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Wadhwa A, Mensah E, Young M, Ogilvy CS. Variability patterns in dual antiplatelet therapy following endovascular repair of intracranial aneurysms: Insight into regimen heterogeneity and the need for a consensus. Acta Neurochir (Wien) 2024; 166:271. [PMID: 38888678 DOI: 10.1007/s00701-024-06137-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Accepted: 05/20/2024] [Indexed: 06/20/2024]
Abstract
This comprehensive review delves into the evolving field of neurointervention for intracranial aneurysms, exploring the critical adjunct of Dual Antiplatelet Therapy (DAPT) to endovascular coiling, stent-assisted coiling (SAC), flow-diversion stents, and flow-disruption (intrasaccular) devices. Despite growing evidence supporting the success of DAPT in reducing thromboembolic events, the lack of consensus on optimal regimens, doses, and duration is evident. Factors contributing to this variability include genetic polymorphisms affecting treatment response and ongoing debates regarding the clinical significance of hemorrhagic complications associated with DAPT. This review analyzes pre- and post-procedural antiplatelet usage across various interventions. The imperative lies in ongoing research to define optimal DAPT durations, ensuring a nuanced approach to the delicate balance between thrombosis and hemorrhage in intracranial aneurysm management.
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Affiliation(s)
- Aryan Wadhwa
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, 110 Francis St, Boston, MA, 02215, USA
| | - Emmanuel Mensah
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, 110 Francis St, Boston, MA, 02215, USA
| | - Michael Young
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, 110 Francis St, Boston, MA, 02215, USA
| | - Christopher S Ogilvy
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, 110 Francis St, Boston, MA, 02215, USA.
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2
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Nasra M, Maingard JT, Hall J, Mitreski G, Kuan Kok H, Smith PD, Russell JH, Jhamb A, Brooks DM, Asadi H. Clipping versus coiling: A critical re-examination of a decades old controversy. Interv Neuroradiol 2024; 30:86-93. [PMID: 36017537 PMCID: PMC10956463 DOI: 10.1177/15910199221122854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2022] [Accepted: 08/10/2022] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Two major studies, The International Subarachnoid Aneurysm Trial and the Barrow Ruptured Aneurysm Trial, compare the long-term outcomes of clipping and coiling. Although these demonstrated coiling's initial benefits, rebleeding and retreatment rates as well as converging patient outcomes sparked controversy regarding its durability. This article will critically examine the available evidence for and against clipping and coiling of intracranial aneurysms. Critics of endovascular treatment state that the initial benefit seen with endovascular coiling decreases over the duration of follow-up and eventually functional outcomes of both treatment modalities are similar. Combined with the increased rate of retreatment and rebleeding, these trials reveal that coiling is not as durable and not as effective as a long-term treatment compared to clipping. Also, due to the cost of devices following endovascular treatment and prolonged hospitalization following clipping, the financial burden has been considered controversial. SUMMARY/KEY MESSAGES Short-term outcomes reveal better morbidity and mortality outcomes following coiling. Despite the higher rates of retreatment and rebleeding with coiling, there was no significant change in functional outcomes following retreatment. Furthermore, examining more recent trials reveals a decreased rate of recurrence and rebleeding with improved technology and expertise. Functional outcomes deteriorate for both cohorts over time while recent results revealed improved long-term cognitive outcomes and levels of health-related quality of life after coiling in comparison to clipping. The expense of longer hospital stays following clipping must be balanced against the expense of endovascular devices in coiling.
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Affiliation(s)
| | - Julian Tam Maingard
- Interventional Neuroradiology Unit, Monash Imaging, Monash Health, Clayton, Victoria, Australia
- Faculty of Medicine Nursing and Health Sciences, Monash University, Clayton, Victoria, Australia
- Department of Radiology, Interventional Neuroradiology Service, Austin Health, Heidelberg, Victoria, Australia
| | - Jonathan Hall
- Department of Interventional Radiology, St Vincent's Health Australia, Fitzroy, Victoria, Australia
| | - Goran Mitreski
- Department of Radiology, Interventional Neuroradiology Service, Austin Health, Heidelberg, Victoria, Australia
| | - Hong Kuan Kok
- Interventional Radiology Service, Northern Hospital, Epping, Victoria, Australia
| | - Paul D. Smith
- Department of Neurosurgery, St Vincent's Hospital, Fitzroy, Victoria, Melbourne, Australia
- Melbourne Medical School, The University of Melbourne, Parkville, Victoria, Australia
| | - Jeremy H. Russell
- Department of Neurosurgery, Austin Health, Heidelberg, Victoria, Australia
| | - Ashu Jhamb
- Department of Interventional Radiology, St Vincent's Health Australia, Fitzroy, Victoria, Australia
| | - Duncan Mark Brooks
- Department of Radiology, Interventional Neuroradiology Service, Austin Health, Heidelberg, Victoria, Australia
- School of Medicine-Faculty of Health, Deakin University, Waurn Ponds, Victoria, Australia
| | - Hamed Asadi
- Interventional Neuroradiology Unit, Monash Imaging, Monash Health, Clayton, Victoria, Australia
- Department of Radiology, Interventional Neuroradiology Service, Austin Health, Heidelberg, Victoria, Australia
- School of Medicine-Faculty of Health, Deakin University, Waurn Ponds, Victoria, Australia
- Stroke Division, Florey Institute of Neuroscience and Mental Health, Parkville, Victoria, Australia
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Hannan CJ, Islim AI, Alalade AF, Bacon A, Ghosh A, Dalton A, Abouharb A, Walsh DC, Bulters D, White E, Chavredakis E, Kounin G, Critchley G, Dow G, Patel HC, Brydon H, Anderson IA, Fouyas I, Galea J, St George J, Bal J, Patel K, Kamel M, Teo M, Fanning N, Mukerji N, Grover P, Mitchell P, Whitfield PC, Trivedi R, Crockett MT, Brennan P, Javadpour M. Radiological follow-up of endovascularly treated intracranial aneurysms: a survey of current practice in the UK and Ireland. Acta Neurochir (Wien) 2023; 165:451-459. [PMID: 36220949 DOI: 10.1007/s00701-022-05379-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Accepted: 09/27/2022] [Indexed: 11/26/2022]
Abstract
PURPOSE Due to the risk of intracranial aneurysm (IA) recurrence and the potential requirement for re-treatment following endovascular treatment (EVT), radiological follow-up of these aneurysms is necessary. There is little evidence to guide the duration and frequency of this follow-up. The aim of this study was to establish the current practice in neurosurgical units in the UK and Ireland. METHODS A survey was designed with input from interventional neuroradiologists and neurosurgeons. Neurovascular consultants in each of the 30 neurosurgical units providing a neurovascular service in the UK and Ireland were contacted and asked to respond to questions regarding the follow-up practice for IA treated with EVT in their department. RESULTS Responses were obtained from 28/30 (94%) of departments. There was evidence of wide variations in the duration and frequency of follow-up, with a minimum follow-up duration for ruptured IA that varied from 18 months in 5/28 (18%) units to 5 years in 11/28 (39%) of units. Young patient age, previous subarachnoid haemorrhage and incomplete IA occlusion were cited as factors that would prompt more intensive surveillance, although larger and broad-necked IA were not followed-up more closely in the majority of departments. CONCLUSIONS There is a wide variation in the radiological follow-up of IA treated with EVT in the UK and Ireland. Further standardisation of this aspect of patient care is likely to be beneficial, but further evidence on the behaviour of IA following EVT is required in order to inform this process.
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Affiliation(s)
| | | | | | - Andrew Bacon
- Department of Neurosurgery, Royal Hallamshire Hospital, Sheffield, UK
| | - Anthony Ghosh
- Department of Neurosurgery, Queen's Hospital Romford, Romford, UK
| | - Arthur Dalton
- Department of Neurosurgery, Charing Cross Hospital, London, UK
| | - Ashraf Abouharb
- Department of Neurosurgery, Royal Victoria Hospital, Belfast, UK
| | | | - Diederik Bulters
- Department of Neurosurgery, Wessex Neurological Centre, University Hospital Southampton, Southampton, UK
| | - Edward White
- Department of Neurosurgery, Queen Elizabeth Hospital, Birmingham, UK
| | - Emmanouil Chavredakis
- Department of Neurosurgery, The Walton Centre for Neurology and Neurosurgery, Liverpool, UK
| | - George Kounin
- Department of Neurosurgery, Hull Royal Infirmary, Hull, UK
| | - Giles Critchley
- Department of Neurosurgery, University Hospitals Sussex, Brighton, UK
| | - Graham Dow
- Department of Neurosurgery, Queen's Medical Centre, Nottingham, UK
| | - Hiren C Patel
- Manchester Centre for Clinical Neurosciences, Manchester, UK
| | - Howard Brydon
- Department of Neurosurgery, Royal Stoke University Hospital, Stoke, UK
| | - Ian A Anderson
- Department of Neurosurgery, Leeds General Infirmary, Leeds, UK
| | - Ioannis Fouyas
- Department of Neurosurgery, Western General Hospital, Edinburgh, UK
| | - James Galea
- Department of Neurosurgery, University Hospital Wales, Cardiff, UK
| | - Jerome St George
- Department of Neurosurgery, Queen Elizabeth University Hospital, Glasgow, UK
| | - Jarnail Bal
- Department of Neurosurgery, Royal London Hospital, London, UK
| | - Krunal Patel
- Department of Neurosurgery, University Hospital Coventry, Coventry, UK
| | - Mahmoud Kamel
- Department of Neurosurgery, Cork University Hospital, Cork, Ireland
| | - Mario Teo
- Department of Neurosurgery, Southmead Hospital, Bristol, UK
| | - Noel Fanning
- Department of Neurosurgery, Cork University Hospital, Cork, Ireland
| | - Nitin Mukerji
- Department of Neurosurgery, James Cook University Hospital, Middlesbrough, UK
| | - Patrick Grover
- Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, UK
| | - Patrick Mitchell
- Department of Neurosurgery, Royal Victoria Infirmary, Newcastle, UK
| | - Peter C Whitfield
- South West Neurosurgery Centre, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - Rikin Trivedi
- Department of Neurosurgery, Addenbrookes Hospital, Cambridge, UK
| | | | - Paul Brennan
- Department of Neuroradiology, Beaumont Hospital, Dublin, Ireland
| | - Mohsen Javadpour
- Department of Neurosurgery, Beaumont Hospital, Dublin, Ireland
- School of Medicine, Trinity College Dublin, Dublin, Ireland
- Royal College of Surgeons in Ireland, Dublin, Ireland
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Lauzier DC, Cler SJ, Kansagra AP. Examining the Value of Neurointerventional Follow-up. World Neurosurg 2021; 155:191-192. [PMID: 34724733 DOI: 10.1016/j.wneu.2021.08.059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- David C Lauzier
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Samuel J Cler
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Akash P Kansagra
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri, USA; Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri, USA; Department of Neurology, Washington University School of Medicine, St. Louis, Missouri, USA
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Salem MM, Salih M, Nwajei F, Gomez-Paz S, Thomas AJ, Ogilvy CS, Moore JM. Cost-Effectiveness Analytic Comparison of Neuroimaging Follow-Up Strategies After Pipeline Embolization Device Treatment of Unruptured Intracranial Aneurysms. World Neurosurg 2021; 158:e206-e213. [PMID: 34757210 DOI: 10.1016/j.wneu.2021.10.154] [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: 09/17/2021] [Revised: 10/22/2021] [Accepted: 10/23/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Flow diversion via a Pipeline embolization device (PED [Medtronic, Dublin, Ireland]) is one of the established modalities for the treatment of unruptured intracranial aneurysms that require a robust follow-up regimen. However, to date, no consensus has been reached regarding the optimal imaging modality and timing intervals for such a strategy. We studied the cost-effectiveness of different neuroimaging follow-up strategies after flow diversion with the PED. METHODS A decision-analytical study using Markov modeling was performed to compare 5 commonly used multistep follow-up strategies with different combinations of digital subtraction angiography (DSA) and magnetic resonance angiography (MRA): 1) DSA at 6 months and MRA at 12 and 24 months; 2) DSA at 6, 12, and 24 months; 3) MRA at 6, 12, and 24 months; 4) DSA at 6 and 12 months and MRA at 24 months; and 5) DSA at 12 months and MRA at 24 months. The input parameters were mainly collected from the latest meta-analysis, and 1-way, 2-way, and probabilistic sensitivity analyses were conducted to assess the robustness of our model. RESULTS Strategy 5, incorporating DSA at 12 months and MRA at 24 months, was the most cost-effective strategy for >99% of the 10,000 iterations in the probabilistic sensitivity analysis at a willingness-to-pay threshold of $100,000/quality-adjusted life-year. The result remained robust in the 1- and 2-way sensitivity analyses. CONCLUSIONS Given the current data, delayed imaging follow-up at 1 year with DSA and 2 years with MRA after PED treatment of unruptured intracranial aneurysms is more cost-effective than early follow-up at 6 months.
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Affiliation(s)
- Mohamed M Salem
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA.
| | - Mira Salih
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Felix Nwajei
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Santiago Gomez-Paz
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Ajith J Thomas
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Christopher S Ogilvy
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Justin M Moore
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
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Lauzier DC, Cler SJ, Chatterjee AR, Osbun JW, Moran CJ, Kansagra AP. The value of long-term angiographic follow-up following Pipeline embolization of intracranial aneurysms. J Neurointerv Surg 2021; 14:585-588. [PMID: 34210838 DOI: 10.1136/neurintsurg-2021-017745] [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: 05/04/2021] [Accepted: 06/16/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND Flow diversion of intracranial aneurysms with the Pipeline Embolization Device (PED) is commonly performed, but the value of long-term angiographic follow-up has not been rigorously evaluated. Here we examine the prevalence of actionable findings of aneurysm recurrence and development of in-stent stenosis in a cohort of patients that underwent long-term angiographic follow-up at multiple time points. METHODS Angiographic data from eligible patients were retrospectively assessed for aneurysm occlusion, in-stent stenosis, and aneurysm regrowth or recurrence. Patients were included in this study if they underwent angiographic imaging at 6 months post-treatment and at least one later time point. RESULTS 100% (132/132) of aneurysms occluded at 6 months remained occluded at final follow-up. 85.7% (6/7), 56.3% (27/48), and 25% (6/24) of aneurysms with entry remnant, subtotal filling, and total filling, respectively, at 6 months were completely occluded at final follow-up. 98.7% (147/149) of PED constructs that demonstrated no stenosis at 6 months demonstrated no stenosis at final angiography, while 44.4% (8/18) of PED constructs demonstrating in-stent stenosis at 6 months had resolution of stenosis on final angiography. CONCLUSIONS Among patients who undergo treatment of intracranial aneurysms with PED, the value of long-term angiography in patients demonstrating complete aneurysm occlusion and no in-stent stenosis on 6 month post-treatment angiography is low.
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Affiliation(s)
- David C Lauzier
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Samuel J Cler
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Arindam R Chatterjee
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri, USA.,Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri, USA.,Department of Neurology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Joshua W Osbun
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri, USA.,Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri, USA.,Department of Neurology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Christopher J Moran
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri, USA.,Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Akash P Kansagra
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri, USA .,Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri, USA.,Department of Neurology, Washington University School of Medicine, St. Louis, Missouri, USA
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Thaci B, Nuño M, Varshneya K, Gerndt CH, Kercher M, Dahlin BC, Waldau B. Three-dimensional aneurysm volume measurements show no correlation between coil packing density and recurrence. Heliyon 2020; 6:e05170. [PMID: 33083618 PMCID: PMC7551363 DOI: 10.1016/j.heliyon.2020.e05170] [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: 03/28/2020] [Revised: 07/03/2020] [Accepted: 10/02/2020] [Indexed: 11/30/2022] Open
Abstract
Objective Endovascular treatment is the mainstay therapy for brain aneurysms. About 15% of patients need re-treatment within six months due to early recanalization. In this study, we investigate risk factors associated with treatment failure. Methods This retrospective cohort study includes endovascularly treated aneurysm cases between July 2012 and December 2015 at the University of California Davis Medical Center with pre-treatment and early post-treatment imaging. Thin cut 3D aneurysm volume rendering was used for morphologic analyses. Univariate and bivariate analyses were conducted to evaluate differences between patients and clinical factors by treatment failure. Results Of the 50 patients who met the inclusion criteria, 41 (82.0%) were female, with an average age of 61 years. Most aneurysms were on the anterior communicating artery (40%) or posterior communicating artery (22.0%), and 34 (68%) aneurysms were ruptured. Early treatment failure was observed in 14 (28.0%) of endovascularly treated patients. Raymond-Roy class (RRC) was significantly associated with treatment failure (p = 0.0052), with 10 out of the 14 cases (71.4%) with early recanalization having an RRC of 3. Coil packing density did not associate with aneurysm recanalization (p = 0.61). Conclusion In our single institution series, patient characteristics, aneurysm characteristics, or coil packing density did not affect early aneurysm recanalization. RRC was the best predictor of early recanalization; however, further confirmation with additional studies are required. Although this study focused on early treatment failure, late recanalization has been shown with longer follow up. Further investigation into factors associated with late treatment failure will need further investigation. New intrasaccular devices and flow diverters will also likely play a role in reducing recurrence in the future as these treatments gain usage.
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Affiliation(s)
- Bart Thaci
- Department of Neurological Surgery, University of California, Davis Medical Center, Sacramento, USA
| | - Miriam Nuño
- Department of Public Health Sciences, Division of Biostatistics, University of California Davis, Davis, USA
| | - Kunal Varshneya
- Department of Neurosurgery, Stanford University School of Medicine, USA
| | - Clayton H Gerndt
- Department of Neurological Surgery, University of California, Davis Medical Center, Sacramento, USA
| | - Matthew Kercher
- Department of Neurological Surgery, University of California, Davis Medical Center, Sacramento, USA
| | - Brian C Dahlin
- Department of Interventional Radiology, University of California, Davis Medical Center, Sacramento, USA
| | - Ben Waldau
- Department of Neurological Surgery, University of California, Davis Medical Center, Sacramento, USA
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Wilde H, Twitchell S, Reese J, Guan J, Eli IM, Karsy M, Taussky P, Grandhi R, Schmidt RH, Couldwell WT. Evaluation of disease severity and treatment intensity as cost drivers for ruptured intracranial aneurysms. Acta Neurochir (Wien) 2020; 162:157-167. [PMID: 31811467 DOI: 10.1007/s00701-019-04153-3] [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: 05/09/2019] [Accepted: 11/18/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND Previous studies have not evaluated the impact of illness severity and postrupture procedures in the cost of care for intracranial aneurysms. We hypothesize that the severity of aneurysm rupture and the aggressiveness of postrupture interventions play a role in cost. METHODS The Value Driven Outcomes database was used to assess direct patient cost during the treatment of ruptured intracranial aneurysm with clipping, coiling, and Pipeline flow diverters. RESULTS One hundred ninety-eight patients (mean age 52.8 ± 14.1 years; 40.0% male) underwent craniotomy (64.6%), coiling (26.7%), or flow diversion (8.6%). Coiling was 1.4× more expensive than clipping (p = .005) and flow diversion was 1.7× more expensive than clipping (p < .001). More severe illness as measured by American Society of Anesthesia, Hunt/Hess, and Fisher scales incurred higher costs than less severe illness (p < .05). Use of a lumbar drain protocol to reduce subarachnoid hemorrhage and use of an external ventricular drain to manage intracranial pressure were associated with reduced (p = .05) and increased (p < .001) total costs, respectively. Patients with severe vasospasm (p < .005), those that received shunts (p < .001), and those who had complications (p < .001) had higher costs. Multivariate analysis showed that procedure type, length of stay, number of angiograms, vasospasm severity, disposition, and year of treatment were independent predictors of cost. CONCLUSIONS These results show for the first time that disease and vasospasm severity and intensity of treatment directly impact the cost of care for patients with aneurysms in the USA. Strategies to alter these variables may prove important for cost reduction.
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Affiliation(s)
- Herschel Wilde
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, 175 N. Medical Drive East, Salt Lake City, UT, 84132, USA
| | - Spencer Twitchell
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, 175 N. Medical Drive East, Salt Lake City, UT, 84132, USA
| | - Jared Reese
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, 175 N. Medical Drive East, Salt Lake City, UT, 84132, USA
| | - Jian Guan
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, 175 N. Medical Drive East, Salt Lake City, UT, 84132, USA
| | - Ilyas M Eli
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, 175 N. Medical Drive East, Salt Lake City, UT, 84132, USA
| | - Michael Karsy
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, 175 N. Medical Drive East, Salt Lake City, UT, 84132, USA
| | - Philipp Taussky
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, 175 N. Medical Drive East, Salt Lake City, UT, 84132, USA
| | - Ramesh Grandhi
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, 175 N. Medical Drive East, Salt Lake City, UT, 84132, USA
| | - Richard H Schmidt
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, 175 N. Medical Drive East, Salt Lake City, UT, 84132, USA
| | - William T Couldwell
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, 175 N. Medical Drive East, Salt Lake City, UT, 84132, USA.
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Twitchell S, Wilde HW, Taussky P, Karsy M, Grandhi R. Initial Treatment for Unruptured Intracranial Aneurysm and Its Follow-up: A Cost Analysis of Pipeline Flow Diverters versus Coiling. Cureus 2019; 11:e5692. [PMID: 31720160 PMCID: PMC6823005 DOI: 10.7759/cureus.5692] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Purpose Intracranial aneurysms are relatively common epidemiological problems for which the surveillance, treatment, and follow-up are costly. Although multiple studies have evaluated the treatment cost of aneurysms, the follow-up costs are often not examined. In our study, we analyzed how follow-up costs after treatment affected the overall cost of different endovascular techniques for treating aneurysms. Materials and methods An institutional database was used to evaluate the upfront and follow-up costs incurred by patients who underwent elective coiling or placement of a pipeline embolization device (PED) for the treatment of unruptured intracranial aneurysms from July 2011 to December 2017. Results A total of 114 patients (coiling, n = 37; PED, n = 77 ) were included in the study. There was no significant difference among patients in mean age [61.3 (±12.8 years) vs. 57.0 (±14.5 years); probability value (p) = 0.2], sex (male: 32.4% vs. 22.1%; p = 0.2), American Society of Anesthesiologists (ASA) grade (p = 0.5), discharge disposition (p = 0.1), mean length of stay [3.1 days (±5.5) vs. 2.4 days (±2.6); p = 0.2) or follow-up period [22.7 months (±18.5) vs. 18.6 months (±14.9); p = 0.2). There were no differences in costs during admission (p = 0.5) or in follow-up (p = 0.3) between coiling and PED treatments. Initial costs were predominantly related to supplies/implants (56.1% vs. 63.7%) for both treatments. Follow-up costs mostly comprised facility costs (68.2% vs. 67.5%), and there were no differences in costs of subgroups such as supplies/implants (10.5% vs. 9.4%), imaging (17.0% vs. 17.8%), or facilties between coiling and PED. Conclusion These results suggest that the upfront and follow-up costs are mostly similar for the treatment of intracranial aneurysms irrespective of whether the providers used coiling or PED endovascular techniques. Hence, we conclude that follow-up costs should not be a deciding factor when considering these treatments.
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Affiliation(s)
- Spencer Twitchell
- Neurosurgery, University of Utah School of Medicine, Salt Lake City, USA
| | - Herschel W Wilde
- Neurosurgery, University of Utah School of Medicine, Salt Lake City, USA
| | - Philipp Taussky
- Neurosurgery, University of Utah School of Medicine, Salt Lake City, USA
| | - Michael Karsy
- Neurosurgery, University of Utah School of Medicine, Salt Lake City, USA
| | - Ramesh Grandhi
- Neurosurgery, University of Utah School of Medicine, Salt Lake City, USA
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10
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Malhotra A, Wu X, Forman HP, Matouk CC, Gandhi D, Sanelli P. Management of Tiny Unruptured Intracranial Aneurysms: A Comparative Effectiveness Analysis. JAMA Neurol 2019; 75:27-34. [PMID: 29159405 DOI: 10.1001/jamaneurol.2017.3232] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Importance Unruptured intracranial aneurysms (UIAs) are relatively common in the general population and are being increasingly diagnosed; a significant proportion are tiny (≤3 mm) aneurysms. There is significant heterogeneity in practice and lack of clear guidelines on the management of incidental, tiny UIAs. It is important to quantify the implications of different management strategies in terms of health benefits to patients. Objective To evaluate the effectiveness of routine treatment (aneurysm coiling) vs 3 strategies for imaging surveillance compared with no preventive treatment or routine follow-up of tiny UIAs. Design, Setting, and Participants A decision-analytic model-based comparative effectiveness analysis was conducted from May 1 to June 30, 2017, using inputs from the medical literature. PubMed searches were performed to identify relevant literature for all key model inputs, each of which was derived from the clinical study with the most robust data and greatest applicability. Analysis included 10 000 iterations simulating adult patients with incidental detections of UIAs 3 mm or smaller and no history of subarachnoid hemorrhage. Interventions The following 5 management strategies for tiny UIAs were evaluated: annual magnetic resonance angiography (MRA) screening, biennial MRA screening, MRA screening every 5 years, aneurysm coiling and follow-up, and no treatment or preventive follow-up. Main Outcomes and Measures A Markov decision model for lifetime rupture was constructed from a societal perspective per 10 000 patients with incidental, tiny UIAs. Outcomes were assessed in terms of quality-adjusted life-years. Probabilistic, 1-way, and 2-way sensitivity analyses were performed. Results In this analysis of 10 000 iterations simulating adult patients with a mean age of 50 years, the base-case calculation shows that the management strategy of no treatment or preventive follow-up has the highest health benefit (mean [SD] quality-adjusted life-years, 19.40 [0.31]). Among the management strategies that incorporate follow-up imaging, MRA every 5 years is the best strategy with the next highest effectiveness (mean [SD] quality-adjusted life-years, 18.05 [0.62]). The conclusion remains robust in probabilistic and 1-way sensitivity analyses. No routine follow-up remains the optimal strategy when the annual growth rate and risk of rupture of growing aneurysms are varied. When the annual risk of rupture of nongrowing UIAs is less than 1.7% (0.23% in base case scenario), no follow-up is the optimal strategy. If annual risk of rupture is more than 1.7%, coiling should be performed directly. Conclusions and Relevance Given the current literature, no preventive treatment or imaging follow-up is the most effective strategy in patients with aneurysms that are 3 mm or smaller, resulting in better health outcomes. More aggressive imaging surveillance for aneurysm growth or preventive treatment should be reserved for patients with a high risk of rupture. Given these findings, it is important to critically evaluate the appropriateness of current clinical practices, and potentially determine specific guidelines to reflect the most effective management strategy for patients with incidental, tiny UIAs.
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Affiliation(s)
- Ajay Malhotra
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Connecticut
| | - Xiao Wu
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Connecticut
| | - Howard P Forman
- Department of Radiology and Biomedical Imaging, of Economics, of Management, and of Public Health, Yale School of Medicine, New Haven, Connecticut
| | - Charles C Matouk
- Department of Neurosurgery and of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Connecticut
| | - Dheeraj Gandhi
- Interventional Neuroradiology, Radiology, Nuclear Medicine, Neurology and Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Pina Sanelli
- Department of Radiology, Northwell Health, Long Island, New York
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11
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Gupta R, Ogilvy CS, Moore JM, Griessenauer CJ, Enriquez-Marulanda A, Leadon M, Adeeb N, Ascanio L, Maragkos GA, Jain A, Schmalz PGR, Alturki AY, Kicielinski K, Schirmer CM, Thomas AJ. Proposal of a follow-up imaging strategy following Pipeline flow diversion treatment of intracranial aneurysms. J Neurosurg 2019; 131:32-39. [PMID: 30004284 DOI: 10.3171/2018.2.jns172673] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2017] [Accepted: 02/08/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE There is currently no standardized follow-up imaging strategy for intracranial aneurysms treated with the Pipeline embolization device (PED). Here, the authors use follow-up imaging data for aneurysms treated with the PED to propose a standardizable follow-up imaging strategy. METHODS A retrospective review of all patients who underwent treatment for ruptured or unruptured intracranial aneurysms with the PED between March 2013 and March 2017 at 2 major academic institutions in the US was performed. RESULTS A total of 218 patients underwent treatment for 259 aneurysms with the PED and had undergone at least 1 follow-up imaging session to assess aneurysm occlusion status. There were 235 (90.7%) anterior and 24 posterior (9.3%) circulation aneurysms. On Kaplan-Meier analysis, the cumulative incidences of aneurysm occlusion at 6, 12, 18, and 24 months were 38.2%, 77.8%, 84.2%, and 85.1%, respectively. No differences in the cumulative incidence of aneurysm occlusion according to aneurysm location (p = 0.39) or aneurysm size (p = 0.81) were observed. A trend toward a decreased cumulative incidence of aneurysm occlusion in patients 70 years or older was observed (p = 0.088). No instances of aneurysm rupture after PED treatment or aneurysm recurrence after occlusion were noted. Sixteen (6.2%) aneurysms were re-treated with the PED; 11 of these had imaging follow-up data available, demonstrating occlusion in 3 (27.3%). CONCLUSIONS The authors propose a follow-up imaging strategy that incorporates 12-month digital subtraction angiography and 24-month MRA for patients younger than 70 years and single-session digital subtraction angiography at 12 months in patients 70 years or older. For recurrent or persistent aneurysms, re-treatment with the PED or use of an alternative treatment modality may be considered.
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Affiliation(s)
- Raghav Gupta
- 1Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts; and
| | - Christopher S Ogilvy
- 1Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts; and
| | - Justin M Moore
- 1Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts; and
| | - Christoph J Griessenauer
- 1Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts; and.,2Department of Neurosurgery, Geisinger Medical Center, Danville, Pennsylvania
| | - Alejandro Enriquez-Marulanda
- 1Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts; and
| | - Madeline Leadon
- 1Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts; and
| | - Nimer Adeeb
- 1Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts; and
| | - Luis Ascanio
- 1Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts; and
| | - Georgios A Maragkos
- 1Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts; and
| | - Abhi Jain
- 2Department of Neurosurgery, Geisinger Medical Center, Danville, Pennsylvania
| | - Philip G R Schmalz
- 1Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts; and
| | - Abdulrahman Y Alturki
- 1Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts; and
| | - Kimberly Kicielinski
- 1Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts; and
| | - Clemens M Schirmer
- 2Department of Neurosurgery, Geisinger Medical Center, Danville, Pennsylvania
| | - Ajith J Thomas
- 1Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts; and
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12
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Malhotra A, Wu X, Brinjikji W, Miller T, Matouk CC, Sanelli P, Gandhi D. Pipeline Endovascular Device vs Stent-Assisted Coiling in Small Unruptured Aneurysms: A Cost-Effectiveness Analysis. Neurosurgery 2019; 85:E1010-E1019. [DOI: 10.1093/neuros/nyz130] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Accepted: 12/24/2018] [Indexed: 11/13/2022] Open
Abstract
AbstractBACKGROUNDBoth stent-assisted coiling (SAC) and flow diversion with the Pipeline Embolization device (PED; Medtronic Inc) have been shown to be safe and clinically effective for treatment of small (<10 mm) unruptured aneurysms. However, the economic impact of these different techniques has not been established.OBJECTIVETo analyze the cost-effectiveness between stent-assisted coiling and flow diversion using PED, including procedural costs, long-term outcomes, and aneurysm recurrence.METHODSA decision-analytical study was performed with Markov modeling methods to simulate patients undergoing SAC or PED for treatment for unruptured aneurysms of sizes 5 and 7 mm. Input probabilities were derived from prior literature, and 1-way, 2-way, and probabilistic sensitivity analyses (PSA) were performed.RESULTSIn base case calculation and PSA, PED was the dominant strategy for both the size groups, with and without consideration of indirect costs. One-way sensitivity analyses show that the conclusion remained robust when varying the retreatment rate of SAC from 0% to 50%, and only changes when the retreatment rate of PED > 49%. PED remained the more cost-effective strategy when the morbidity and mortality of PED increased by <55% and when those of SAC decreased by <37%. SAC only became cost-effective when the total cost of PED is >$73000 more expensive than the total cost of SAC.CONCLUSIONWith increasing use of PED for treatment of small unruptured anterior circulation aneurysms, our study indicates that PED is cost-effective relative to stent coiling irrespective of aneurysm size. This is due to lower aneurysm recurrence rate, as well as better health outcomes.
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Affiliation(s)
- Ajay Malhotra
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Connecticut
| | - Xiao Wu
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Connecticut
| | - Waleed Brinjikji
- Department of Radiology and Neurosurgery, Mayo Clinic, Rochester, Minnesota
| | - Timothy Miller
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Charles C Matouk
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Connecticut
- Department of Neurosurgery, Yale School of Medicine, New Haven, Connecticut
| | - Pina Sanelli
- Department of Radiology, Northwell Health, Manhasset, New York
| | - Dheeraj Gandhi
- Interventional Neuroradiology, Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, Maryland
- Department of Neurology, University of Maryland School of Medicine, Baltimore, Maryland
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland
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13
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Murray TÉ, Brennan P, Maingard JT, Chandra RV, Little DM, Brooks DM, Kok HK, Asadi H, Lee MJ. Treatment of Visceral Artery Aneurysms Using Novel Neurointerventional Devices and Techniques. J Vasc Interv Radiol 2019; 30:1407-1417. [PMID: 31036460 DOI: 10.1016/j.jvir.2018.12.733] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2018] [Revised: 12/30/2018] [Accepted: 12/30/2018] [Indexed: 10/26/2022] Open
Abstract
The presence of branching vessels, a wide aneurysm neck, and/or fusiform morphology represents a challenge to conventional endovascular treatment of visceral artery aneurysms. A variety of techniques and devices have emerged for the treatment of intracranial aneurysms, in which more aggressive treatment algorithms aimed at smaller and morphologically diverse aneurysms have driven innovation. Here, modified neurointerventional techniques including the use of compliant balloons, scaffold- or stent-assisted coil embolization, and flow diversion are described in the treatment of visceral aneurysms. Neurointerventional devices and their mechanisms of action are described in the context of their application in the peripheral arterial system.
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Affiliation(s)
- Timothy Éanna Murray
- Department of Interventional Radiology, Beaumont Hospital, Beaumont Road, Dublin, Ireland.
| | - Paul Brennan
- Department of Interventional Neuroradiology, Beaumont Hospital, Beaumont Road, Dublin, Ireland
| | - Julian T Maingard
- Department of Interventional Radiology and Interventional Neuroradiology Unit, Austin Health, Melbourne, Australia; School of Medicine, Faculty of Health, Deakin University, Waurn Ponds, Australia
| | - Ronil V Chandra
- Interventional Neuroradiology Unit, Monash Imaging, Monash Health, Melbourne, Australia
| | - Dilly M Little
- Department of Urology and Transplant Surgery, Beaumont Hospital, Beaumont Road, Dublin, Ireland
| | - D Mark Brooks
- Department of Interventional Radiology and Interventional Neuroradiology Unit, Austin Health, Melbourne, Australia; School of Medicine, Faculty of Health, Deakin University, Waurn Ponds, Australia
| | - Hong K Kok
- Interventional Radiology Service, Northern Hospital Radiology, Melbourne, Australia
| | - Hamed Asadi
- Department of Interventional Radiology and Interventional Neuroradiology Unit, Austin Health, Melbourne, Australia; School of Medicine, Faculty of Health, Deakin University, Waurn Ponds, Australia; Interventional Neuroradiology Unit, Monash Imaging, Monash Health, Melbourne, Australia
| | - Michael J Lee
- Department of Interventional Radiology, Beaumont Hospital, Beaumont Road, Dublin, Ireland; Royal College of Surgeons in Ireland, Dublin, Ireland
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14
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Howe C, Mishra S, Kim YS, Chen Y, Ye SH, Wagner WR, Jeong JW, Byun HS, Kim JH, Chun Y, Yeo WH. Stretchable, Implantable, Nanostructured Flow-Diverter System for Quantification of Intra-aneurysmal Hemodynamics. ACS NANO 2018; 12:8706-8716. [PMID: 30021063 DOI: 10.1021/acsnano.8b04689] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Random weakening of an intracranial blood vessel results in abnormal blood flow into an aneurysmal sac. Recent advancements show that an implantable flow diverter, integrated with a medical stent, enables a highly effective treatment of cerebral aneurysms by guiding blood flow into the normal vessel path. None of such treatment systems, however, offers post-treatment monitoring to assess the progress of sac occlusion. Therefore, physicians rely heavily on either angiography or magnetic resonance imaging. Both methods require a dedicated facility with sophisticated equipment settings and time-consuming, cumbersome procedures. In this paper, we introduce an implantable, stretchable, nanostructured flow-sensor system for quantification of intra-aneurysmal hemodynamics. The open-mesh membrane device is capable of effective implantation in complex neurovascular vessels with extreme stretchability (500% radial stretching) and bendability (180° with 0.75 mm radius of curvature) for monitoring of the treatment progress. A collection of quantitative mechanics, fluid dynamics, and experimental studies establish the fundamental aspects of design criteria for a highly compliant, implantable device. Hemocompatibility study using fresh ovine blood captures the device feasibility for long-term insertion in a blood vessel, showing less platelet deposition compared to that in existing implantable materials. In vitro demonstrations of three types of flow sensors show quantification of intra-aneurysmal blood flow in a pig aorta and the capability of observation of aneurysm treatment with a great sensitivity (detection limit as small as 0.032 m/s). Overall, this work describes a mechanically soft flow-diverter system that offers an effective treatment of aneurysms with an active monitoring of intra-aneurysmal hemodynamics.
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Affiliation(s)
- Connor Howe
- Department of Mechanical and Nuclear Engineering, Institute for Engineering and Medicine, Center for Rehabilitation Science and Engineering , Virginia Commonwealth University , Richmond , Virginia 23284 , United States
| | - Saswat Mishra
- George W. Woodruff School of Mechanical Engineering, College of Engineering , Georgia Institute of Technology , Atlanta , Georgia 30332 , United States
| | - Yun-Soung Kim
- George W. Woodruff School of Mechanical Engineering, College of Engineering , Georgia Institute of Technology , Atlanta , Georgia 30332 , United States
| | - Yanfei Chen
- Department of Industrial Engineering , University of Pittsburgh , Pittsburgh , Pennsylvania 15261 , United States
| | - Sang-Ho Ye
- Department of Bioengineering , University of Pittsburgh , Pittsburgh , Pennsylvania 15261 , United States
| | - William R Wagner
- Department of Bioengineering , University of Pittsburgh , Pittsburgh , Pennsylvania 15261 , United States
| | - Jae-Woong Jeong
- School of Electrical Engineering , Korea Advanced Institute of Science and Technology , Daejeon , Republic of Korea 34141
| | - Hun-Soo Byun
- Department of Chemical and Biomolecular Engineering , Chonnam National University , Yeosu , Jeonnam 59626 , South Korea
| | - Jong-Hoon Kim
- School of Engineering and Computer Science , Washington State University , Vancouver , Washington 98686 , United States
| | - Youngjae Chun
- Department of Industrial Engineering , University of Pittsburgh , Pittsburgh , Pennsylvania 15261 , United States
- Department of Bioengineering , University of Pittsburgh , Pittsburgh , Pennsylvania 15261 , United States
| | - Woon-Hong Yeo
- Department of Mechanical and Nuclear Engineering, Institute for Engineering and Medicine, Center for Rehabilitation Science and Engineering , Virginia Commonwealth University , Richmond , Virginia 23284 , United States
- George W. Woodruff School of Mechanical Engineering, College of Engineering , Georgia Institute of Technology , Atlanta , Georgia 30332 , United States
- Institute for Electronics and Nanotechnology, Bioengineering Interdisciplinary Program, Petit Institute for Bioengineering & Bioscience, and Center for Flexible Electronics , Georgia Institute of Technology , Atlanta , Georgia 30332 , United States
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15
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Adeeb N, Gupta R, Schneider AM, Leadon M, Enriquez A, Griessenauer CJ, Salem M, Alturki A, Schmalz P, Ogilvy CS, Thomas AJ, Moore JM. Defining a Clopidogrel Response Cut-Off Value Using Light Transmission Aggregometry Before Pipeline Embolization of Unruptured Intracranial Aneurysms. World Neurosurg 2018; 113:e146-e152. [DOI: 10.1016/j.wneu.2018.01.198] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Accepted: 01/29/2018] [Indexed: 10/18/2022]
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16
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Malhotra A, Wu X, Geng B, Hersey D, Gandhi D, Sanelli P. Management of Small Unruptured Intracranial Aneurysms: A Survey of Neuroradiologists. AJNR Am J Neuroradiol 2018; 39:875-880. [PMID: 29650787 DOI: 10.3174/ajnr.a5631] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Accepted: 01/03/2018] [Indexed: 12/21/2022]
Abstract
BACKGROUND AND PURPOSE The long-term history and management of unruptured intracranial aneurysms is not well understood. Our aim was to determine current practice patterns in the management of unruptured intracranial aneurysms, especially regarding imaging surveillance for conservatively managed aneurysms of this type. MATERIALS AND METHODS An on-line survey was designed to examine physician practice and preference regarding the management of small unruptured intracranial aneurysms (≤7 mm in diameter). The survey was circulated to members of the American Society of Neuroradiology. Participation was voluntary, and all responses were anonymous. RESULTS A total of 227 individual survey responses were obtained and included in the analysis with 54.6% (124/227) from diagnostic neuroradiologists (practicing >50% neuroradiology) and one-third (29%) from neurointerventional radiologists. One hundred seventy-three of 227 responded that routine, periodic imaging surveillance would be appropriate for conservatively managed unruptured intracranial aneurysms, and 84% of respondents recommended surveillance frequency of at least once a year. Fifty-nine percent favored indefinite, life-long follow-up for small unruptured intracranial aneurysms, and a similar number of respondents favored noncontrast MR angiography for aneurysm follow-up. Significant heterogeneity was found in size measurements used to assess aneurysms and criteria used to define growth on surveillance imaging. CONCLUSIONS The natural history of intracranial aneurysms is not well-understood. A large proportion of incidentally detected, unruptured aneurysms are small (<7 mm). The survey results show significant heterogeneity in practice even among neuroradiologists and underlies the need to standardize imaging practice. Further studies are needed to assess the optimal frequency and duration of surveillance imaging for unruptured intracranial aneurysms. The criteria used to measure aneurysms and define growth on imaging also need to be standardized.
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Affiliation(s)
- A Malhotra
- From the Department of Radiology and Biomedical Imaging (A.M.), Yale School of Medicine, New Haven, Connecticut
| | - X Wu
- Yale School of Medicine (X.W., B.G.), New Haven, Connecticut
| | - B Geng
- Yale School of Medicine (X.W., B.G.), New Haven, Connecticut
| | - D Hersey
- Clinical Information Services (D.H.), Cushing/Whitney Medical Library, Yale University, New Haven, Connecticut
| | - D Gandhi
- Department of Interventional Neuroradiology (D.G.), University of Maryland School of Medicine, Baltimore, Maryland
| | - P Sanelli
- Department of Radiology (P.S.), Northwell Health, New York, New York
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Fargen KM, Soriano-Baron HE, Rushing JT, Mack W, Mocco J, Albuquerque F, Ducruet AF, Mokin M, Linfante I, Wolfe SQ, Wilson JA, Hirsch JA. A survey of intracranial aneurysm treatment practices among United States physicians. J Neurointerv Surg 2017; 10:44-49. [DOI: 10.1136/neurintsurg-2016-012808] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2016] [Revised: 11/22/2016] [Accepted: 01/12/2017] [Indexed: 11/04/2022]
Abstract
BackgroundRecent surveys have failed to examine cerebrovascular aneurysm treatment practices among US physicians.ObjectiveTo survey physicians who are actively involved in the care of patients with cerebrovascular aneurysms to determine current aneurysm treatment preferences.MethodsA 25-question SurveyMonkey online survey was designed and distributed electronically to members of the Society of NeuroInterventional Surgery, Society of Vascular and Interventional Neurology, and the American Association of Neurological Surgeons/Congress of Neurological Surgeons Combined Cerebrovascular Section.Results211 physicians completed the survey. Most respondents recommend endovascular treatment as the first-line management strategy for most ruptured (78%) and unruptured (71%) aneurysms. Thirty-eight per cent of respondents indicate that they routinely treat all patients with subarachnoid hemorrhage regardless of grade. Most physicians use the International Study of Unruptured Intracranial Aneurysms data for counseling patients on natural history risk (80%); a small minority (11%) always or usually recommend treatment of anterior circulation aneurysms of <5 mm. Two-thirds of respondents continue to recommend clipping for most middle cerebral artery aneurysms, while most (51%) recommend flow diversion for wide-necked internal carotid artery aneurysms. Follow-up imaging schedules are highly variable. Neurosurgeons at academic institutions and those practicing longer were more likely to recommend clipping surgery for aneurysms (p<0.05).ConclusionsThis survey demonstrates considerable variability in patient selection for intracranial aneurysm treatment, preferred treatment strategies, and follow-up imaging schedules among US physicians.
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