Trends in Hospital-to-Hospital Transfers for Aneurysmal Subarachnoid Hemorrhage: A Single-Institution Experience from 2006 to 2017

Focused selection of open cerebrovascular cases for residents interested in cerebrovascular neurosurgery

INTRODUCTION

National and international trends continue to show greater emphasis on endovascular techniques for the treatment of cerebrovascular disease. The cerebrovascular neurosurgeon however must be adequately equipped to treat these patients via both open and endovascular techniques.

METHODS

The decline in open cerebrovascular cases for aneurysm clipping has forced many trainees to pursue open cerebrovascular fellowships to increase case volume. An alternative strategy has been employed at our institution, which is early identification of subspecialty focus with resident driven self-selection of open cerebrovascular cases.

RESULTS

This has allowed recent graduates to obtain enfolded endovascular training and a significant number of open cerebrovascular cases in order to obtain competence and exposure.

DISCUSSION

We advocate for further self-selection paradigms supplemented with simulation training in order to obviate the need for extended post-residency fellowships.

Changes in Short-Term Outcomes After Discharge in Patients with Aneurysmal Subarachnoid Hemorrhage: A Multicenter, Prospective, Observational Study

OBJECTIVE

The objective of the study was to clarify the prevalence of and factors associated with changes in patients' outcomes between discharge and 3 months after the onset of aneurysmal subarachnoid hemorrhage (aSAH). Additionally, the World Federation of Neurosurgical Societies (WFNS) and modified WFNS (mWFNS) scales were compared.

METHODS

The data of curatively treated patients with aSAH, collected prospectively in the mWFNS scale study between January 2010 and December 2012, were analyzed retrospectively. The improvement or decline in the modified Rankin Scale (mRS) scores between discharge and 3 months after onset was determined. A multivariable logistic regression analysis was performed to identify factors, such as age and WFNS and mWFNS grades, associated with changes in the outcome.

RESULTS

The mRS scores improved in 28.3% and declined in 2.5% of the patients. WFNS and mWFNS grades Ⅱ-V on admission were significantly associated with improved mRS scores at 3 months after onset. Older age (age: 65-74 years vs. age <65 years, odds ratio: 6.59, 95% confidence interval: 1.28-34.01; age ≥75 years vs. age <65 years, odds ratio: 17.67, 95% confidence interval: 2.11-148.26) and WFNS grade III were significantly associated with a decline in mRS scores at 3 months after onset.

CONCLUSIONS

The optimal timing for postdischarge assessment of outcomes may be at 3 months after onset, especially in older patients with aSAH. The mWFNS scale is presumed to more accurately assess the outcomes of patients with aSAH than the WFNS scale, as demonstrated in this study.

The times they are a-changin': increasing complexity of aneurysmal subarachnoid hemorrhages in patients treated from 2004 to 2018

BACKGROUND

Nationwide study results have suggested varying trends in the incidence of aneurysmal subarachnoid hemorrhage (aSAH) over time. Herein, trends over time for aSAH treated at a quaternary care center are compared to low-volume hospitals.

METHODS

Cases were retrospectively reviewed for patients with aSAH treated at our institution. Trend analyses were performed on the number of aSAH hospitalizations, treatment type, Charlson Comorbidity Index (CCI), Hunt and Hess (HH) grade, aneurysm location, aneurysm type, and in-hospital mortality. The National Inpatient Sample (NIS) was queried to compare the CCI scores of our patients with those of patients in low-volume hospitals (<20 aSAH/year) in our census division.

RESULTS

Some 1248 patients (321 during 2004-2006; 927 during 2008-2018) hospitalized with aSAH were treated with endovascular therapy (489, 39%) or microsurgery (759, 61%). A significant downtrend in the annual aSAH caseload occurred (123 patients in 2004, 75 in 2018, p<0.001). A linear uptrend was observed for the mean CCI score of patients (R²=0.539, p<0.001), with no change to in-hospital mortality (R²=0.220, p=0.24). Mean (SD) CCI for small-volume hospitals treating aSAH within our division was significantly lower than that of our patient population (1.8 [1.6] vs 2.1 [2.0]) for 2012-2015.

CONCLUSIONS

A decreasing number of patients were hospitalized with aSAH throughout the study. Compared with patients with aSAH admitted in 2004, those admitted more recently were sicker in terms of preexisting comorbidity and neurologic complexity. These trends could be attributable to the increasing availability of neurointerventional services at smaller-volume hospitals capable of treating healthier patients.