making processes and policymakers in facilitating Value-Based Healthcare.

EVIDENCE ACQUISITION

Databases (PubMed, Embase, Cochrane Library, the Centre for Reviews and Dissemination, EBSCO, and Web of Science) were searched for studies published until October 2020 that had performed economic evaluations in aneurysmal subarachnoid hemorrhage patients by comparing EVT with neurosurgical clipping. The quality of reporting and methodology of these evaluations was assessed using the associated instruments (i.e. CHEERS statement and CHEC-list, respectively).

EVIDENCE SYNTHESIS

A total of 6 studies met the inclusion criteria. All included studies reported both effects and costs, however five did not relate effects to costs. Only one study related effects directly to costs, thus conducted a full economic evaluation. The reporting quality scored 81% and the methodological quality scored 30%.

CONCLUSIONS

The quality of published cost-effectiveness studies on the treatment of aneurysmal subarachnoid hemorrhage is poor. Six studies reported both outcomes and costs, however only one study performed a full economic evaluation comparing EVT to neurosurgical clipping. Although the reporting quality was sufficient, the methodological quality was poor. Further research that relates health-related quality of life measures to costs of EVT and neurosurgical clipping is required - specifically focusing on both reporting and methodological quality. Different subgroup analyses and modeling could also enhance the findings.

A cost-utility analysis comparing endovascular coiling to neurosurgical clipping in the treatment of aneurysmal subarachnoid haemorrhage

Endovascular coiling (EC) has been identified in systematic reviews and meta-analyses to produce more favourable clinical outcomes in comparison to neurosurgical clipping (NC) when surgically treating a subarachnoid haemorrhage from a ruptured aneurysm. Cost-effectiveness analyses between both interventions have been done, but no cost-utility analysis has yet been published. This systematic review aims to perform an economic analysis of the relative utility outcomes and costs from both treatments in the UK. A cost-utility analysis was performed from the perspective of the National Health Service (NHS), over a 1-year analytic horizon. Outcomes were obtained from the randomised International Subarachnoid Aneurysm Trial (ISAT) and measured in terms of the patient's modified Rankin scale (mRS) grade, a 6-point disability scale that aims to quantify a patient's functional outcome following a stroke. The mRS score was weighted against the Euro-QoL 5-dimension (EQ-5D), with each state assigned a weighted utility value which was then converted into quality-adjusted life years (QALYs). A sensitivity analysis using different utility dimensions was performed to identify any variation in incremental cost-effectiveness ratio (ICER) if different input variables were used. Costs were measured in pounds sterling (£) and discounted by 3.5% to 2020/2021 prices. The cost-utility analysis showed an ICER of - £144,004 incurred for every QALY gained when EC was utilised over NC. At NICE's upper willingness-to-pay (WTP) threshold of £30,000, EC offered a monetary net benefit (MNB) of £7934.63 and health net benefit (HNB) of 0.264 higher than NC. At NICE's lower WTP threshold of £20,000, EC offered an MNB of £7478.63 and HNB of 0.374 higher than NC. EC was found to be more 'cost-effective' than NC, with an ICER in the bottom right quadrant of the cost-effectiveness plane-indicating that it offers greater benefits at lower costs. This is supported by the ICER being below the NICE's threshold of £20,000-£30,000 per QALY, and both MNB and HNB having positive values (> 0).

Clipping of Posterior Circulation Intracranial Aneurysms: Maintenance of a Necessary Skill in Low-Resource Settings

The treatment paradigm for intracranial aneurysms has evolved with technological advancements, resulting in improved patient outcomes. In particular, the management of posterior circulation aneurysms has shifted to favor endovascular therapy (EVT). However, this modality is not always accessible in low-resource settings.

In our country (Trinidad and Tobago), neuroendovascular services are not readily available. We report a case of a patient with a ruptured left posterior inferior cerebellar artery (PICA) aneurysm (Fisher grade 4) who underwent a far-lateral craniotomy and clip ligation. It was done by a fellowship-trained vascular neurosurgeon in a public hospital and resulted in an excellent patient outcome. This highlights the need to maintain this surgical skill set in resource-poor countries, in spite of the increasing popularity of endovascular therapy.

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.

Cost-effectiveness analysis of endovascular coiling and neurosurgical clipping for aneurysmal subarachnoid hemorrhage in Thailand

BACKGROUND

For patients with aneurysmal subarachnoid hemorrhage (aSAH), the Universal Coverage Scheme in Thailand covers the full costs of surgical and endovascular procedures except for those of embolization coils and assisting devices. Costs and effectiveness were compared between endovascular coiling and neurosurgical clipping to inform reimbursement policy decisions.

METHODS

Costs and quality-adjusted life years (QALYs) were compared between coiling and clipping using the decision tree and Markov models. Mortality and functional outcomes of clipping were derived from national and hospital databases, and relative efficacies of coiling were obtained from meta-analyses of randomized controlled trials. Risks of rebleeding were abstracted from the International Subarachnoid Aneurysm Trial. Costs of the primary treatments, retreatments and follow-up care as well as utilities were obtained from hospital-based data. Non-health and indirect costs were abstracted from standard cost lists.

RESULTS

Coiling and clipping contributed 10.59 and 9.28 QALYs to patients aged in their 50s. Under the societal and healthcare perspectives, the incremental costs incurred by coiling compared with clipping were US$1923 and $4343, respectively, which were equal to the incremental cost-effectiveness ratio of US$1470 and $3321 per QALY gained, respectively. Coiling became a cost-saving option when the costs of coil devices were reduced by 65.7%. At the country's cost-effectiveness threshold of US$5156, the probability of coiling being cost-effective was 71.3% and 65.6%, under the societal and healthcare perspectives, respectively.

CONCLUSION

Endovascular treatment for aSAH is cost-effective and this evidence supports coverage by national insurance.

Continental Survey of Access to Diagnostic Tools and Endovascular Management of Aneurysmal Subarachnoid Hemorrhage in Africa

Rationale: Interventional neurovascular procedures are effective in lowering the burden of mortality and complications resulting from aneurysmal subarachnoid hemorrhage (aSAH). Despite the wide uptake of interventional neurovascular procedures in high-income countries, access to care in low- and middle-income countries remains limited, and little is known about accessibility in Africa. In this survey, we decided to assess access to diagnostic tools and treatment of aSAH in Africa.

Methodology: A Google form e-survey was distributed to African neurosurgery centers accepting responses from January 4th to March 21st 2021. Data on accessibility to diagnostic tools, treatment methodologies, and interventional neuroradiology personnel in African centers were collected. Ninety five percent confidence intervals were computed for each variable.

Results: Data was received from 36 neurosurgical centers in 16 African countries (16/54, 30%). Most centers were public institutions. Ninety four percent of the centers had the necessary resources for a lumbar puncture (LP) and a laboratory for the diagnosis of aSAH. Most centers had at least one computed tomography (CT) scanner, 81% of the centers had access to CT angiography and some had access to conventional angiography. Forty seven percent of the centers could obtain a head CT within 2 h of presentation in an emergency. Sixty one percent of centers provided clipping of intracranial aneurysms whilst only 22% of centers could perform the endovascular treatment. Sixty four percent of centers did not have an endovascular specialist.

Conclusion: This survey highlights health inequity in access to endovascular treatment for aSAH. Lack of diagnostic tools to identify an aneurysm and a shortfall of qualified endovascular specialists are prime reasons for this. Our findings can inform health system strengthening policies including the acquisition of equipment and capacity building in Africa.

Long-Term Medical Resource Consumption between Surgical Clipping and Endovascular Coiling for Aneurysmal Subarachnoid Hemorrhage: A Propensity Score-Matched, Nationwide, Population-Based Cohort Study

Purpose: To estimate long-term medical resource consumption in patients with subarachnoid aneurysmal hemorrhage (SAH) receiving surgical clipping or endovascular coiling. Patients and methods: From Taiwan’s National Health Insurance Research Database, we enrolled patients with aneurysmal SAH who received clipping or coiling. After propensity score matching and adjustment for confounders, a generalized linear mixed model was used to determine significant differences in the accumulative hospital stay (days), intensive care unit (ICU) stay, and total medical cost for aneurysmal SAH, as well as possible subsequent surgical complications and recurrence. Results: The matching process yielded a final cohort of 8102 patients (4051 and 4051 in endovascular coil embolization and surgical clipping, respectively) who were eligible for further analysis. The mean accumulative hospital stay significantly differed between coiling (31.2 days) and clipping (46.8 days; p < 0.0001). After the generalized linear model adjustment of gamma distribution with a log link, compared with the surgical clipping procedure, the adjusted odds ratios (aOR; 95% confidence interval [CI]) of the medical cost of accumulative hospital stay for the endovascular coil embolization procedure was 0.63 (0.60, 0.66; p < 0·0001). The mean accumulative ICU stay significantly differed between the coiling and clipping groups (9.4 vs. 14.9 days; p < 0.0001). The aORs (95% CI) of the medical cost of accumulative ICU stay in the endovascular coil embolization group was 0.61 (0.58, 0.64; p < 0.0001). The aOR (95% CI) of the total medical cost of index hospitalization in the endovascular coil embolization group was 0·85 (0.82, 0.87; p < 0.0001). Conclusions: Medical resource consumption in the coiling group was lower than that in the clipping group.

Surgical Clip Ligation of Anterior Communicating Artery Aneurysm in a Resource-Limited Setting

Anterior communicating artery (ACOM) aneurysm clipping with intraoperative measures to ensure total occlusion and avoid ischemic complications is standard in countries such as the United States. However, alternatives need to be considered in resource-limited settings. The clipping of an unruptured, superiorly projecting ACOM aneurysm in a resource-limited setting is presented and special nuances that optimize safety are described. Careful surgical technique, meticulous identification of relevant anatomy, post-ligation inspection of the aneurysm and adjacent vessels, and possibly needle puncture of the aneurysm dome are critical to achieve favorable results.

Predictors of 90-Day Readmission Rate After Unruptured Intracranial Aneurysm Repair

OBJECTIVE

The repair of unruptured intracranial aneurysms has increased since 2000. In this study, we analyzed the Nationwide Readmission Database (NRD) to determine the rate of 90-day readmission. Our objective is to examine readmission trends after unruptured aneurysm repair.

METHODS

This study used the 2013 and 2014 NRD. Patient data included standard demographic, comorbidity, and payer information. We selected patients who had undergone microsurgical or endovascular repair for a nonruptured aneurysm. We excluded patients who were under 18 years of age, had a subarachnoid hemorrhage, or were discharged to home the same day. Readmission was calculated by counting the number of days between the end of the index visit and earliest readmission date.

RESULTS

A total of 2180 of 29,694 patients (7.34%) were readmitted within 90 days of their initial hospitalization. They were younger (mean, 52.6 years; 95% confidence interval [CI], 51.4-53.8) than patients not readmitted (mean, 57.4 years; 95% CI, 57.1-57.8; P < 0.0001). In total, endovascular repair was more frequent than microsurgery (79.8% vs. 20.2%, respectively). Mean days to readmission was 41.8 (95% CI, 39.7-43.9) and was higher for women (P < 0.0001). The odds ratio for readmission after an endovascular repair was 1.54 (95% CI, 1.27-1.86).

CONCLUSIONS

In this study of over 28,000 patients treated for an unruptured aneurysm, the 90-day readmission rate was 7.34%. Endovascular patients had higher odds of readmission than microsurgical patients. Patients with common medical comorbidities (hypertension, obesity, renal failure, and diabetes) were less likely to be readmitted than patients without those conditions.

Outcome of Microsurgical Clipping for Multiple Versus Single Intracranial Aneurysms: A Single-Institution Retrospective Comparative Cohort Study

OBJECTIVE

To evaluate the results of microsurgical clipping for single intracranial aneurysm (SIA) and multiple intracranial aneurysms (MIA) and compare the outcomes.

METHODS

All patients who underwent surgery for intracranial aneurysm (IA) at our institution over a 3-year period (June 2013 to May 2016) were included in this study.

RESULTS

A total of 157 patients with 225 IAs were included. Forty-one of these patients had MIA (109 IAs, mean, 2.7 ± 1.2; range, 2-7), and remaining 116 had SIA. In the patients with MIA, all aneurysms were secured during the same admission whenever possible. Depending on the locations of the IAs and condition of brain during surgery (tense/lax), all aneurysms were secured on same day (in a single session, single or multiple craniotomy in 28 patients) or on different days (multiple sessions in 13 patients). Postoperative control angiography (DSA) before discharge could be done for 216 aneurysms (MIA, n = 105; SIA, n = 111). Successful occlusion of the aneurysm from circulation was noted in 96.2% (101/105) of MIA and 93.7% (104/111) of SIA. Follow-up of 6 months or longer was available for 146 patients. A modified Rankin Scale score ≤2 was considered a good outcome. Univariate analysis of the entire group revealed no significant difference in clinical outcomes between patients with SIA and MIA both at discharge (good outcome: MIA, 82.9%; SIA, 93.1%; P = 0.068) and at a final follow-up of ≥6 months (good outcome: MIA, 87.2%; SIA, 94.4%; P = 0.164). Clipping for MIA was not associated with poor outcome in multivariate analysis.

CONCLUSIONS

Comparable clinical outcomes and high rates of complete aneurysm occlusion following microsurgical clipping can be expected in patients with SIA and patients with MIA.

Cohesion Between Research Literature and Health System Level Efforts to Address Global Neurosurgical Inequity: A Scoping Review

BACKGROUND

Research output on global neurosurgery (GNS) has exponentially increased in recent years. As research efforts increase, we must first analyze how the current body of GNS literature fits into the macroscopic schema of systems-based policies. The aim of this study was to identify and categorize GNS research based on health system domains.

METHODS

PubMed, CINAHL, and Embase were searched for GNS literature published from 1999 to 2019. Then, health system domains were defined and itemized based on publicly available documents from the Program in Global Surgery and Social Change. This items chart was subsequently used to categorize the GNS literature into health system domains.

RESULTS

A total 63 articles were determined to focus on a health system domain. Of these articles, 6 focused on multiple domains, yielding an adjusted total of 70 articles. Overall, the most represented health system domain was service delivery (21 articles), followed by workforce (19), infrastructure (15), financing (12) and information management (3). A total of 30 low- and middle-income countries (LMICs) were represented across all articles. In addition, the first author was affiliated with an institution from a high-income country for 71.4% of the articles.

CONCLUSIONS

This review highlighted the pressing need for more research into information management in the context of GNS. In addition, health system-focused GNS literature represented only 20% of all LMICs (30/143). The trends in authorship should be noted, because many ethical (and practical) issues may arise if there is a disconnect in the objectives of the authors and the neurosurgeons in LMICs.

Adenosine-Induced transient asystole during surgical treatment of basilar artery aneurysms

Aim

To evaluate the safety and efficacy of adenosine-induced transient asystole (AITA) during surgery for basilar artery aneurysms.

Materials and Methods

All the patients with basilar artery aneurysms operated using AITA at our institute during two years period (August 2013-July 2015) were included in this study.

Results

Adenosine was used in 11 patients with 13 basilar artery aneurysms. Seven of these aneurysms were basilar bifurcation aneurysms, four were basilar-superior cerebellar artery junction aneurysms, and two were distal basilar trunk aneurysms. The indications for AITA were narrow corridor for placement of temporary clip in 11 aneurysms, intraop rupture in 1 aneurysm, and circumferential dissection of a large aneurysm in 1. The mean dose of adenosine used for inducing asystole was 19.4 mg (range: 15-30 mg) and the mean total dose of adenosine used was 40.6 mg (range: 18-90 mg). A mean of 2 (range: 1-5) AITAs were required during surgical treatment of these aneurysms. The mean duration of a systole was 27 s (range: 9-76 s). There were no complications related to AITA in these patients except for transient rebound hypertension in one patient. Check angiogram revealed complete obliteration of 11 aneurysms and small residual neck in 2 aneurysms. Modified Rankin Scale at three months of follow-up was 0 in seven patients, 1 in two patients, 4 in one patient, and 6 in one patient.

Conclusion

AITA during surgical management of basilar artery aneurysms is a safe and effective technique and has an important role during surgery for these aneurysms.

Management of Aneurysmal Subarachnoid Hemorrhage: Variation in Clinical Practice and Unmet Need for Follow-up among Survivors-A Single-Center Perspective

OBJECTIVE

The purpose of the present study is to investigate the existence and/or prevalence of clinical practice variation in management of aneurysmal subarachnoid hemorrhage (aSAH) and to determine the need for long-term follow-up.

METHODS

A single-center study was carried out of patients with aSAH over a 5-year period divided into 2 halves (2.5 years each) before and after addition of a dually trained cerebrovascular neurosurgeon. In-hospital clinical practice, clinical outcome (mortality and discharge destination) and long-term outcome (modified Rankin Scale score and Telephone Interview for Cognitive Status [TICS]) were compared using descriptive summaries and nonparametric tests.

RESULTS

Among 251 patients admitted with aSAH, 115 (45.8%) were before the index event, whereas 136 (54.2%) were during the later period. The aneurysm-securing procedure changed from coil embolization to clip ligation (12/115 [10.4%] vs. 84/136 [61.8%]; P < 0.0001) during the latter years. Interventional treatment for cerebral vasospasm has decreased (58/115 [50.4%] vs. 49/136 [36.0%]; P = 0.0002). Patients surviving hospitalization had more clinic follow-up after discharge during the latter period (42/85 [49.4%] vs. 76/105 [72.4%]; P = 0.0012) and ventriculoperitoneal shunt placement for delayed hydrocephalus (1/85 [1.2%] vs. 9/105 [8.6%]; P = 0.02). A subcohort of aSAH survivors (n = 46) had lower median TICS score during the earlier study period (31.5 [interquartile range, 22-36] vs. 33 [interquartile range, 27-38]; P = 0.038). Similarly, preictal smoking status and hyperlipidemia were associated with adverse TICS score in a multivariate model (P = 0.007).

CONCLUSIONS

Postdischarge clinical follow-up has improved facilitating recognition and treatment of delayed hydrocephalus. Existence of cognitive deficits among survivors calls for establishment of multidisciplinary clinics for long-term management of aSAH.

Surgical Versus Endovascular Management of Ruptured and Unruptured Intracranial Aneurysms: Emergent Issues and Future Directions

Ideal management of unruptured intracranial aneurysms (UIAs) and ruptured intracranial aneurysms (RIAs) is a controversial issue. Over the last few decades, a significant paradigm shift has occurred away from open microsurgical clipping toward endovascular coil embolization. Multiple studies have been performed with mixed results. Some studies suggest that endovascular treatment produces better clinical and functional outcomes, but is associated with increased need for retreatment. Other studies report increased durability in aneurysms treated with microsurgical clipping, but that clipping may be associated with worse functional outcomes in some cases. Further complicating the dialogue are variable costs associated with different treatment modalities, including country-dependent cost differences. Here we provide a review of some of the major studies comparing open surgery versus endovascular treatment for both RIAs and UIAs to distill their key findings and corresponding implications for clinical practice. We relate these research results to our institution's experience with RIAs and UIAs and describe our approach to treatment of these conditions. Finally, we discuss implications of the paradigm shift for both open and endovascular surgery, including educational initiatives directed toward preserving important microsurgical tenets in the setting of diminishing surgical volume.

Microsurgical Clipping of Distal Basilar Trunk Aneurysm during Adenosine-Induced Profound Hypotension

A 46-year-old male presented with a history of sudden severe headache 1 week back, altered sensorium and right hemiparesis for 2 days. On examination, Glasgow Coma Scale (GCS) was E4V4M6 and the patient had right hemiparesis (power – 4/5). Computed tomography (CT) revealed diffuse subarachnoid hemorrhage (Fisher's Grade III). CT angiogram revealed distal basilar trunk aneurysm arising between the origin of the left posterior cerebral artery and superior cerebellar artery, ectatic dilatation of distal basilar trunk, and a left middle cerebral artery (MCA) bifurcation aneurysm. Basilar trunk aneurysm was approached through subtemporal route and aneurysm was clipped during adenosine-induced profound hypotension (AIPH) without application of temporary clip. Single bolus 6 mg of adenosine was given, and aneurysm was successfully clipped during AIPH (systolic <60 mmHg). There were no complications related to adenosine. Ectatic part of distal basilar trunk was wrapped with Teflon. The left MCA bifurcation aneurysm was clipped in the same session. At 3-month follow-up, the patient's sensorium was normal (GCS-E4V5M6) and the right hemiparesis improved (4+/5). Adenosine enhances the safety of clipping these aneurysms by providing transient cardiac arrest or profound hypotension. In developing countries, microsurgical clipping is a cost-effective treatment option for basilar artery aneurysms.

Has Outcome of Subarachnoid Hemorrhage Changed With Improvements in Neurosurgical Services?

Background and Purpose- Though reports suggest decreasing fatality rates of subarachnoid hemorrhage with time, trends in outcome are not reported much especially from developing countries. This study was to analyze changes in outcome across 2 decades and elucidate probable factors. Methods- Prospective databases during 1996 to 2015 were reviewed for neurological outcome at 3 months in relation to demographics, Hunt and Hess grade, Fisher grade, and definitive treatment; and compared between 2 decades, contrasted by establishment of intensive care unit with continuous monitoring and other advancements. Univariate and multivariate analyses were performed. Results- Of the total 2039 patients, 1035 were managed in the former and 1004 in the recent decades. Compared with the former decade, there is delayed age at presentation (46 versus 49 years, P<0.001), poorer Fisher grades (81% versus 87%, P<0.001), and more patients with Hunt and Hess grade 2 (24% versus 39%, P<0.001) in the recent decade. While all patients in databases of the former decade had undergone clipping, 6% in the recent decade underwent coiling. 11% in the recent decade could not undergo definitive treatment. Despite this, there was significantly higher overall favorable outcome (50% versus 60%; odds ratio, 1.5; P<0.001) in recent decade. Favorable outcome of surgical clipping per se improved significantly from 50% to 67% (odds ratio 2.0; P<0.001). Though the improvement was across subgroups, it was more marked among Hunt and Hess grade 3 and Fisher grades 3 and 4. In multivariate analyses, both overall outcome (adjusted odds ratio, 1.7; 95% CI, 1.4-2.1; P<0.001) and surgical outcome (adjusted odds ratio, 1.8; 95% CI, 1.5-2.2; P<0.001) were significantly better in recent decade, independent of known prognostic factors. Conclusions- This is probably the first report to show independent improvement in outcome of subarachnoid hemorrhage with betterment in neurosurgical services from developing country. Dedicated intensive care unit care and focused management protocols could be the likely causes for improvement. Resource-constrained institutions may target patients in Hunt and Hess grade 3 and Fisher grades 3 and 4 for optimal intensive care unit utilization.

Trends for in-hospital metrics in the treatment of intracranial aneurysms in Minas Gerais, Brazil

Background: Aneurysmal subarachnoid hemorrhage (ASAH) and unruptured aneurysm (URA) are particularly important because of the high mortality rates, and physical and cognitive impairment, which affect the economically active population. The present work aims at describing the scenario regarding in-hospital indicators related to the following therapeutic approaches: vascular microsurgery (VMS) and endovascular therapy (EVT) in the state of Minas Gerais, Brazil, in order to gather information to construct hypotheses and plan actions. Methods: The study has an ecological design and it is also analytical for the time trends of 2008-2014. Trends for VMS and EVT therapies and mortality are estimated using linear regression, followed by the Prais-Winsten procedure. Data were obtained through Hospital Information System (Sistema de Informações Hospitalares - SIH) of Brazilian Public Health System (Sistema Único de Saúde - SUS). Results: In 2014, 601 procedures were performed, and out of these, 373 (62%) were triggered by SAH and 228 (38%) by URA. The frequency of procedures performed in males and in females results in a ratio of 1:2 for SAH procedures and 1:3 for URA procedures. A heterogeneous distribution of therapeutic approaches was seen among the hospital studied, suggesting a technological preference, which determines the therapeutic approach. Conclusion: Technological bias was observed for aneurysm treatment in Minas Gerais's hospitals. EVT is seen to have a growing trend to detriment of VMS (β₁ = 0.024; p = 0.025), with a stable mortality for both therapeutics in both pathologies (SAH and URA). EVT has been associated with a shorter hospital stay, with higher expenses for both ASAH and URA treatment. EVT showed an inverse correlation with in-hospital fatality for ASAH treatment.

Comparative Cost Analysis for the Surgical and Endovascular Treatment of Ruptured Intracranial Aneurysms in Taiwan: A Nationwide Population-Based Cohort Study

OBJECTIVE

Using a database that enabled longitudinal follow-up, we assessed the cost, outcome, complications, and readmission rate of ruptured cerebral aneurysms repaired by surgical clipping and endovascular coiling.

METHODS

This study was a retrospective review of data from a series of patients who underwent surgical clipping or endovascular coiling of ruptured cerebral aneurysms between 1996 and 2013. The medical records and hospital cost data were all examined.

RESULTS

A total of 7690 and 1380 cases were treated with clipping and coiling, respectively. Patients treated with clipping had more comorbidities and were older. The average total cost for endovascular coiling was $13,974.3, whereas the average total cost for surgical clipping was $16,581.7. Perioperative (30-day) mortality was 10.7% in patients with coiled aneurysms, compared with 12.6% in those with clipped aneurysms (P = 0.045). After 1 year of follow-up, clipping was associated with a significantly longer length of hospital stay (P < 0.001) and significantly higher total hospital costs (P < 0.001).

CONCLUSIONS

In Taiwan, the total hospital costs for the surgical clipping of cerebral aneurysms were higher than for endovascular coiling, and the surgical results were associated with significant complications. We suggest that the indications for coiling might need to be expanded from the current standards dictated by the guidelines in Taiwan.

Cost-effectiveness of interventions to control cardiovascular diseases and diabetes mellitus in South Asia: a systematic review

OBJECTIVES

More than 80% of cardiovascular diseases (CVD) and diabetes mellitus (DM) burden now lies in low and middle-income countries. Hence, there is an urgent need to identify and implement the most cost-effective interventions, particularly in the resource-constraint South Asian settings. Thus, we aimed to systematically review the cost-effectiveness of individual-level, group-level and population-level interventions to control CVD and DM in South Asia.

METHODS

We searched 14 electronic databases up to August 2016. The search strategy consisted of terms related to 'economic evaluation', 'CVD', 'DM' and 'South Asia'. Per protocol two reviewers assessed the eligibility and methodological quality of studies using standard checklists, and extracted incremental cost-effectiveness ratios of interventions.

RESULTS

Of the 2949 identified studies, 42 met full inclusion criteria. Critical appraisal of studies revealed 15 excellent, 18 good and 9 poor quality studies. Most studies were from India (n=37), followed by Bangladesh (n=3), Pakistan (n=2) and Bhutan (n=1). The economic evaluations were based on observational studies (n=9), randomised trials (n=12) and decision models (n=21). Together, these studies evaluated 301 policy or clinical interventions or combination of both. We found a large number of interventions were cost-effective aimed at primordial prevention (tobacco taxation, salt reduction legislation, food labelling and food advertising regulation), and primary and secondary prevention (multidrug therapy for CVD in high-risk group, lifestyle modification and metformin treatment for diabetes prevention, and screening for diabetes complications every 2-5 years). Significant heterogeneity in analytical framework and outcome measures used in these studies restricted meta-analysis and direct ranking of the interventions by their degree of cost-effectiveness.

CONCLUSIONS

The cost-effectiveness evidence for CVD and DM interventions in South Asia is growing, but most evidence is from India and limited to decision modelled outcomes. There is an urgent need for formal health technology assessment and policy evaluations in South Asia using local research data.

PROSPERO REGISTRATION NUMBER

CRD42013006479.

Procedural complications of endovascular treatment in patients with aneurysmal subarachnoid haemorrhage treated at a single centre

BACKGROUND

We present a single-centre experience of procedural complications suffered by patients undergoing endovascular treatment for a ruptured saccular intracranial aneurysm at Tampere University Hospital, Finland, between 2000 and 2014.

METHOD

From 2000 to 2014, we treated 1,253 patients with aneurysmal subarachnoid haemorrhage, 491 of whom received endovascular treatment. Clinical data were collected retrospectively from the hospital's aneurysm database. A procedural complication was defined as having occurred whenever there was a documented new event in the patient's medical records or a note of a technical complication written by an interventionist after endovascular treatment. Procedural complications could be with or without clinical symptoms.

RESULTS

Nearly 40% (491/1253) of the patients were treated with the endovascular method. Procedural complications occurred in 11.4% (56/491) of cases. The morbidity rate was 4.5% (22/491) and the mortality rate was 0.2% (1/491). Of the 56 complications, ischaemic complications occurred in 52% (29/56), haemorrhagic complications occurred in 27% (15/56) and technical complications occurred in 21% (12/56) of cases. In 61% (34/56) of the cases, the procedural complication did not cause any clinical symptoms.

CONCLUSIONS

The total risk for procedural complications leading to postoperative disability or death at our institute was 4.7%. The complication frequency is in accordance with previous reports. Endovascular treatment of ruptured intracranial aneurysms is a safe treatment method when patient selection is carefully performed.

A Systematic Review and Meta-Analysis on Economic Comparison Between Endovascular Coiling Versus Neurosurgical Clipping for Ruptured Intracranial Aneurysms

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.

Small Aneurysms Account for the Majority and Increasing Percentage of Aneurysmal Subarachnoid Hemorrhage: A 25-Year, Single Institution Study

BACKGROUND

Prospective studies of unruptured aneurysms have shown very low rates of rupture for small aneurysms (&lt;10 mm) and suggested that the risk of treatment outweighs benefit. However, common clinical practice shows that patients with aneurysmal subarachnoid hemorrhage (aSAH) frequently have small aneurysms.

OBJECTIVE

To investigate trends in size and location of ruptured aneurysms over a 25-yr period.

METHODS

A prospective, Institutional Review Board-approved database of all patients presenting to our institution with aSAH from 1991 to 2016 was analyzed. Cerebral angiography identified the source of hemorrhage. Patients with nonaneurysmal etiologies were excluded.

RESULTS

Complete data were available for 1306/1562 patients (84%) with aSAH from 1991 to 2016. The average age was 53 yr and 72% of patients were female. The average size of ruptured aneurysms over 25 yr was 8.0 mm. The average size of ruptured aneurysms decreased steadily with each 5-yr interval from 10.1 mm (1991-1996) to 6.6 mm (2012-2016; P &lt; .001). Overall, very small aneurysms (&lt;5 mm) were responsible for aSAH in 41% of patients. The percentage of very small ruptured aneurysms rose from 29% during the initial 5-yr period (1991-1996) to 50% in the most recent period. Likewise, the percentage of ruptured aneurysms that were 5 to 9 mm rose from 26% to 34% (P &lt; .001). In the past 5 yr, aneurysms &lt;10 mm accounted for 84% of aSAH. Vessel of origin (P = .097) and aneurysm location (P = .322) did not vary with time.

CONCLUSION

Ruptured small and very small aneurysms represent a majority and increasing share of aSAH. Identification and prophylactic treatment of these aneurysms remains an important clinical role for cerebrovascular neurosurgery.

Medicare expenditures for elderly patients undergoing surgical clipping or endovascular intervention for subarachnoid hemorrhage

OBJECTIVE The impact of treatment method-surgical clipping or endovascular coiling-on the cost of care for patients with aneurysmal subarachnoid hemorrhage (SAH) is debated. Here, the authors investigated the association between treatment method and long-term Medicare expenditures in elderly patients with aneurysmal SAH. METHODS The authors performed a cohort study of 100% of the Medicare fee-for-service claims data for elderly patients who had undergone treatment for ruptured cerebral aneurysms in the period from 2007 to 2012. To control for measured confounding, the authors used propensity score-adjusted multivariable regression analysis with mixed effects to account for clustering at the hospital referral region (HRR) level. An instrumental variable (regional rates of coiling) analysis was used to control for unmeasured confounding by creating pseudo-randomization on the treatment method. RESULTS During the study period, 3210 patients underwent treatment for ruptured cerebral aneurysms and met the inclusion criteria. Of these patients, 1206 (37.6%) had surgical clipping and 2004 (62.4%) had endovascular coiling. The median total Medicare expenditures in the 1st year after admission for SAH were $113,000 (IQR $77,500-$182,000) for surgical clipping and $103,000 (IQR $72,900-$159,000) for endovascular coiling. When the authors adjusted for unmeasured confounders by using an instrumental variable analysis, clipping was associated with increased 1-year Medicare expenditures by $19,577 (95% CI $4492-$34,663). CONCLUSIONS In a cohort of Medicare patients with aneurysmal SAH, after controlling for unmeasured confounding, surgical clipping was associated with increased 1-year expenditures in comparison with endovascular coiling.

Medicare expenditures for elderly patients undergoing surgical clipping or endovascular intervention for unruptured cerebral aneurysms

BACKGROUND

The cost difference between the two treatment options (surgical clipping and endovascular therapy) for unruptured cerebral aneurysms remains an issue of debate. We investigated the association between treatment method for unruptured cerebral aneurysms and Medicare expenditures in elderly patients.

METHODS

We performed a cohort study of 100% Medicare fee-for-service claims data for elderly patients who underwent treatment for unruptured cerebral aneurysms from 2007 to 2012. In order to control for measured confounding we used multivariable regression analysis with mixed effects to account for clustering at the Hospital Referral Region (HRR) level. An instrumental variable (regional rates of endovascular treatment) analysis was used to control for unmeasured confounding by creating pseudo-randomization on the treatment method.

RESULTS

During the study period 8705 patients underwent treatment for unruptured cerebral aneurysms and met the inclusion criteria. Of these, 2585 (29.7%) had surgical clipping and 6120 (70.3%) had endovascular treatment. The median total Medicare expenditures in the first year after the admission for the procedure were $46 800 (IQR $31 000-$74 400) for surgical clipping and $48 100 (IQR $34 500-$73 900) for endovascular therapy. When we adjusted for unmeasured confounders, using an instrumental variable analysis, clipping was associated with increased 7-day Medicare expenditures by $3527 (95% CI $972 to $5736) and increased 1-year Medicare expenditures by $15 984 (95% CI $9017 to $22 951).

CONCLUSIONS

In a cohort of Medicare patients, after controlling for unmeasured confounding, we demonstrated that surgical clipping of unruptured cerebral aneurysms was associated with increased 1-year expenditures compared with endovascular treatment.

Cost-Effectiveness Analysis of Endovascular Coiling versus Neurosurgical Clipping for Intracranial Aneurysms in Republic of Korea

PURPOSE

The International Subarachnoid Aneurysm Trial (ISAT) revealed that in ruptured intracranial aneurysms (RA), endovascular coiling (EC) yields better clinical outcomes than neurosurgical clipping (NC) at 1 year. In unruptured aneurysms (UIA), EC is being increasingly used as an alternative to NC due to patients' preference. There is a lot of difference in treatment cost (EC vs. NC) between countries. There is one recently published study dealing with the comparative cost analysis only in UIAs in South Korea. But it is a hospital-based study. So, the authors performed a nation-wide cost effective comparison in our country.

MATERIALS AND METHODS

This study was a retrospective analysis of healthcare big data open systems in Health Insurance Review & Assessment Service (HIRA). Hospital cost data of the recent 5 years (from January 2010 to December 2014) were analyzed according to patients' age and sex and the presence of subarachnoid hemorrhage.

RESULTS

When comparing the total hospital costs for NC of a UIA (n=13,756) and EC of a UIA (n=17,666), NC [mean±standard deviation (SD): ￦7,987,179±3,855,029] resulted in significantly lower total hospital costs than EC [￦10,201,645±5,001,626, p<0.0001], although a shorter hospital stay with EC of a UIA [8.6 ±7.4 days] vs. NC [15.0 ±8.3 days, p<0.0001]. When comparing the total hospital costs for NC of a RA (n=7,293) and EC of a RA (n=6,954), NC [￦13,914,993±6,247,914] resulted in significantly lower total hospital costs than EC [￦16,702,446±7,841,141, p<0.0001], although shorter hospital stays for EC of a RA [19.8 ±11.4] vs. NC [23.0 ±10.3, p<0.0001].

CONCLUSION

The total hospital costs for the NC of both UIAs and RAs were found to be lower than those for EC in South Korea.

Cost Comparison of Surgical and Endovascular Treatment of Unruptured Giant Intracranial Aneurysms

BACKGROUND

Giant intracranial aneurysms (GIAs), which are defined as intracranial aneurysms (IAs) with a diameter of ≥25 mm, are most likely associated with the highest treatment costs of all IAs. However, the treatment costs of unruptured GIAs have so far not been reported.

OBJECTIVE

To examine direct costs of endovascular and surgical treatment of unruptured GIAs.

METHODS

We retrospectively examined 55 patients with unruptured GIAs treated surgically (37 patients) or endovascularly (18 patients) between April 2004 and March 2014. We analyzed the costs of all hospital stays, interventions, and imaging with a median follow-up of 46 months.

RESULTS

There was no difference in the costs of hospital stay between surgical and endovascular treatment groups ($10,565 vs. $14,992; P = .37). Imaging costs were significantly higher in the surgical group than in the endovascular treatment group ($2890 vs. $1612; P < .01), as were the costs of the intervention room and personnel involved in the intervention ($5566 vs. $1520; P < .01). Implants used per patient were more expensive in the endovascular group than in the surgical treatment group ($20,885 vs. $167). The total direct treatment costs were higher in the endovascular group ($52,325) than in the surgical treatment group ($20,619; P < .01). Treatment costs were associated with the type of treatment and GIA location but not with patient age, sex, or GIA size.

CONCLUSION

Endovascular GIA treatment produced higher direct costs than surgical GIA treatment mainly due to higher implant costs. Reducing endovascular implant costs may be the most effective tool to decrease direct costs of GIA treatment.

Cost of Treatment of Cerebral Aneurysm Embolization: Study of Associated Factors

Background

Surgical clipping or endovascular coiling are the main procedures used in the treatment of cerebral aneurysms, with a preference for endovascular coiling. In Morocco, the number of patients needing endovascular coiling is growing, but many of them do not have access to this technique. The aim of this study was to determine the main parameters associated with variations in the total cost of this procedure in order to establish the amount (lump sum) that may be reimbursed by health insurance funds.

Methods

One hundred and seventeen patients with 124 aneurysms were admitted for treatment of one or more intracranial aneurysms between January 2010 and December 2015. The overall cost of hospitalization was assessed by using the micro-costing technique. The calculation was based on the tariffs of medical procedures as defined by the Ministry of Health in Morocco. A regression analysis was used to define the correlation between the overall cost and the various parameters.

Results

Univariate linear regression showed that the total cost was influenced by overall duration of hospitalization, ICU duration of hospitalization and size of aneurysm. On the other hand, univariate linear regression showed that the total cost was not influenced by sex, localization of aneurysm, and size of the aneurysm’s neck. However, multivariate linear regression showed that the total cost was influenced by one type of insurance health, overall duration of hospitalization, ICU duration of hospitalization, size of the aneurysm, and size of the aneurysm’s neck.

Conclusion

Setting a rate for reimbursement of patients who have had coiling treatment for a cerebral aneurysm should take into account the results of our study in order to limit the costs borne by patients. The parameters that influence the overall cost must be reimbursed in each case while the parameters that do not influence treatment costs could be included in a lump sum.

Clinical outcome after surgical clipping or endovascular coiling for cerebral aneurysms: a pragmatic meta-analysis of randomized and non-randomized trials with short- and long-term follow-up

BACKGROUND

Two randomized trials have evaluated clipping and coiling in patients with ruptured aneurysms. Aggregated evidence for management of ruptured and unruptured aneurysms is missing.

OBJECTIVE

To conduct a meta-analysis evaluating clinical outcome after aneurysm treatment.

METHODS

PubMed, Cochrane Central Register of Controlled Trials, and Clinicaltrials.gov were searched for studies evaluating aneurysm treatment. The primary outcome measure was an independent clinical outcome (modified Rankin scale 0-2, Glasgow Outcome Scale 4-5, or equivalent). Secondary outcomes were poor outcome and mortality. ORs were calculated on an intention-to-treat basis with 95% CIs. Outcome heterogeneity was evaluated with Cochrane's Q test (significance level cut-off value at <0.10) and I² (significance cut-off value >50%) with the Mantel-Haenszel method for dichotomous outcomes. A p value <0.05 was regarded as statistically significant.

RESULTS

Searches yielded 18 802 articles. All titles were assessed, 403 abstracts were evaluated, and 183 full-text articles were read. One-hundred and fifty articles were qualitatively assessed and 85 articles were included in the meta-analysis. Patients treated with coiling (randomized controlled trials (RCTs)) had higher independent outcome at short-term follow-up (OR=0.67, 95% CI 0.57 to 0.79). Independent outcome was favored for coiling at intermediate and long-term follow-up (RCTs and observational studies combined-OR=0.80, 0.68 to 0.94 and OR=0.81, 0.71 to 0.93, respectively). Independent outcome and lower mortality was favored after coiling in unruptured aneurysms (database registry studies) at short-term follow-up (OR=0.34, 0.29 to 0.41 and OR=1.74, 1.52 to 1.98, respectively).

CONCLUSIONS

This meta-analysis evaluating clinical outcome after coiling or clipping for intracranial aneurysms, indicates a higher independent outcome and lower mortality after coiling.

Provider costs for prevention and treatment of cardiovascular and related conditions in low- and middle-income countries: a systematic review

BACKGROUND

The burden of cardiovascular disease (CVD) and CVD risk conditions is rapidly increasing in low- and middle-income countries, where health systems are generally ill-equipped to manage chronic disease. Policy makers need an understanding of the magnitude and drivers of the costs of cardiovascular disease related conditions to make decisions on how to allocate limited health resources.

METHODS

We undertook a systematic review of the published literature on provider-incurred costs of treatment for cardiovascular diseases and risk conditions in low- and middle-income countries. Total costs of treatment were inflated to 2012 US dollars for comparability across geographic settings and time periods.

RESULTS

This systematic review identified 60 articles and 143 unit costs for the following conditions: ischemic heart disease, non-ischemic heart diseases, stroke, heart failure, hypertension, diabetes, and chronic kidney disease. Cost data were most readily available in middle-income countries, especially China, India, Brazil, and South Africa. The most common conditions with cost studies were acute ischemic heart disease, type 2 diabetes mellitus, stroke, and hypertension.

CONCLUSIONS

Emerging economies are currently providing a base of cost evidence for NCD treatment that may prove useful to policy-makers in low-income countries. Initial steps to publicly finance disease interventions should take account of costs. The gaps and limitations in the current literature include a lack of standardized reporting as well as sparse evidence from low-income countries.

International survey on neuroradiological interventional and therapeutic devices and materials

A web-based survey was performed among the members of the World Federation of Interventional and Therapeutic Neuroradiology to determine the differences in availability, pricing, and performance of endovascular devices with special focus on coils, intra-arterial stroke devices, detachable balloons, and liquid embolic materials. The results of this survey show that the quality of the majority of interventional neuroradiology devices is good and compatibility issues are limited. Individual action towards suppliers is recommended to discuss the availability and pricing of devices and embolization materials.

Quality of life and outcome after treatment of ruptured cerebral aneurysms: results of a single center in Switzerland

OBJECT

To evaluate the subjective outcome and quality of life (QoL) of patients who suffered from aneurysmal subarachnoid hemorrhage and underwent endovascular coiling or microsurgical clipping in a single center.

METHODS

For this retrospective single-center study, we included patients who underwent aneurysm occlusion at the Cantonal Hospital of Aarau between January 2000 and December 2006. The QoL, the functional status, and the level of independence were assessed by means of the Short Form (SF)-12 Health Survey, the modified Rankin Scale (mRS), and the Barthel Index. The questionnaires were sent to and completed by the patients. A total of 104 patients with a mean age of 53.14 years (range, 18-80 years) were included in the study. In 63 (60.6 %) of the cases, the aneurysm was clipped; in 41 (39.4 %) of the cases, endovascular coiling was performed.

RESULTS

The SF-12 scores for the PCS (Physical Component Summary) and MCS (Mental Component Summary) were similar for both clipped (PCS 45.35; MCS 46.55) and coiled (PCS 46.31; MCS 47.87) patients. The mean values were, on average, 4.17 points lower for the PCS and 2.79 points lower for the MCS when compared with the mean of the US population, with a mean of 50 (standard deviation (SD) 10). The mean Barthel Index for the entire group was 92.26 (SD 16.8) and was almost identical for both the clipped (92.54; SD 16.21) and coiled (91.83; SD 17.9) patients (p = 0.56). The mean mRS did not differ between the coiled and clipped patients (coiled 1.63; clipped 1.56; p = 0.97) CONCLUSIONS: There were no significant differences in the functional and mental health scores between the two groups of clipped and coiled patients who were treated at our center, but both groups were lower than population-based scores. Although the neurologic condition and the imaging results on admission were worse in the coiled group, the long-term results did not differ significantly.

A predictive model of hospitalization cost after cerebral aneurysm clipping

BACKGROUND

Cost containment is the cornerstone of the Affordable Care Act. Although studies have compared the cost of cerebral aneurysm clipping (CAC) and coiling, they have not focused on identification of drivers of cost after CAC, or prediction of its magnitude. The objective of the present study was to develop and validate a predictive model of hospitalization cost after CAC.

METHODS

We performed a retrospective study involving CAC patients who were registered in the Nationwide Inpatient Sample (NIS) database from 2005 to 2010. The two cohorts of ruptured and unruptured aneurysms underwent 1:1 randomization to create derivation and validation subsamples. Regression techniques were used for the creation of a parsimonious predictive model.

RESULTS

Of the 7798 patients undergoing CAC, 4505 (58%) presented with unruptured and 3293 (42%) with ruptured aneurysms. Median hospitalization cost was US$24,398 (IQR $17,079 to $38,249) and $73,694 (IQR $46,270 to $115,128) for the two cohorts, respectively. Common drivers of cost identified in the multivariate analyses included the following: length of stay, number of admission diagnoses and procedures, hospital size and region, and patient income. The models were validated in independent cohorts and demonstrated final R(2) values very similar to the initial models. The predicted and observed values in the validation cohort demonstrated good correlation.

CONCLUSIONS

This national study identified significant drivers of hospitalization cost after CAC. The presented model can be utilized as an adjunct in the cost containment debate and the creation of data driven policies.

Cost Comparison of Endovascular Treatment of Anterior Circulation Aneurysms With the Pipeline Embolization Device and Stent-Assisted Coiling

BACKGROUND:

The Pipeline embolization device (PED) is a new endovascular option for wide-necked or fusiform anterior circulation aneurysms that were classically treated by coil embolization with adjunctive use of a stent. However, stent-coiling incurs significant equipment and implant costs.

OBJECTIVE:

To determine whether PED embolization is more economical than stent-assisted coiling.

METHODS:

Sixty consecutive patients with anterior circulation aneurysms who underwent treatment with the PED (30 patients) or by single-stage stent-assisted coiling (30 patients) were identified from a prospective single-center aneurysm database. The hospital costs of equipment and implants were analyzed and compared for each group.

RESULTS:

The mean aneurysm size for patients treated with the PED was 9.8 vs 7.3 mm for patients treated by stent-assisted coiling. The total combined costs of proximal access/guide catheters, microcatheters, and microwires were equivalent between the 2 groups. The cost of implants, however, was significantly lower in the PED group ($13 175 ± 726 vs $19 069 ± 2015; P = .013), despite this group having a larger mean aneurysm size. Furthermore, the total procedure cost was significantly lower for the PED group vs the stent-coiling group ($16 445 ± 735 vs $22 145 ± 2022; P = .02), a 25.7% cost reduction. This represents a 27.1% reduction in the cost per millimeter of aneurysm treated in the PED group ($2261 ± 299) vs the stent-coiling group ($3102 ± 193; P = .02).

CONCLUSION:

Treatment of anterior circulation aneurysms by flow diversion with the PED has lower procedure costs compared with treatment with traditional stent-assisted coiling.

Hospitalization costs for endovascular and surgical treatment of ruptured aneurysms in the United States are substantially higher than Medicare payments

BACKGROUND AND PURPOSE

Endovascular and surgical options are both available for treatment of ruptured cerebral aneurysms. Knowledge of the costs relative to Medicare reimbursement for hospitalization of these patients is important for understanding the economic impact of these patients on hospitals.

MATERIALS AND METHODS

Using the NIS, we identified hospitalizations for clipping and coiling of ruptured cerebral aneurysms from 2001 to 2008 by cross-matching ICD-9 codes for diagnosis of ruptured aneurysm with procedure codes for clipping or coiling of cerebral aneurysms. Hospital costs for 2008 were correlated with age, sex, and discharge status. For discharges of Medicare patients, we compared Medicare payments with costs for respective MS-DRG.

RESULTS

For 2008, the average Medicare payment for craniotomy and endovascular intracranial procedures without complication (MS-DRG 22) was $30,380. Medicare discharges with DRG 22, for patients undergoing clipping had median costs of $59,799 in 2008. Those undergoing coiling had median costs of $36,543. Reimbursement for discharges with complications or comorbidities (MS-DRG 21) was $36,304. Median costs for hospitalization of clipped patients with MS DRG 21 was $79,916 and for coiled patients, $56,910. Reimbursement for MS-DRG 20 (major complications or comorbidities) was $41,748, with patients undergoing clipping incurring a median cost of $83,737 and those undergoing coiling incurring a median cost of $83,277.

CONCLUSIONS

Hospitalization costs for patients undergoing clipping and coiling of unruptured cerebral aneurysms are substantially higher than Medicare payments.