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Charalambous LT, Adil SM, Rajkumar S, Gramer R, Kirsch E, Liu B, Zomorodi A, McClellan M, Lad SP. A Nationwide Analysis of Aneurysmal Subarachnoid Hemorrhage Mortality, Complications, and Health Economics in the USA. Transl Stroke Res 2023; 14:347-356. [PMID: 35881231 PMCID: PMC10149048 DOI: 10.1007/s12975-022-01065-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 06/21/2022] [Accepted: 07/13/2022] [Indexed: 11/25/2022]
Abstract
Aneurysmal subarachnoid hemorrhage (aSAH) is a devastating neurological condition. Endovascular coiling or surgical clipping have equivocal success rates, but relatively little is known regarding the health economics and complications of these procedures at the population level. We aimed to analyze the complication profiles and healthcare resource utilization (HRCU) associated with the treatment of aSAH in the USA. We performed a retrospective analysis utilizing the IBM MarketScan database between 2008 and 2015. Primary outcomes included economic analysis stratified by post-operative complication; determination of the effect of several factors on total cost by multivariable regression; and analysis of the incidence, timing, and associated HCRU of aSAH-related post-operative complications. Of the 2374 patients meeting inclusion criteria for economic analysis, 1783 (75.1%) patients had at least one of the ten complications. The most common complications included hydrocephalus (43.8%), transient cerebral ischemia (including vasospasm) (30.6%), ischemic stroke (29.1%), syndrome of inappropriate antidiuretic hormone (SIADH)/hyposmolarity/hyponatremia (22.1%), and seizures (14.9%). Patients who experienced complications had higher median 90-day total costs [$161,127 (Q1 to Q3, $101,411 to $257,662)] than those who did not [$97,376 (Q1 to Q3, $55,692 to $147,447)]. Length of stay was longest for those with pulmonary embolism and pneumonia (27 days) and shortest for those with SIADH/hyposmolarity/hyponatremia (16 days). Brain compression/herniation had the highest mortality rate (19.5%). In total, 14.6% of all patients experienced a readmission within 30 days. In conclusion, patients with aSAH have high post-operative complication rates and costs. Development of novel interventions to reduce complications and improve outcomes is crucial.
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Affiliation(s)
- Lefko T Charalambous
- Department of Neurosurgery, Duke University Medical Center, Duke University, Box 3807, Durham, NC, 27710, USA.
| | - Syed M Adil
- Department of Neurosurgery, Duke University Medical Center, Duke University, Box 3807, Durham, NC, 27710, USA
| | - Shashank Rajkumar
- Department of Neurosurgery, Duke University Medical Center, Duke University, Box 3807, Durham, NC, 27710, USA
| | - Robert Gramer
- Department of Neurosurgery, Duke University Medical Center, Duke University, Box 3807, Durham, NC, 27710, USA
| | - Elayna Kirsch
- Department of Neurosurgery, Duke University Medical Center, Duke University, Box 3807, Durham, NC, 27710, USA
| | - Beiyu Liu
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, NC, USA
| | - Ali Zomorodi
- Department of Neurosurgery, Duke University Medical Center, Duke University, Box 3807, Durham, NC, 27710, USA
| | - Mark McClellan
- Duke-Robert J. Margolis Center for Health Policy, Duke University, Box 3807, Durham, NC, 27710, USA
| | - Shivanand P Lad
- Department of Neurosurgery, Duke University Medical Center, Duke University, Box 3807, Durham, NC, 27710, USA.
- Duke-Robert J. Margolis Center for Health Policy, Duke University, Box 3807, Durham, NC, 27710, USA.
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Lo YL, Bih ZL, Yu YH, Li MC, Chen HM, Wu SY. Long-Term Medical Resource Consumption between Surgical Clipping and Endovascular Coiling for Aneurysmal Subarachnoid Hemorrhage: A Propensity Score-Matched, Nationwide, Population-Based Cohort Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18115989. [PMID: 34199671 PMCID: PMC8199713 DOI: 10.3390/ijerph18115989] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 05/28/2021] [Accepted: 06/02/2021] [Indexed: 12/21/2022]
Abstract
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.
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Affiliation(s)
- Yang-Lan Lo
- Department of Neurosurgery, Lo-Hsu Medical Foundation, Lotung Poh-Ai Hospital, Yilan 256, Taiwan;
| | - Zen Lang Bih
- Department of Emergency Medicine, Lo-Hsu Medical Foundation, Lotung Poh-Ai Hospital, Yilan 256, Taiwan;
| | - Ying-Hui Yu
- Department of Colorectal Surgery, Lo-Hsu Medical Foundation, Lotung Poh-Ai Hospital, Yilan 256, Taiwan; (Y.-H.Y.); (M.-C.L.)
| | - Ming-Chang Li
- Department of Colorectal Surgery, Lo-Hsu Medical Foundation, Lotung Poh-Ai Hospital, Yilan 256, Taiwan; (Y.-H.Y.); (M.-C.L.)
| | - Ho-Min Chen
- Department of Food Nutrition and Health Biotechnology, College of Medical and Health Science, Asia University, Taichung 413, Taiwan;
- Big Data Center, Lo-Hsu Medical Foundation, Lotung Poh-Ai Hospital, Yilan 256, Taiwan
| | - Szu-Yuan Wu
- Department of Food Nutrition and Health Biotechnology, College of Medical and Health Science, Asia University, Taichung 413, Taiwan;
- Big Data Center, Lo-Hsu Medical Foundation, Lotung Poh-Ai Hospital, Yilan 256, Taiwan
- Division of Radiation Oncology, Lo-Hsu Medical Foundation, Lotung Poh-Ai Hospital, Yilan 256, Taiwan
- Department of Healthcare Administration, College of Medical and Health Science, Asia University, Taichung 413, Taiwan
- Graduate Institute of Business Administration, Fu Jen Catholic University, Taipei 242062, Taiwan
- Centers for Regional Anesthesia and Pain Medicine, Wan Fang Hospital, Taipei Medical University, Taipei 110, Taiwan
- Correspondence: or
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Lu VM, Chen SH, Young CC, Starke RM. Nature, content and shifts over time of the most impactful unruptured intracranial aneurysms articles: a bibliometric analysis. J Neurointerv Surg 2021; 13:177-181. [PMID: 32606102 PMCID: PMC8372190 DOI: 10.1136/neurintsurg-2020-016238] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 06/01/2020] [Accepted: 06/02/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND The management of unruptured intracranial aneurysms (UIAs) has evolved significantly over the last few decades. Our objective was to evaluate the 100 most cited UIA articles by bibliometric analysis to identify nature, content and shifts over time. METHODS Elsevier's Scopus database was interrogated for the 100 most cited articles that focused on UIA. Older versus newer articles were compared, with categorical data analyzed using Pearson's Chi-square, and continuous data analyzed using Wilcoxon's rank-sum test. RESULTS The 100 most cited articles were published between 1975 and 2015, with the majority of these reporting patient clinical outcomes (n=69). There were 47/69 (68%) articles that described surgical intervention, with 38/47 (81%) and 18/47 (38%) including endovascular and open approaches, respectively . Publications peaked in 2004 (n=8), and the most common country of correspondence was the United States (n=59). Compared to older articles, newer articles had statistically higher citation rates (P<0.01), higher number of authors (P<0.01) with more multiple institution collaborations (P=0.01), greater disclosures of funding (P<0.01), more focus on endovascular treatments (P=0.04), in more journals with a clinical, non-surgical focus (P<0.01) published under open access policies (P<0.01). CONCLUSIONS In the 100 most cited articles about UIAs to date, there is a distinct shift towards more co-authored efforts utilizing multi-institutional efforts focused on endovascular approaches supported by funding. The emergence of endovascular techniques has refreshed the need for more contemporary rupture risk prediction models and natural history data to validate current attitudes towards clinical management after these minimally invasive procedures for UIAs.
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Affiliation(s)
- Victor M Lu
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
- Department of Neurological Surgery, University of Miami, Miami, Florida, USA
| | - Stephanie H Chen
- Department of Neurological Surgery, University of Miami, Miami, Florida, USA
| | - Christopher C Young
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Robert M Starke
- Department of Neurological Surgery, University of Miami, Miami, Florida, USA
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Koo AB, Elsamadicy AA, Lin IH, David WB, Sujijantarat N, Santarosa C, Cord BJ, Zetchi A, Hebert R, Bahrassa F, Malhotra A, Matouk CC. Predictors of Extended Length of Stay Following Treatment of Unruptured Adult Cerebral Aneurysms: A Study of The National Inpatient Sample. J Stroke Cerebrovasc Dis 2020; 29:105230. [PMID: 33066916 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105230] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 07/26/2020] [Accepted: 07/30/2020] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND In an unprecedented era of soaring healthcare costs, payers and providers alike have started to place increased importance on measuring the quality of surgical procedures as a surrogate for operative success. One metric used is the length of hospital stay (LOS) during index admission. For the treatment of unruptured cerebral aneurysms, the determinants of extended length of stay are relatively unknown. The aim of this study was to identify the patient- and hospital-level factors associated with extended LOS following treatment for unruptured cerebral aneurysms. METHODS The National Inpatient Sample years 2010 - 2014 was queried. Adults (≥18 years) with unruptured aneurysms undergoing either clipping or coiling were selected using the International Classification of Diseases, Ninth Revision, Clinical Modification coding system. Extended LOS was defined as greater than 75th percentile for the entire cohort (>5 days). Weighted patient demographics, comorbidities, complications, LOS, disposition and total cost were recorded. Multivariate logistic regression was used to determine the odds ratio for risk-adjusted extended LOS. The primary outcome was the degree which patient comorbidities or postoperative complications correlated with extended LOS. RESULTS A total of 46,880 patients were identified for which 9,774 (20.8%) patients had extended LOS (Normal LOS: 37,106; Extended LOS: 9,774). Patients in the extended LOS cohort presented with a greater number of comorbidities compared to the normal LOS cohort. A greater proportion of the normal LOS cohort was coiled (Normal LOS: 63.0% vs. Extended LOS: 33.5%, P<0.001), while more patients in the extended LOS cohort were clipped (Normal LOS: 37.0% vs. Extended LOS: 66.5%, P<0.001). The overall complication rate was higher in the extended LOS cohort (Normal LOS: 7.3% vs. Extended LOS: 43.8%, P<0.001). On average, the extended LOS cohort incurred a total cost nearly twice as large (Normal LOS: $26,050 ± 13,430 vs. Extended LOS: $52,195 ± 37,252, P<0.001) and had more patients encounter non-routine discharges (Normal LOS: 8.5% vs. Extended LOS: 52.5%, P<0.001) compared to the normal LOS cohort. On weighted multivariate logistic regression, multiple patient-specific factors were associated with extended LOS. These included demographics, preadmission comorbidities, choice of procedure, and inpatient complications. The odds ratio for extended LOS was 5.14 (95% CI, 4.30 - 6.14) for patients with 1 complication and 19.58 (95% CI, 15.75 - 24.34) for patients with > 1 complication. CONCLUSIONS Our study demonstrates that extended LOS after treatment of unruptured aneurysms is influenced by a number of patient-level factors including demographics, preadmission comorbidities, type of aneurysm treatment (open surgical versus endovascular), and, importantly, inpatient complications. A better understanding of these independent predictors of prolonged length of hospital stay may help to improve patient outcomes and decrease overall healthcare costs.
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Affiliation(s)
- Andrew B Koo
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT
| | | | - I-Hsin Lin
- Yale Center for Analytical Sciences, New Haven, CT
| | - Wyatt B David
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT
| | | | - Corrado Santarosa
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT
| | - Branden J Cord
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT
| | - Akli Zetchi
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT
| | - Ryan Hebert
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT
| | - Farhad Bahrassa
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT
| | - Ajay Malhotra
- Department of Radiology & Biomedical Imaging, Yale University School of Medicine, New Haven, CT
| | - Charles C Matouk
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT; Department of Radiology & Biomedical Imaging, Yale University School of Medicine, New Haven, CT.
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Sun J, Wang Z, Su P, Liu J, Li J, Ma G, Cen J, Chang Q, Liu X, Zhao N. [Long-term clinical outcomes of patients with aneurysmal subarachnoid hemorrhage in Yunnan Province]. NAN FANG YI KE DA XUE XUE BAO = JOURNAL OF SOUTHERN MEDICAL UNIVERSITY 2020; 40:1353-1358. [PMID: 32990220 DOI: 10.12122/j.issn.1673-4254.2020.09.20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To investigate the clinical outcomes of patients with aneurysmal subarachnoid hemorrhage (aSAH) after surgeries in Yunnan Province. METHODS We retrospectively analyzed the demographic features, vascular risk factors, severity at admission, and aneurysm locations in 85 patients with aSAH receiving surgical interventions in Yunnan Province. All the patients were treated by aneurysm clipping or coiling and followed up for clinical outcomes and recovery of daily activities evaluated by modified Rankin Scale (mRS) and Activities of Daily Living (ADL) scale, respectively. RESULTS Thirty-four of the patients (40.0%) underwent aneurysm clipping and 51 (60.0%) underwent aneurysm coiling. During a median follow- up period of 66.23 months (IOR, 12.03 months), 84.7% of the patients had low mRS scores, and 78.8% lived independently. The WFNS grade at admission was significantly correlated with the follow-up mRS scores (95%CI: 1.48-19.09, P=0.011) and ADL (95%CI: 2.55-28.77, P < 0.001). Multivariate analysis showed that age (95%CI: 1.02-1.23, P=0.017; 95%CI: 1.00-1.15, P=0.038) and a high WFNS grade at admission (95%CI: 2.19-141.48, P=0.007; 95%CI: 2.84-82.61, P=0.002) were independent predictors of both mRS and ADL scores at follow-up. There was no significant difference in clinical outcomes or the length of hospital stay between the two treatment strategies (P > 0.05), but the cost of hospitalization was significantly higher in coiling group than in the clipping group (P < 0.001). CONCLUSIONS Both aging and a high WFNS grade at admission are associated with a poor prognosis of aSAH, for which aneurysm clipping and coiling have similar long- term outcomes, but for patients with a high WFNS score, aneurysm clipping is favored over coiling in terms of health economics.
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Affiliation(s)
- Jie Sun
- Department of Neurosurgery, Kunming First People's Hospital, Kunming 650000, China
| | - Zeyi Wang
- Department of Neurosurgery, Kunming First People's Hospital, Kunming 650000, China
| | - Ping Su
- Department of Neurosurgery, Kunming First People's Hospital, Kunming 650000, China
| | - Jun Liu
- Department of Neurosurgery, Kunming First People's Hospital, Kunming 650000, China
| | - Junyan Li
- Department of Neurosurgery, Kunming First People's Hospital, Kunming 650000, China
| | - Gang Ma
- Department of Neurosurgery, Kunming First People's Hospital, Kunming 650000, China
| | - Jianchang Cen
- Department of Neurosurgery, Kunming First People's Hospital, Kunming 650000, China
| | - Qian Chang
- Department of Neurosurgery, Kunming First People's Hospital, Kunming 650000, China
| | - Xinghai Liu
- Department of Neurosurgery, Kunming First People's Hospital, Kunming 650000, China
| | - Nan Zhao
- Department of Neurosurgery, Kunming First People's Hospital, Kunming 650000, China
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Zopfs D, Lennartz S, Pennig L, Glauner A, Abdullayev N, Bremm J, Große Hokamp N, Persigehl T, Kabbasch C, Borggrefe J, Laukamp KR. Virtual monoenergetic images and post-processing algorithms effectively reduce CT artifacts from intracranial aneurysm treatment. Sci Rep 2020; 10:6629. [PMID: 32313094 PMCID: PMC7170914 DOI: 10.1038/s41598-020-63574-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Accepted: 04/01/2020] [Indexed: 11/09/2022] Open
Abstract
To evaluate artifact reduction by virtual monoenergetic images (VMI) and metal artifact reduction algorithms (MAR) as well as the combination of both approaches (VMIMAR) compared to conventional CT images (CI) as standard of reference. In this retrospective study, 35 patients were included who underwent spectral-detector CT (SDCT) with additional MAR-reconstructions due to artifacts from coils or clips. CI, VMI, MAR and VMIMAR (range: 100-200 keV, 10 keV-increment) were reconstructed. Region-of-interest based objective analysis was performed by assessing mean and standard deviation of attenuation (HU) in hypo- and hyperdense artifacts from coils and clips. Visually, extent of artifact reduction and diagnostic assessment were rated. Compared to CI, VMI ≥ 100 keV, MAR and VMIMAR between 100-200 keV increased attenuation in hypoattenuating artifacts (CI/VMI200keV/MAR/VMIMAR200keV, HU: -77.6 ± 81.1/-65.1 ± 103.2/-36.9 ± 27.7/-21.1 ± 26.7) and decreased attenuation in hyperattenuating artifacts (HU: 47.4 ± 32.3/42.1 ± 50.2/29.5 ± 18.9/20.8 ± 25.8). However, differences were only significant for MAR in hypodense and VMIMAR in hypo- and hyperdense artifacts (p < 0.05). Visually, hypo- and hyperdense artifacts were significantly reduced compared to CI by VMI≥140/100keV, MAR and VMIMAR≥100keV. Diagnostic assessment of surrounding brain tissue was significantly improved in VMI≥100keV, MAR and VMIMAR≥100keV. The combination of VMI and MAR facilitates a significant reduction of artifacts adjacent to intracranial coils and clips. Hence, if available, these techniques should be combined for optimal reduction of artifacts following intracranial aneurysm treatment.
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Affiliation(s)
- David Zopfs
- Institute for Diagnostic and Interventional Radiology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Simon Lennartz
- Institute for Diagnostic and Interventional Radiology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany.,Else Kröner Forschungskolleg Clonal Evolution in Cancer, University Hospital Cologne, Weyertal 115b, 50931, Cologne, Germany
| | - Lenhard Pennig
- Institute for Diagnostic and Interventional Radiology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Andreas Glauner
- Institute for Diagnostic and Interventional Radiology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Nuran Abdullayev
- Institute for Diagnostic and Interventional Radiology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Johannes Bremm
- Institute for Diagnostic and Interventional Radiology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Nils Große Hokamp
- Institute for Diagnostic and Interventional Radiology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Thorsten Persigehl
- Institute for Diagnostic and Interventional Radiology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Christoph Kabbasch
- Institute for Diagnostic and Interventional Radiology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Jan Borggrefe
- Institute for Diagnostic and Interventional Radiology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Kai Roman Laukamp
- Institute for Diagnostic and Interventional Radiology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany. .,University Hospitals Cleveland Medical Center, Department of Radiology, Cleveland, OH, USA. .,Case Western Reserve University, Department of Radiology, Cleveland, OH, USA.
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Surgical Versus Endovascular Management of Ruptured and Unruptured Intracranial Aneurysms: Emergent Issues and Future Directions. World Neurosurg 2019; 136:17-27. [PMID: 31899398 DOI: 10.1016/j.wneu.2019.12.127] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Revised: 12/20/2019] [Accepted: 12/21/2019] [Indexed: 12/25/2022]
Abstract
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.
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