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Chen C, Qiao H, Cui Z, Wang C, Zhang C, Feng Y. Clipping and coiling of intracranial aneurysms in the elderly patients: clinical features and treatment outcomes. Front Neurol 2023; 14:1282683. [PMID: 38020622 PMCID: PMC10667704 DOI: 10.3389/fneur.2023.1282683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Accepted: 10/16/2023] [Indexed: 12/01/2023] Open
Abstract
Objective In recent years, more and more cases of intracranial aneurysms (IAs) have been found in elderly patients, and neurosurgical interventions have increased, but there is still no consensus on the best treatment strategy for elderly patients. In elderly patients, endovascular coiling (EC) is more popular than surgical clipping (SC) due to its advantages of less trauma and faster recovery. However, SC has made great progress in recent years, significantly improving the prognosis of elderly patients. Therefore, it is necessary to further explore the effects of different treatment modalities on clinical prognosis, hospital stay, and hospital cost of elderly IA patients, and select the most appropriate treatment modalities. Methods The authors retrospectively analyzed 767 patients with intracranial aneurysms admitted to the facility between August 2017 and December 2022. Prognostic risk factors and multivariate logistic regression were analyzed for elderly patients treated with EC or SC. The area under the receiver operating characteristic (ROC) curve was used to calculate the predictive power of each independent predictor between the treatment groups. Results Our study included 767 patients with aneurysms, of whom 348 (45.4%) were elderly, 176 (22.9%) underwent endovascular coiling, and 172 (22.4%) underwent microsurgical clipping. A comparison of elderly patients treated with EC and SC showed a higher prevalence of hypertension in the EC group (P = 0.011) and a higher Hunt-Hess score on admission in the SC group (P = 0.010). Patients in the EC group had shorter hospital stays but higher costs (P = 0.000 and P = 0.000, respectively). Patients treated with SC had a higher incidence of postoperative cerebral infarction and poor prognosis (P = 0.002 and P = 0.008, respectively). Through multi-factor logistic analysis, it was found that age (OR 1.209, 95% CI 1.047-1.397, P = 0.010), length of stay (LOS) (OR 1.160, 95 CI% 1.041-1.289, P = 0.007), and complications (OR 31.873, 95 CI% 11.677-320.701, P = 0.000) was an independent risk factor for poor prognosis in elderly patients with EC. In elderly patients treated with SC, age (OR 1.105, 95% CI 1.010-1.209, P = 0.029) was an independent risk factor for poor prognosis. Conclusion EC and SC interventions in elderly adults carry higher risks compared to non-older adults, and people should consider these risks and costs when making a decision between intervention and conservative treatment. In elderly patients who received EC or SC treatments, EC showed an advantage in improving outcomes in elderly patients although it increased the economic cost of the patient's hospitalization.
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Affiliation(s)
| | | | | | | | | | - Yugong Feng
- Department of Neurosurgery, The Affiliated Hospital of Qingdao University, Qingdao, China
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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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Nia AM, Lall RR, Kan P, Srinivasan VM. Trends and Outcomes of Endovascular Embolization and Surgical Clipping for Ruptured Intracranial Aneurysms: A Propensity-Matched Study of 1332 Patients in the United States. World Neurosurg 2022; 161:e674-e681. [PMID: 35218963 PMCID: PMC9081193 DOI: 10.1016/j.wneu.2022.02.077] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 02/16/2022] [Accepted: 02/17/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To describe recent trends in treatment and outcomes of endovascular coil embolization and microsurgical clipping treatment strategies for ruptured intracranial aneurysms. METHODS Using International Classification of Diseases, Tenth Revision, codes, 1332 propensity-matched patients >18 years old who underwent coiling or clipping were identified. Patient demographics, baseline characteristics, comorbidities, and clinical outcomes were evaluated within 1 year postoperatively. Pooled and individual studies of the International Classification of Diseases codes investigated differences in clinical outcomes owing to aneurysm location. Outcomes were mortality, intensive care, surgical complications, hydrocephalus, and vasospasm. RESULTS After propensity matching for baseline characteristics and comorbidities, 666 patients were included in the coiling and clipping cohorts. There was no significant difference in 1-year mortality between cohorts. However, incidence of intensive care, surgical/medical complications, and vasospasm was significantly lower in the pooled coiling cohort (P = 0.02, P = 0.03, and P = 0.014) compared with the clipping cohort within 1 year postoperatively. Additionally, individual International Classification of Diseases code analysis revealed that coiling of anterior communicating artery aneurysms was associated with significantly fewer surgical/medical complications and hydrocephalus (P = 0.0008 and P = 0.015) and coiling of posterior communicating artery aneurysms was associated with substantially less vasospasm treatment (P = 0.034) compared with the respective clipping cohorts. CONCLUSIONS Analysis revealed no difference in 1-year mortality between coiling and clipping. Clinical outcomes, including intensive care, surgical complications, and vasospasm, favored coiling regardless of aneurysm location. Patients with coiling of anterior communicating artery aneurysms had significantly less hydrocephalus and patients with coiling of posterior communicating artery aneurysms had substantially less vasospasm treatment within 1 year compared with the clipping cohort.
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Affiliation(s)
- Anna M Nia
- Department of Neurosurgery, University of Texas Medical Branch, Galveston, Texas, USA.
| | - Rishi R Lall
- Department of Neurosurgery, University of Texas Medical Branch, Galveston, Texas, USA
| | - Peter Kan
- Department of Neurosurgery, University of Texas Medical Branch, Galveston, Texas, USA
| | - Visish M Srinivasan
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
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Caffes N, Wenger N, Cannarsa G, Oliver J, Onwukwe C, Gandhi D, Simard JM. Unruptured cerebral aneurysms in elderly patients: key challenges and management. Ann Med 2021; 53:1839-1849. [PMID: 34664535 PMCID: PMC8530485 DOI: 10.1080/07853890.2021.1990393] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 10/03/2021] [Indexed: 12/01/2022] Open
Abstract
Unruptured cerebral aneurysms are increasingly identified in elderly patients as the global life expectancy continues to rise and non-invasive vascular imaging becomes more prevalent. The optimal management of unruptured aneurysms in elderly patients remains controversial. Variability in life expectancy, comorbidities and rupture risk coupled with heterogenous endovascular and surgical treatments contribute to a paucity of clear guidelines, and current management is highly individualized. Elderly patients present unique considerations including frailty, cognitive dysfunction, vasculopathy, reduced life expectancy and overall worse prognosis in case of rupture which shape the risks and likelihood of success of endovascular and microsurgical treatment. In this review, we provide a comprehensive overview of unruptured cerebral aneurysms in the elderly, with a particular focus on the natural history, key challenges associated with advanced age, management and future innovations to further refine treatment.Key MessagesThe management of unruptured cerebral aneurysms in elderly patients remains controversial.Key challenges including frailty, cognitive dysfunction, reduced life expectancy, vasculopathy and poor prognosis with aneurysm rupture add complexity to endovascular and surgical decision making not encountered with younger demographics.A thorough understanding of available treatment options, likelihood of treatment success and associated risks weighed against the risk of aneurysm rupture informs patient discussion and management.
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Affiliation(s)
- Nicholas Caffes
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Nicole Wenger
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Gregory Cannarsa
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Jeffrey Oliver
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Chimdiya Onwukwe
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Dheeraj Gandhi
- Department of Radiology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - J. Marc Simard
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, USA
- Department Pathology, University of Maryland School of Medicine, Baltimore, MD, USA
- Department of Physiology, University of Maryland School of Medicine, Baltimore, MD, USA
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Zheng J, Xu R, Sun X, Zhang X. Small vs. Large Unruptured Cerebral Aneurysm: Concerns With the Age of Patient. Front Neurol 2021; 12:735456. [PMID: 34621238 PMCID: PMC8490624 DOI: 10.3389/fneur.2021.735456] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Accepted: 08/16/2021] [Indexed: 11/13/2022] Open
Abstract
Objective: The coiling and clipping of unruptured cerebral aneurysms (UCAs) in older patients has increased rapidly, and aneurysm size was a significant factor for decision-making in the treatment of UCAs. The purpose of the study was to investigate the impact of age on the functional outcomes of patients between the small versus large UCAs. Methods: We conducted a retrospective study for consecutive cases of UCAs admitted from May 2011 to December 2020. According to the maximum diameter of UCA, patients were divided into small UCAs (≤ 5 mm) group and large UCAs (>5 mm) group. Baseline characteristics, clinical complications, and outcomes of patients between the two groups were analyzed. Results: A total of 564 UCA patients received preventive treatment, including 165 small UCAs and 399 large UCAs. Compared with the small UCA group, the incidence of ischemia event in the large UCA group was significantly higher (7.3 vs. 2.4%; p = 0.029). Multivariable analysis demonstrating age (p = 0.006) and treatment modality (p < 0.001) were independent risk factors associated with poor outcome for patients with large UCAs. Conclusions: Preventive treatment of small UCAs is safe and effective, but older patients with large UCAs are at high risk of poor outcome, and the operations should be more cautious.
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Affiliation(s)
- Jianfeng Zheng
- Department of Neurosurgery, the First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Ru Xu
- Department of Neurosurgery, the First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xiaochuan Sun
- Department of Neurosurgery, the First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xiaodong Zhang
- Department of Neurosurgery, the First Affiliated Hospital of Chongqing Medical University, Chongqing, China
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Pontes FGDB, da Silva EM, Baptista-Silva JC, Vasconcelos V. Treatments for unruptured intracranial aneurysms. Cochrane Database Syst Rev 2021; 5:CD013312. [PMID: 33971026 PMCID: PMC8109849 DOI: 10.1002/14651858.cd013312.pub2] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Unruptured intracranial aneurysms are relatively common lesions in the general population, with a prevalence of 3.2%, and are being diagnosed with greater frequency as non-invasive techniques for imaging of intracranial vessels have become increasingly available and used. If not treated, an intracranial aneurysm can be catastrophic. Morbidity and mortality in aneurysmal subarachnoid hemorrhage are substantial: in people with subarachnoid hemorrhage, 12% die immediately, more than 30% die within one month, 25% to 50% die within six months, and 30% of survivors remain dependent. However, most intracranial aneurysms do not bleed, and the best treatment approach is still a matter of debate. OBJECTIVES To assess the risks and benefits of interventions for people with unruptured intracranial aneurysms. SEARCH METHODS We searched CENTRAL (Cochrane Library 2020, Issue 5), MEDLINE Ovid, Embase Ovid, and Latin American and Caribbean Health Science Information database (LILACS). We also searched ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform from inception to 25 May 2020. There were no language restrictions. We contacted experts in the field to identify further studies and unpublished trials. SELECTION CRITERIA Unconfounded, truly randomized trials comparing conservative treatment versus interventional treatments (microsurgical clipping or endovascular coiling) and microsurgical clipping versus endovascular coiling for individuals with unruptured intracranial aneurysms. DATA COLLECTION AND ANALYSIS Two review authors independently selected trials for inclusion according to the above criteria, assessed trial quality and risk of bias, performed data extraction, and applied the GRADE approach to the evidence. We used an intention-to-treat analysis strategy. MAIN RESULTS We included two trials in the review: one prospective randomized trial involving 80 participants that compared conservative treatment to endovascular coiling, and one randomized controlled trial involving 136 participants that compared microsurgical clipping to endovascular coiling for unruptured intracranial aneurysms. There was no difference in outcome events between conservative treatment and endovascular coiling groups. New perioperative neurological deficits were more common in participants treated surgically (16/65, 24.6%; 15.8% to 36.3%) versus 7/69 (10.1%; 5.0% to 19.5%); odds ratio (OR) 2.87 (95% confidence interval (CI) 1.02 to 8.93; P = 0.038). Hospitalization for more than five days was more common in surgical participants (30/65, 46.2%; 34.6% to 58.1%) versus 6/69 (8.7%; 4.0% to 17.7%); OR 8.85 (95% CI 3.22 to 28.59; P < 0.001). Clinical follow-up to one year showed 1/48 clipped versus 1/58 coiled participants had died, and 1/48 clipped versus 1/58 coiled participants had become disabled (modified Rankin Scale > 2). All the evidence is of very low quality. AUTHORS' CONCLUSIONS There is currently insufficient good-quality evidence to support either conservative treatment or interventional treatments (microsurgical clipping or endovascular coiling) for individuals with unruptured intracranial aneurysms. Further randomized trials are required to establish if surgery is a better option than conservative management, and if so, which surgical approach is preferred for which patients. Future studies should include consideration of important characteristics such as participant age, gender, aneurysm size, aneurysm location (anterior circulation and posterior circulation), grade of ischemia (major stroke), and duration of hospitalizations.
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Affiliation(s)
| | - Edina Mk da Silva
- Emergency Medicine and Evidence Based Medicine, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Jose Cc Baptista-Silva
- Evidence Based Medicine, Cochrane Brazil, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Vladimir Vasconcelos
- Department of Surgery, Division of Vascular and Endovascular Surgery, Universidade Federal de São Paulo, São Paulo, Brazil
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Semeraro V, Gasparrini F, Vidali S, Gandini R. Direct ultrasound-guided puncture of vertebral artery V2 segment during mechanical thrombectomy. BMJ Case Rep 2021; 14:14/1/e238979. [PMID: 33500306 PMCID: PMC7839913 DOI: 10.1136/bcr-2020-238979] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
An 83-year-old man experienced left upper limb uncontrolled movements preceded by intense gasping during night rest, which progressed to unconsciousness and respiratory arrest requiring intubation. He was diagnosed with acute stroke due to distal occlusion of the basilar artery and received indication for endovascular thrombectomy. Standard endovascular approach includes percutaneous puncture of the femoral or radial arteries; however, the presence of unfavourable vascular anatomies (stenotic origin and tortuosity) did not allow catheterisation of the intracranial vessels through conventional access, and based on the consistent time lapse from onset of symptoms and deterioration of the clinical condition, a direct right vertebral artery ultrasound-guided puncture was performed. After one attempt of a triaxial technique, a complete recanalisation of the basilar artery and of its distal branches was achieved. Direct percutaneous puncture of the vertebral artery represents a rescue access strategy for treatment of posterior circulation stroke when other routes are not feasible.
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Affiliation(s)
- Vittorio Semeraro
- Department of Diagnostic and Interventional Imaging, Santissima Annunziata Hospital, Taranto, Italy
| | - Fulvio Gasparrini
- Diagnostic and Interventional Imaging, University Hospital Policlinico Tor Vergata, Roma, Lazio, Italy
| | - Sofia Vidali
- Diagnostic and Interventional Imaging, University Hospital Policlinico Tor Vergata, Roma, Lazio, Italy
| | - Roberto Gandini
- Diagnostic and Interventional Imaging, University Hospital Policlinico Tor Vergata, Roma, Lazio, Italy
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Impact of acetylsalicylic acid in patients undergoing cerebral aneurysm surgery - should the neurosurgeon really worry about it? Neurosurg Rev 2021; 44:2889-2898. [PMID: 33495921 PMCID: PMC8490225 DOI: 10.1007/s10143-021-01476-7] [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: 09/08/2020] [Revised: 12/16/2020] [Accepted: 01/08/2021] [Indexed: 11/03/2022]
Abstract
There has been an increase in the use of acetylsalicylic acid (ASA, Aspirin®) among patients with stroke and heart disease as well as in aging populations as a means of primary prevention. The potentially life-threatening consequences of a postoperative hemorrhagic complication after neurosurgical operative procedures are well known. In the present study, we evaluate the risk of continued ASA use as it relates to postoperative hemorrhage and cardiopulmonary complications in patients undergoing cerebral aneurysm surgery. We retrospectively analyzed 200 consecutive clipping procedures performed between 2008 and 2018. Two different statistical models were applied. The first model consisted of two groups: (1) group with No ASA impact - patients who either did not use ASA at all as well as those who had stopped their use of the ASA medication in time (> = 7 days prior to operation); (2) group with ASA impact - all patients whose ASA use was not stopped in time. The second model consisted of three groups: (1) No ASA use; (2) Stopped ASA use (> = 7 days prior to operation); (3) Continued ASA use (did not stop or did not stop in time, <7 days prior to operation). Data collection included demographic information, surgical parameters, aneurysm characteristics, and all hemorrhagic/thromboembolic complications. A postoperative hemorrhage was defined as relevant if a consecutive operation for hematoma removal was necessary. An ASA effect has been assumed in 32 out of 200 performed operations. A postoperative hemorrhage occurred in one out these 32 patients (3.1%). A postoperative hemorrhage in patients without ASA impact was detected and treated in 5 out of 168 patients (3.0%). The difference was statistically not significant in either model (ASA impact group vs. No ASA impact group: OR = 1.0516 [0.1187; 9.3132], p = 1.000; RR = 1.0015 [0.9360; 1.0716]). Cardiopulmonary complications were significantly more frequent in the group with ASA impact than in the group without ASA impact (p = 0.030). In this study continued ASA use was not associated with an increased risk of a postoperative hemorrhage. However, cardiopulmonary complications were significantly more frequent in the ASA impact group than in the No ASA impact group. Thus, ASA might relatively safely be continued in patients with increased cardiovascular risk and cases of emergency cerebrovascular surgery.
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Xie Q, Gu Y, Song Y, Leng B, Zheng Y, Xu F. One-stage coiling versus clipping of multiple intracranial aneurysms in elderly patients. Clin Neurol Neurosurg 2020; 201:106415. [PMID: 33352450 DOI: 10.1016/j.clineuro.2020.106415] [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: 09/05/2020] [Revised: 11/23/2020] [Accepted: 11/24/2020] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Although multiple intracranial aneurysms (MIAs) are frequent and disastrous, determining treatment strategy for them is often complicated, especially in elderly patients (≥60 years old). We evaluated the safety and effectiveness of one-stage coiling versus surgical clipping for MIAs in elderly patients. METHODS All elderly patients who underwent one-stage embolization or surgical clipping for more than two aneurysms were identified in our hospital between January 2012 and June 2018. Patient characteristics and clinical outcomes at discharge and follow-up were retrospectively evaluated. RESULTS A total of 32 patients with 76 IAs underwent one-stage coiling and 21 patients with 46 IAs underwent one-stage clipping were enrolled in this study. Patients who underwent clipping were younger (mean age 64.1 versus 67.2, P = 0.006) and had lower total hospital costs (mean14764 $ versus 24,620 $, P < 0.001) compared with patients who underwent coiling. Immediate posttreatment angiography showed complete occlusion in 56 aneurysms, near complete in 11 and incomplete in 2 in coiling group. Aneurysms wrapping was performed in 2, incomplete clipping in 1 and complete clipping in 41 aneurysms in clipping group. At discharge, 49 (92.5 %) patients were in a good condition (GOS score 4 and 5), 4 (7.5 %) were disabled. At 12 months after discharge, 25 (92.6 %) and 16 (94.1 %) patients had favorable outcomes in the coiling and clipping groups, respectively. CONCLUSIONS Both one-stage coiling and surgical clipping are safe, effective methods for treating MIAs in elderly patients.
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Affiliation(s)
- Qiang Xie
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, 200040, China
| | - Yahua Gu
- Department of Nursing, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, 200040, China
| | - Yanbing Song
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, 200040, China
| | - Bing Leng
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, 200040, China; Neurosurgical Institute, Fudan University, Shanghai, 200040, China; Shanghai Clinical Medical Center of Neurosurgery, Shanghai, 200040, China; Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Shanghai, 200040, China
| | - Yongtao Zheng
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, 200040, China
| | - Feng Xu
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, 200040, China; Neurosurgical Institute, Fudan University, Shanghai, 200040, China; Shanghai Clinical Medical Center of Neurosurgery, Shanghai, 200040, China; Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Shanghai, 200040, China.
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10
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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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Lee SW, Kwon HJ, Jeong EO, Koh HS, Kim KH, Choi SW, Kim SH, Youm JY. Endovascular coil embolization for unruptured intracranial aneurysms in patients over 80 years of age. J Cerebrovasc Endovasc Neurosurg 2020; 22:237-244. [PMID: 33050684 PMCID: PMC7820267 DOI: 10.7461/jcen.2020.e2020.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Accepted: 09/29/2020] [Indexed: 12/02/2022] Open
Abstract
Objective As the average life span in modern society continues to increase, much interest is focused on high-risk procedures in elderly patients, including major surgical operations. We investigated the results of endovascular coiling of unruptured intracranial aneurysms (UIA) in patients over 80 years of age. Methods We retrospectively analyzed 39 patients aged over 80 years who underwent coil embolization for UIA between April 2007 and April 2019 at our hospital. Results Complete occlusion on digital subtraction angiography (DSA) immediately after surgery was performed in 44 (84.6%) of 52 cases of cerebral aneurysms. Four patients (7.7%) had residual aneurysmal necks, and four (7.7%) had contrast flow in the aneurysmal sac. Follow-up magnetic resonance angiography (mean: 8.2 months) was performed in 37 aneurysms in 24 patients. There was evidence of blood flow in the neck in seven cases (18.9%) and aneurysm in two cases (5.4%). Follow-up DSA (mean: 20.5 months) was performed in 14 aneurysms in 11 patients, and 11 aneurysms (78.6%) had complete occlusion, 1 aneurysm (7.1%) had an aneurysmal neck, and 2 aneurysms (14.3%) had contrast filling into the aneurysmal sac. Coil embolization procedure-related complications occurred in 3 patients (7.7%). Cerebral infarction occurred in 1 (2.6%), arterial dissection in 1 (2.6%), and hypoesthesia in 1 (2.6%). Conclusions Active treatment of UIA in elderly patients over 80 years of age through endovascular coil embolization can be considered.
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Affiliation(s)
- Seok-Won Lee
- Department of Neurosurgery, Chungnam National University Hospital, Daejeon, Korea
| | - Hyon-Jo Kwon
- Department of Neurosurgery, Chungnam National University Hospital, Daejeon, Korea.,Department of Neurosurgery, School of Medicine, Chungnam National University, Daejeon, Korea
| | - Eun-Oh Jeong
- Department of Neurosurgery, Chungnam National University Hospital, Daejeon, Korea
| | - Hyeon-Song Koh
- Department of Neurosurgery, Chungnam National University Hospital, Daejeon, Korea.,Department of Neurosurgery, School of Medicine, Chungnam National University, Daejeon, Korea
| | - Kyung Hwan Kim
- Department of Neurosurgery, Chungnam National University Hospital, Daejeon, Korea
| | - Seung-Won Choi
- Department of Neurosurgery, Chungnam National University Hospital, Daejeon, Korea.,Department of Neurosurgery, School of Medicine, Chungnam National University, Daejeon, Korea
| | - Seon-Hwan Kim
- Department of Neurosurgery, Chungnam National University Hospital, Daejeon, Korea.,Department of Neurosurgery, School of Medicine, Chungnam National University, Daejeon, Korea
| | - Jin-Young Youm
- Department of Neurosurgery, Chungnam National University Hospital, Daejeon, Korea.,Department of Neurosurgery, School of Medicine, Chungnam National University, Daejeon, Korea
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12
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Cho WC, Shin YS, Kim BS, Choi JH. Treatment outcome after coiling or clipping for elderly patients with unruptured intracranial aneurysms. J Cerebrovasc Endovasc Neurosurg 2020; 22:78-84. [PMID: 32665914 PMCID: PMC7329562 DOI: 10.7461/jcen.2020.22.2.78] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 04/03/2020] [Accepted: 04/04/2020] [Indexed: 11/23/2022] Open
Abstract
Objective The purpose of this study was to analyze treatment outcomes according to treatment modality for elderly patients over 75 years with unruptured intracranial aneurysm. Methods Fifty-four elderly patients treated in a single tertiary institute between January 2010 and December 2018 were retrospectively reviewed. We compared clinical outcome, radiological results, and complications between the coiling and clipping groups. Results A total of 55 procedures were performed in 54 patients. Of 55 aneurysms, 44 were treated endovascularly and 11 were treated surgically. There was no significant difference in patient baseline characteristics including mean age, sex, and preexisting co-morbidity between the two groups. Even though there was no significant difference (p=0.373), procedure-related symptomatic complication occurred only in coiling group (3 out of 44 patients, 6.6%). Mortality rate was significantly higher in clipping group (1 out of 11 patients, 9.1%) than in coiling group (0%, p=0.044). Good clinical outcome (modified Rankin Scale 0–2) at 90 days was achieved in 43 cases treated with coiling (97.7%), and 10 cases with clipping (90.9%, p=0.154). Conclusions Clipping is more invasive procedure and takes longer operation time, which might lead to unpredictable mortality in elderly patients. Coiling might have high procedure-related stroke rate due to tortuous vessels with atherosclerosis. Therefore, aggressive treatment of elderly patients should be carefully considered based on patient’s medical condition and angiographic findings.
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Affiliation(s)
- Woo Cheul Cho
- Department of Neurosurgery, Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Yong Sam Shin
- Department of Neurosurgery, Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Bum-Soo Kim
- Department of Radiology, Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Jai Ho Choi
- Department of Neurosurgery, Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea
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13
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Jee TK, Nam TM, Yeon JY, Kim KH, Jeon P, Kim JS, Hong SC. Intracranial Aneurysms in Young Adult Patients: Surgical and Endovascular Treatment Outcomes. World Neurosurg 2020; 136:e214-e222. [PMID: 31899407 DOI: 10.1016/j.wneu.2019.12.124] [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: 09/06/2019] [Revised: 12/19/2019] [Accepted: 12/20/2019] [Indexed: 11/27/2022]
Abstract
BACKGROUND Despite its relative rarity, the potential for loss of productive years makes aneurysmal subarachnoid hemorrhage (SAH) a considerably important entity in young adult patients (20-39 years of age). This study aimed to analyze outcomes of microsurgery (MS) and endovascular treatment (EVT) for saccular intracranial aneurysms (IAs) in young adult patients. METHODS A total of 276 young adult patients with 315 IAs, treated with MS or EVT between January 2001 and December 2015, were studied. Major recurrence and treatment-related complications were the primary outcome measures. Functional outcomes in patients with SAH were also assessed. RESULTS Major recurrence occurred in 21 cases (6.7%). Younger age (adjusted hazard ratio [aHR], 3.77; 95% confidence interval [CI], 1.45-9.83; P = 0.007), ruptured IA (aHR, 6.44; 95% CI, 2.09-19.89; P = 0.001), size (aHR, 1.84; 95% CI, 1.06-3.18; P = 0.030), and EVT (aHR, 7.21; 95% CI, 2.44-21.35; P < 0.001) were independently related to major recurrence. Treatment-related complications occurred in 5 cases (1.6%) and did not differ between the MS and EVT groups (P > 0.999). Unfavorable outcomes (modified Rankin scale score ≥2) were identified in 30 patients (19.6%) with SAH, and only Hunt and Hess grade was independently associated with unfavorable functional outcome. CONCLUSIONS Both MS and EVT are safe for treating IAs in young adult patients. MS showed better durability of treatment and may be preferred over EVT in young patients in view of their longer life expectancy compared with older patients.
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Affiliation(s)
- Tae Keun Jee
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Taek Min Nam
- Department of Neurosurgery, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Republic of Korea
| | - Je Young Yeon
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Keon Ha Kim
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Pyoung Jeon
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jong-Soo Kim
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Seung-Chyul Hong
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.
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14
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Ikawa F, Michihata N, Akiyama Y, Iihara K, Matano F, Morita A, Kato Y, Iida K, Kurisu K, Fushimi K, Yasunaga H. Treatment Risk for Elderly Patients with Unruptured Cerebral Aneurysm from a Nationwide Database in Japan. World Neurosurg 2019; 132:e89-e98. [DOI: 10.1016/j.wneu.2019.08.252] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Revised: 08/29/2019] [Accepted: 08/30/2019] [Indexed: 11/28/2022]
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15
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Kwinta BM, Kliś KM, Krzyżewski RM, Wilk A, Dragan M, Grzywna E, Popiela T. Elective Management of Unruptured Intracranial Aneurysms in Elderly Patients in a High-Volume Center. World Neurosurg 2019; 126:e1343-e1351. [DOI: 10.1016/j.wneu.2019.03.094] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Revised: 03/08/2019] [Accepted: 03/09/2019] [Indexed: 10/27/2022]
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16
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Acioly MA, Shaikh KA, White IK, Ziemba-Davis M, Bohnstedt BN, Cohen-Gadol A. Predictors of Outcomes and Complications After Microsurgical and Endovascular Treatment of 1300 Intracranial Aneurysms. World Neurosurg 2019; 122:e516-e529. [PMID: 31108070 DOI: 10.1016/j.wneu.2018.10.094] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Revised: 10/13/2018] [Accepted: 10/16/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND We performed a rigorous statistical analysis of the complications and outcomes of patients with ruptured or unruptured intracranial aneurysms. Our emphasis was on the potential predictive factors when both surgical and endovascular management are offered by a team with balanced microsurgical and endovascular expertise. METHODS From January 2005 to December 2011, 1297 consecutive patients presenting with ruptured (n=829) or unruptured (n=468) aneurysms were prospectively enrolled in our vascular database. The treatment modality was determined by consensus of the endovascular and microsurgical teams. The patients' medical and neurological conditions and aneurysm characteristics were compared against the postintervention complication rates and outcomes using multivariate analyses. RESULTS The patients mostly underwent clipping for ruptured (63.7%) or unruptured (56.6%) aneurysms. For ruptured aneurysms, higher Hunt and Hess and Fisher grades on admission were key predictors of increased neurological (P < 0.001 and P < 0.001, respectively) and medical (P < 0.001 and P=0.041, respectively) complication rates. No significant differences in the outcomes were observed between the coiling or clipping groups during the follow-up period. For the unruptured group, a family history of intracranial aneurysms was the most relevant predictor for reducing neurological complication rates and increasing survival at 6 months. Hypertension was, however, the strongest factor associated with complications negatively affecting the outcomes. CONCLUSIONS For the ruptured and unruptured groups both, the outcomes were generally good, although neurological and medical complications were reasonably more frequent for the ruptured aneurysms. Coiling provided a sustained benefit in lowering the complication rates only in the short term for the unruptured aneurysms. Smoking was associated, paradoxically, with improved outcomes.
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Affiliation(s)
- Marcus André Acioly
- Division of Neurosurgery, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil; Division of Neurosurgery, Fluminense Federal University, Niterói-Rio de Janeiro, Brazil
| | - Kashif A Shaikh
- Department of Neurological Surgery, Indiana University School of Medicine and Goodman Campbell Brain and Spine, Indianapolis, Indiana, USA
| | - Ian K White
- Department of Neurological Surgery, Indiana University School of Medicine and Goodman Campbell Brain and Spine, Indianapolis, Indiana, USA
| | - Mary Ziemba-Davis
- Department of Neurological Surgery, Indiana University School of Medicine and Goodman Campbell Brain and Spine, Indianapolis, Indiana, USA
| | - Bradley N Bohnstedt
- Department of Neurosurgery, Oklahoma University, Oklahoma City, Oklahoma, USA
| | - Aaron Cohen-Gadol
- Department of Neurological Surgery, Indiana University School of Medicine and Goodman Campbell Brain and Spine, Indianapolis, Indiana, USA.
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17
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Pontes FGDB, Vasconcelos V, Baptista-Silva JCC, da Silva EMK. Treatments for unruptured intracranial aneurysms. Hippokratia 2019. [DOI: 10.1002/14651858.cd013312] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Felipe Gomes de Barros Pontes
- University Hospital Prof. Alberto Antunes (Federal University of Alagoas); Department of Surgery; Maceio Alagoas Brazil 57036-730
| | - Vladimir Vasconcelos
- Universidade Federal de São Paulo; Department of Surgery, Division of Vascular and Endovascular Surgery; Rua Borges Lagoa, 754 São Paulo Brazil 04038-001
| | - Jose CC Baptista-Silva
- Universidade Federal de São Paulo; Evidence Based Medicine, Cochrane Brazil; Rua Borges Lagoa, 564, cj 124 São Paulo São Paulo Brazil 04038-000
| | - Edina MK da Silva
- Universidade Federal de São Paulo; Emergency Medicine and Evidence Based Medicine; Rua Borges Lagoa 564 cj 64 Vl. Clementino São Paulo São Paulo Brazil 04038-000
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18
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Recent Trends in Electively Treated Unruptured Intracranial Aneurysms. J Stroke Cerebrovasc Dis 2019; 28:2011-2017. [PMID: 30982717 DOI: 10.1016/j.jstrokecerebrovasdis.2019.03.010] [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: 01/17/2019] [Accepted: 03/02/2019] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND AND PURPOSE To determine recent treatment and outcome trends in patients undergoing elective surgical clipping (SC) or endovascular therapy (EVT) for unruptured intracranial aneurysms (UIAs) in the United States. METHODS Data were extracted and analyzed from the National Inpatient Sample, Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality for all patients admitted for elective EVT or SC of UIAs between 2011 and 2014. Treatment trends, in-hospital mortality, complication rates, length of stay (LOS) and total hospital costs were evaluated and analyzed. RESULTS A total of 31,070 patients with UIAs were included in our analysis, of which 14,411 and 16,659 underwent elective SC and EVT, respectively. There was no significant difference in in-hospital mortality rates between the 2 groups. EVT was associated with lower in-hospital complication rates, decreased median LOS (.8 days versus 3.3 days, P ≤ .0001), and an increased likelihood of discharge to home (92.9% versus 72.9%, P = .0001). Median total hospital charges were similar in both treatment cohorts. Independent predictors of mortality in the elective population were age over 40 years (P ≤ .0001), weekend treatment (P ≤ .0001), and high co-morbidity status (P ≤ .0001). CONCLUSIONS In-hospital mortality rates were similar in elective EVT and SC UIA patients; however, EVT was associated with lower in-hospital complication rates and shorter LOS.
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19
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Bohnstedt BN, Conger AR, Edwards J, Ziemba-Davis M, Edwards G, Brom J, Shah K, Cohen-Gadol AA. Anterior Communicating Artery Complex Aneurysms: Anatomic Characteristics as Predictors of Surgical Outcome in 300 Cases. World Neurosurg 2019; 122:e896-e906. [DOI: 10.1016/j.wneu.2018.10.172] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Revised: 10/23/2018] [Accepted: 10/26/2018] [Indexed: 11/25/2022]
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20
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Horcajadas A, Ortiz I, Jorques AM, Katati MJ. Resultados clínicos y de costes del tratamiento endovascular frente al quirúrgico en aneurismas incidentales. Neurocirugia (Astur) 2018; 29:267-274. [DOI: 10.1016/j.neucir.2018.07.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Revised: 06/22/2018] [Accepted: 07/03/2018] [Indexed: 11/16/2022]
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21
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Controversies on treatment of unruptured intracranial aneurysms. Value of UIATS and PHASES scores in a daily practice in a Spanish population. INTERDISCIPLINARY NEUROSURGERY 2018. [DOI: 10.1016/j.inat.2018.02.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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22
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Kim YD, Bang JS, Lee SU, Jeong WJ, Kwon OK, Ban SP, Kim TK, Kim SB, Oh CW. Long-term outcomes of treatment for unruptured intracranial aneurysms in South Korea: clipping versus coiling. J Neurointerv Surg 2018; 10:1218-1222. [DOI: 10.1136/neurintsurg-2018-013757] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Revised: 03/23/2018] [Accepted: 04/03/2018] [Indexed: 11/04/2022]
Abstract
BackgroundThe long-term outcomes of endovascular coiling and surgical clipping for the treatment of unruptured intracranial aneurysms are unclear.MethodsWe performed a nationwide retrospective cohort study using claims data from the Korean Health Insurance Review and Assessment Service on patients undergoing surgical clipping or endovascular coiling from 2008 to 2014. Inverse probability treatment weighting for average treatment effect on the treated and the multiple imputation method were used to balance covariates and handle missing values. The primary outcome was all-cause mortality at 7 years.ResultsWe identified 26 411 patients of whom 11 777 underwent surgical clipping and 14 634 underwent endovascular coiling. After adjustment with the use of inverse probability treatment weighting for average treatment effect on the treated, all-cause mortality rates at 7 years were 3.8% in the endovascular coiling group and 3.6% in the surgical clipping group (HR 1.05; 95% CI 0.86 to 1.28; P=0.60, log-rank test). The adjusted probabilities of aneurysm rupture at 7 years were 0.9% after endovascular coiling and 0.7% after surgical clipping (HR 0.9; 95% CI 0.61 to 1.34; P=0.63, log-rank test). The probabilities of retreatment at 7 years after adjustment were 4.9% in the endovascular coiling group and 3.2% in the surgical clipping group (HR 1.52; 95% CI 1.28 to 1.81; P<0.001, log-rank test).ConclusionsAll-cause mortality at 7 years was similar between the elective surgical clipping and endovascular coiling groups in patients with unruptured aneurysms who had no history of subarachnoid hemorrhage due to aneurysm rupture.
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23
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Silva NA, Shao B, Sylvester MJ, Eloy JA, Gandhi CD. Unruptured aneurysms in the elderly: perioperative outcomes and cost analysis of endovascular coiling and surgical clipping. Neurosurg Focus 2018; 44:E4. [DOI: 10.3171/2018.1.focus17714] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVEObservation and neurosurgical intervention for unruptured intracranial aneurysms (UIAs) in the elderly population is rapidly increasing. Cerebral aneurysm coiling (CACo) is favored over cerebral aneurysm clipping (CAC) in elderly patients, yet some elderly individuals still undergo CAC. The cost-effectiveness of treating UIAs requires further exploration. Understanding the effect of intervention on hospital charges and length of stay (LOS) as well as perioperative mortality and complications can further shed light on its economic impact. The purpose of this study was to analyze the cost and perioperative outcomes of UIAs in elderly patients (≥ 65 years of age) after CACo or CAC intervention.METHODSRetrospective cohorts of CACo and CAC admissions were extracted from National (Nationwide) Inpatient Sample data obtained between 2002 and 2013, forming parallel intervention groups to compare the following outcomes between elderly and nonelderly patients: average LOS and mean hospital admission costs, in-hospital mortality, and complications. Covariates included sex, race or ethnicity, and comorbidities.RESULTSElderly patients undergoing CAC experienced an average LOS of 8.0 days, whereas elderly patients undergoing CACo stayed an average of 3.2 days. The mean hospital charges incurred during admission totaled $95,960 in the elderly patients who underwent CAC versus $87,960 in the ones who underwent CACo. Elderly patients in whom CAC was performed had a 2.2% rate of in-hospital mortality, with a 2.6 greater adjusted odds of in-hospital mortality than nonelderly patients treated with CAC. In contrast, elderly patients who underwent CACo had a 1.36 greater adjusted odds of in-hospital mortality than their nonelderly counterparts. Compared to nonelderly patients receiving both interventions, elderly individuals had a significantly higher prevalence of various comorbidities and incidence of complications. Elderly patients who received CAC experienced a 10.3% incidence rate of perioperative stroke, whereas their CACo counterparts experienced this complication at a rate of 3.5%. Elderly patients treated with CAC had greater odds of perioperative acute renal failure, whereas their CACo counterparts had greater odds of perioperative deep venous thrombosis and pulmonary embolism.CONCLUSIONSIntervention with CAC and CACo in the elderly is resource intensive and is associated with higher risk than in the nonelderly. Those deciding between intervention and conservative management should consider these risks and costs, especially the 2.2% postoperative mortality rate associated with CAC in the elderly population. Further comparative cost-effectiveness research is needed to weigh these costs and outcomes against those of conservative management.
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Affiliation(s)
| | | | - Michael J. Sylvester
- 2Department of Otolaryngology, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Jean Anderson Eloy
- 1Department of Neurological Surgery and
- 3Department of Otolaryngology, University of Michigan, Ann Arbor, Michigan; and
- 4Department of Neurological Surgery, Westchester Medical Center/New York Medical College, Valhalla, New York
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Naragum V, AbdalKader M, Nguyen TN, Norbash A. Balloon-Assisted Cannulation for Difficult Anterior Cerebral Artery Access. INTERVENTIONAL NEUROLOGY 2018; 7:48-52. [PMID: 29628945 DOI: 10.1159/000481542] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
The anterior communicating artery is a common location for intracranial aneurysms. Compared to surgical clipping, endovascular coiling has been shown to improve outcomes for patients with ruptured aneurysms and we have seen a paradigm shift favoring this technique for treating aneurysms. Access to the anterior cerebral artery can be challenging, especially in patients with tortuous anatomy or subarachnoid hemorrhage or in patients presenting with vasospasm. We present a technique for cannulating the anterior cerebral artery using a balloon inflated in the proximal middle cerebral artery as a rebound surface.
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Affiliation(s)
- Varun Naragum
- Department of Neurology and Radiology, Boston Medical Center, Boston, Massachusetts, USA
| | - Mohamad AbdalKader
- Department of Radiology, Boston Medical Center, Boston, Massachusetts, USA
| | - Thanh N Nguyen
- Department of Neurology and Radiology, Boston Medical Center, Boston, Massachusetts, USA.,Department of Neurology, Neurosurgery Radiology, Boston Medical Center, Boston, Massachusetts, USA
| | - Alexander Norbash
- Department of Department of Radiology, University of California, San Diego, California, USA
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25
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Maldaner N, Burkhardt JK, Stienen MN, Goldberg J, Bervini D, Bijlenga P, Croci D, Zumofen D, D’Alonzo D, Marbacher S, Maduri R, Daniel RT, Serra C, Esposito G, Neidert MC, Bozinov O, Regli L. Decision-making and neurosurgeons' agreement in the management of aneurysmal subarachnoid haemorrhage based on computed tomography angiography. Acta Neurochir (Wien) 2018; 160:253-260. [PMID: 29214402 DOI: 10.1007/s00701-017-3415-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2017] [Accepted: 11/23/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND To determine the neurosurgeon's agreement in aneurysmal subarachnoid haemorrhage (aSAH) management with special emphasis on the rater's level of experience. A secondary aim was to analyse potential aneurysm variables associated with the therapeutic recommendation. METHOD Basic clinical information and admission computed tomography angiography (CTA) images of 30 consecutive aSAH patients were provided. Twelve neurosurgeons independently evaluated aneurysm characteristics and gave recommendations regarding the emergency management and aneurysm occlusion therapy. Inter-rater variability and predictors of treatment recommendation were evaluated. RESULTS There was an overall moderate agreement in treatment decision [κ = 0.43; 95% confidence interval ((CI), 0.387-0.474] with moderate agreement for surgical (κ = 0.43; 95% CI, 0.386-0.479) and endovascular treatment recommendation (κ = 0.45; 95% CI, 0.398-0.49). Agreement on detailed treatment recommendations including clip, coil, bypass, stent, flow diverter and ventriculostomy was low to moderate. Inter-rater agreement did not significantly differ between residents and consultants. Middle cerebral artery (MCA) aneurysm location was a positive predictor of surgical treatment [odds ratio (OR), 49.57; 95% CI, 10.416-235.865; p < 0.001], while patients aged >65 years (OR, 0.12; 95% CI, 0.03-0.0434; p = 0.001), fusiform aneurysm type (OR, 0.18; 95% CI, 0.044-0.747; p = 0.018) and intracerebral haematoma (ICA) aneurysm location (OR, 0.24; 95% CI, 0.088-0.643; p = 0.005) were associated with a recommendation for endovascular treatment. CONCLUSIONS Agreement on aSAH management varies considerably across neurosurgeons, while therapeutic decision-making is challenging on an individual patient level. However, patients aged >65 years, fusiform aneurysm shape and ICA location were associated with endovascular treatment recommendation, while MCA aneurysm location remains a surgical domain in the opinion of neurosurgeons without formal endovascular training.
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26
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Akbarian-Tefaghi H, Kalakoti P, Sun H, Sharma K, Thakur JD, Patra DP, Dossani RH, Savardekar A, Notarianni C, Zipfel GJ, Nanda A. Impact of Hospital Caseload and Elective Admission on Outcomes After Extracranial-Intracranial Bypass Surgery. World Neurosurg 2017; 108:716-728. [DOI: 10.1016/j.wneu.2017.09.082] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Revised: 09/11/2017] [Accepted: 09/13/2017] [Indexed: 10/18/2022]
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27
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Sun H, Kalakoti P, Sharma K, Thakur JD, Dossani RH, Patra DP, Phan K, Akbarian-Tefaghi H, Farokhi F, Notarianni C, Guthikonda B, Nanda A. Proposing a validated clinical app predicting hospitalization cost for extracranial-intracranial bypass surgery. PLoS One 2017; 12:e0186758. [PMID: 29077743 PMCID: PMC5659612 DOI: 10.1371/journal.pone.0186758] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Accepted: 10/06/2017] [Indexed: 11/17/2022] Open
Abstract
OBJECT United States healthcare reforms are focused on curtailing rising expenditures. In neurosurgical domain, limited or no data exists identifying potential modifiable targets associated with high-hospitalization cost for cerebrovascular procedures such as extracranial-intracranial (ECIC) bypass. Our study objective was to develop a predictive model of initial cost for patients undergoing bypass surgery. METHODS In an observational cohort study, we analyzed patients registered in the Nationwide Inpatient Sample (2002-2011) that underwent ECIC bypass. Split-sample 1:1 randomization of the study cohort was performed. Hospital cost data was modelled using ordinary least square to identity potential drivers impacting initial hospitalization cost. Subsequently, a validated clinical app for estimated hospitalization cost is proposed (https://www.neurosurgerycost.com/calc/ec-ic-by-pass). RESULTS Overall, 1533 patients [mean age: 45.18 ± 19.51 years; 58% female] underwent ECIC bypass for moyamoya disease [45.1%], cerebro-occlusive disease (COD) [23% without infarction; 12% with infarction], unruptured [12%] and ruptured [4%] aneurysms. Median hospitalization cost was $37,525 (IQR: $16,225-$58,825). Common drivers impacting cost include Asian race, private payer, elective admission, hyponatremia, neurological and respiratory complications, acute renal failure, bypass for moyamoya disease, COD without infarction, medium and high volume centers, hospitals located in Midwest, Northeast, and West region, total number of diagnosis and procedures, days to bypass and post-procedural LOS. Our model was validated in an independent cohort and using 1000-bootstrapped replacement samples. CONCLUSIONS Identified drivers of hospital cost after ECIC bypass could potentially be used as an adjunct for creation of data driven policies, impact reimbursement criteria, aid in-hospital auditing, and in the cost containment debate.
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Affiliation(s)
- Hai Sun
- Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana, United States of America
| | - Piyush Kalakoti
- Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana, United States of America
| | - Kanika Sharma
- Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana, United States of America
| | - Jai Deep Thakur
- Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana, United States of America
| | - Rimal H Dossani
- Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana, United States of America
| | - Devi Prasad Patra
- Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana, United States of America
| | - Kevin Phan
- NeuroSpine Surgery Research Group (NSURG), Barker St Randwick, Prince of Wales Private Hospital, Sydney, Australia
| | - Hesam Akbarian-Tefaghi
- Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana, United States of America
| | - Frank Farokhi
- Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana, United States of America
| | - Christina Notarianni
- Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana, United States of America
| | - Bharat Guthikonda
- Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana, United States of America
| | - Anil Nanda
- Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana, United States of America
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Comparison of the Prevalence of Ruptured and Unruptured Cerebral Aneurysms in a Poor Urban Minority Population. J Stroke Cerebrovasc Dis 2017. [DOI: 10.1016/j.jstrokecerebrovasdis.2017.05.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Ahn JM, Oh JS, Yoon SM, Shim JH, Oh HJ, Bae HG. Procedure-related Complications during Endovascular Treatment of Intracranial Saccular Aneurysms. J Cerebrovasc Endovasc Neurosurg 2017; 19:162-170. [PMID: 29159149 PMCID: PMC5680079 DOI: 10.7461/jcen.2017.19.3.162] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Revised: 09/15/2017] [Accepted: 09/27/2017] [Indexed: 11/23/2022] Open
Abstract
Objective We evaluate the rates and outcomes of major procedure-related complications during coiling. Materials and Methods Between 2007 and 2015, 436 intracranial saccular aneurysms were treated. Complications are categorized as three types: intraprocedural aneurysm rupture (IAR), thromboembolism (TE), and post-procedural early rebleeding (PER). And we evaluated the risk factors of procedure related complications by multivariate analysis. Results Complications occurred in 61 aneurysms (14%). The overall incidence of complications in subarachnoid hemorrhage (SAH) was significantly higher than in unruptured intracranial aneurysm (UIA) (20% vs. 6%). The incidence of IAR and TE were higher in SAH than in UIA (IAR 12% vs. 4%, TE 7% vs. 3%, p < 0.05). Five PER occurred only in SAH. In 34 UIA which were treated with balloon-assisted coiling (BAC), all these patients had good recovery despite 3 patients had the IAR. The incidence of IAR and TE were not different between BAC and non-BAC groups (p > 0.05). All 7 patients who had IAR during BAC had good recovery. In multiple logistic regression analysis, female gender, SAH, and intraventricular hemorrhage were associated with procedure related complication (p < 0.05). Conclusion Endovascular coil embolization is a minimally invasive procedure, but incidence of its complication is not low, especially in SAH. BAC can be a good tool to avoid poor outcome from unexpected IAR during coiling. While IA tirofiban injection is a useful therapy in TE during coiling, sometimes we are aware of the risk of the early rebleeding in SAH patients.
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Affiliation(s)
- Jae-Min Ahn
- Department of Neurosurgery, Soonchunhyang University Cheonan Hospital, Cheonan, Korea
| | - Jae-Sang Oh
- Department of Neurosurgery, Soonchunhyang University Cheonan Hospital, Cheonan, Korea
| | - Seok-Mann Yoon
- Department of Neurosurgery, Soonchunhyang University Cheonan Hospital, Cheonan, Korea
| | - Jae-Hyun Shim
- Department of Neurosurgery, Soonchunhyang University Cheonan Hospital, Cheonan, Korea
| | - Hyuk-Jin Oh
- Department of Neurosurgery, Soonchunhyang University Cheonan Hospital, Cheonan, Korea
| | - Hack-Gun Bae
- Department of Neurosurgery, Soonchunhyang University Cheonan Hospital, Cheonan, Korea
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Changing paradigm in the management of elderly patients with intracranial aneurysms: An institutional review. J Clin Neurosci 2017; 43:94-102. [PMID: 28599841 DOI: 10.1016/j.jocn.2017.05.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Accepted: 05/21/2017] [Indexed: 12/29/2022]
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Nakamizo A, Michiwaki Y, Kawano Y, Amano T, Matsuo S, Fujioka Y, Tsumoto T, Yasaka M, Okada Y. Impact of antithrombotic treatment on clinical outcomes after craniotomy for unruptured intracranial aneurysm. Clin Neurol Neurosurg 2017; 161:93-97. [PMID: 28865323 DOI: 10.1016/j.clineuro.2017.08.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Revised: 08/21/2017] [Accepted: 08/27/2017] [Indexed: 10/19/2022]
Abstract
OBJECTIVE Patients receiving antithrombotic treatment occasionally undergo craniotomy. We aimed to explore the impact of perioperative use of antithrombotic agents on the occurrence of surgical complications and clinical outcomes in patients with unruptured intracranial aneurysm (UIA). PATIENTS AND METHODS We retrospectively analyzed 401 consecutive patients who had undergone craniotomy for UIA at our institution between January 2006 and December 2016. Patients were divided into two groups: those who received oral antiplatelet and/or anticoagulant agents during the perioperative period (antithrombotic treatment group, n=45); and those who did not (no antithrombotic treatment group, n=356). In the antithrombotic treatment group, 40 patients received antiplatelet alone, 2 received anticoagulant alone, and 3 received antiplatelet plus anticoagulant. RESULTS The two groups showed no significant differences in mortality, morbidity, or occurrence of symptomatic brain infarction, but intracranial hemorrhage was more frequent in the antithrombotic treatment group than in the no antithrombotic treatment group (p=0.0187). Multivariate analysis revealed posterior location of the aneurysm (odds ratio (OR), 8.10; 95% confidence interval (CI), 2.77-23.68; p=0.0001) and surgical procedure (OR, 5.48; 95%CI, 1.68-17.86; p=0.0048) as significantly correlated with severe morbidity, and intracranial hemorrhage as correlated significantly with antithrombotic treatment (OR, 3.83; 95%CI, 1.36-10.76; p=0.0110). CONCLUSIONS This study provides important information about the occurrence of intracranial hemorrhage and clinical outcomes in patients undergoing antithrombotic treatment during the perioperative period of craniotomy for UIA.
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Affiliation(s)
- Akira Nakamizo
- Department of Neurosurgery, Clinical Research Institute, National Hospital Organization, Kyushu Medical Center, Japan.
| | - Yuhei Michiwaki
- Department of Neurosurgery, Clinical Research Institute, National Hospital Organization, Kyushu Medical Center, Japan
| | - Yousuke Kawano
- Department of Neurosurgery, Clinical Research Institute, National Hospital Organization, Kyushu Medical Center, Japan
| | - Toshiyuki Amano
- Department of Neurosurgery, Clinical Research Institute, National Hospital Organization, Kyushu Medical Center, Japan
| | - Satoshi Matsuo
- Department of Neurosurgery, Clinical Research Institute, National Hospital Organization, Kyushu Medical Center, Japan
| | - Yutaka Fujioka
- Department of Neurosurgery, Clinical Research Institute, National Hospital Organization, Kyushu Medical Center, Japan
| | - Tomoyuki Tsumoto
- Department of Neuroendovascular Surgery, Clinical Research Institute, National Hospital Organization, Kyushu Medical Center, Japan
| | - Masahiro Yasaka
- Department of Cerebrovascular Medicine and Neurology, Clinical Research Institute, National Hospital Organization, Kyushu Medical Center, Japan
| | - Yasushi Okada
- Department of Cerebrovascular Medicine and Neurology, Clinical Research Institute, National Hospital Organization, Kyushu Medical Center, Japan
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Oravec CS, Motiwala M, Reed K, Kondziolka D, Barker FG, Michael LM, Klimo P. Big Data Research in Neurosurgery: A Critical Look at this Popular New Study Design. Neurosurgery 2017; 82:728-746. [DOI: 10.1093/neuros/nyx328] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Accepted: 05/17/2017] [Indexed: 01/10/2023] Open
Affiliation(s)
- Chesney S Oravec
- College of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Mustafa Motiwala
- College of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Kevin Reed
- College of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Douglas Kondziolka
- Department of Neurosurgery, New York University Langone Medical Center, New York, New York
| | - Fred G Barker
- Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts
| | - L Madison Michael
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee
- Semmes Murphey Clinic, Memphis, Tennessee
| | - Paul Klimo
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee
- Semmes Murphey Clinic, Memphis, Tennessee
- Department of Neurosurgery, Le Bonheur Children's Hospital, Memphis, Tennessee
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Abstract
The prevalence of unruptured cerebral aneurysms (UCAs) in elderly patients is increasing in our aging population. UCA management in elderly patients has some difficulties, such as reduced life expectancy, increased comorbidities and treatment risks, and poor prognosis in case of rupture. In this review article, we summarize the most recent findings on the natural history, therapeutic options and treatment results for UCAs exclusively in elderly patients, and describe possible medical treatments for patients with UCAs.
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Affiliation(s)
- Tomohito Hishikawa
- Department of Neurological Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences
| | - Isao Date
- Department of Neurological Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences
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Rinaldo L, Lanzino G. Increased Age Associated with Reduced Likelihood of Recurrence After Coiling of Ruptured Aneurysms. World Neurosurg 2017; 100:381-387. [DOI: 10.1016/j.wneu.2017.01.029] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Revised: 01/06/2017] [Accepted: 01/09/2017] [Indexed: 12/01/2022]
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Bekelis K, Gottlieb D, Su Y, Lanzino G, Lawton MT, MacKenzie TA. Medicare expenditures for elderly patients undergoing surgical clipping or endovascular intervention for subarachnoid hemorrhage. J Neurosurg 2017; 126:805-810. [PMID: 27203138 PMCID: PMC5549790 DOI: 10.3171/2016.2.jns152994] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
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.
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Affiliation(s)
- Kimon Bekelis
- Section of Neurosurgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH
| | - Dan Gottlieb
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH
| | - Yin Su
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH
| | | | - Michael T. Lawton
- Department of Neurosurgery, University of California San Francisco Medical Center, San Francisco, CA
| | - Todd A. MacKenzie
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH
- Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Hanover, NH
- Department of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH
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Bekelis K, Gottlieb DJ, Su Y, O’Malley AJ, Labropoulos N, Goodney P, Lawton MT, MacKenzie TA. Comparison of clipping and coiling in elderly patients with unruptured cerebral aneurysms. J Neurosurg 2017; 126:811-818. [PMID: 27203150 PMCID: PMC5116411 DOI: 10.3171/2016.1.jns152028] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVE The comparative effectiveness of the 2 treatment options-surgical clipping and endovascular coiling-for unruptured cerebral aneurysms remains an issue of debate and has not been studied in clinical trials. The authors investigated the association between treatment method for unruptured cerebral aneurysms and outcomes in elderly patients. METHODS The authors performed a cohort study of 100% of Medicare fee-for-service claims data for elderly patients who had treatment for unruptured cerebral aneurysms between 2007 and 2012. To control for measured confounding, the authors used propensity score conditioning and inverse probability weighting with mixed effects to account for clustering at the level of the hospital referral region (HRR). An instrumental variable (regional rates of coiling) analysis was used to control for unmeasured confounding and to create pseudo-randomization on the treatment method. RESULTS During the study period, 8705 patients underwent treatment for unruptured cerebral aneurysms and met the study inclusion criteria. Of these patients, 2585 (29.7%) had surgical clipping and 6120 (70.3%) had endovascular coiling. Instrumental variable analysis demonstrated no difference between coiling and clipping in 1-year postoperative mortality (OR 1.25, 95% CI 0.68-2.31) or 90-day readmission rate (OR 1.04, 95% CI 0.66-1.62). However, clipping was associated with a greater likelihood of discharge to rehabilitation (OR 6.39, 95% CI 3.85-10.59) and 3.6 days longer length of stay (LOS; 95% CI 2.90-4.71). The same associations were present in propensity score-adjusted and inverse probability-weighted models. CONCLUSIONS In a cohort of Medicare patients, there was no difference in mortality and the readmission rate between clipping and coiling of unruptured cerebral aneurysms. Clipping was associated with a higher rate of discharge to a rehabilitation facility and a longer LOS.
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Affiliation(s)
- Kimon Bekelis
- Section of Neurosurgery, Dartmouth-Hitchcock Medical Center, Lebanon
| | - Daniel J. Gottlieb
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon
| | - Yin Su
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon
| | - A. James O’Malley
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon
- Department of Biomedical Data Science, Hanover, New Hampshire
| | - Nicos Labropoulos
- Department of Radiology, Stony Brook University Medical Center, Stony Brook, New York
| | - Philip Goodney
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Michael T. Lawton
- Department of Neurosurgery, University of California, San Francisco Medical Center, San Francisco, California
| | - Todd A. MacKenzie
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon
- Department of Biomedical Data Science, Hanover, New Hampshire
- Department of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon
- Department of Community and Family Medicine, Dartmouth-Hitchcock Medical Center, Lebanon
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Bekelis K, Gottlieb D, Su Y, Labropoulos N, Bovis G, Lawton MT, MacKenzie TA. Medicare expenditures for elderly patients undergoing surgical clipping or endovascular intervention for unruptured cerebral aneurysms. J Neurointerv Surg 2017; 9:324-328. [PMID: 27013232 PMCID: PMC5035560 DOI: 10.1136/neurintsurg-2016-012313] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2016] [Revised: 03/02/2016] [Accepted: 03/08/2016] [Indexed: 11/04/2022]
Abstract
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.
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Affiliation(s)
- Kimon Bekelis
- Section of Neurosurgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH
| | - Dan Gottlieb
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH
| | - Yin Su
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH
| | - Nicos Labropoulos
- Department of Radiology, Stony Brook University Medical Center, Stony Brook, NY
| | - George Bovis
- Department of Neurosurgery, Rush University Medical Center, Chicago, IL
| | - Michael T. Lawton
- Department of Neurosurgery, University of California, San Francisco Medical Center, San Francisco, CA
| | - Todd A. MacKenzie
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH
- Geisel School of Medicine at Dartmouth, Hanover, NH
- Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Hanover, NH
- Department of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH
- Department of Community and Family Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH
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Rinaldo L, McCutcheon BA, Murphy ME, Shepherd DL, Maloney PR, Kerezoudis P, Bydon M, Lanzino G. Quantitative analysis of the effect of institutional case volume on complications after surgical clipping of unruptured aneurysms. J Neurosurg 2017; 127:1297-1306. [PMID: 28059649 DOI: 10.3171/2016.9.jns161875] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The mechanism by which greater institutional case volume translates into improved outcomes after surgical clipping of unruptured intracranial aneurysms (UIAs) is not well established. The authors thus aimed to assess the effect of case volume on the rate of various types of complications after clipping of UIAs. METHODS Using information on the outcomes of inpatient admissions for surgical clipping of UIAs collected within a national database, the relationship of institutional case volume to the incidence of different types of complications after clipping was investigated. Complications were subdivided into different categories, which included all complications, ischemic stroke, intracerebral hemorrhage, medical complications, infectious complications, complications related to anesthesia, and wound complications. The relationship of case volume to different types of complications was assessed using linear regression analysis. The relationships between case volume and overall complication and stroke rates were fit with both linear and quadratic equations. The numerical cutoff for institutional case volume above and below which the authors found the greatest differences in mean overall complication and stroke rate was determined using classification and regression tree (CART) analysis. RESULTS Between October 2012 and September 2015, 125 health care institutions reported patient outcomes from a total of 6040 cases of clipping of UIAs. On linear regression analysis, increasing case volume was negatively correlated to both overall complications (r2 = 0.046, p = 0.0234) and stroke (r2 = 0.029, p = 0.0557) rate, although the relationship of case volume to the complication (r2 = 0.092) and stroke (r2 = 0.067) rate was better fit with a quadratic equation. On CART analysis, the cutoff for the case number that yielded the greatest difference in overall complications and stroke rate between higher- or lower-volume centers was 6 cases/year and 3 cases/year, respectively. CONCLUSIONS Although the authors confirm that increasing case volume is associated with reduced complications after clipping of UIAs, their results suggest that the relationship between case volume and complications is not necessarily linear. Moreover, these results indicate that the effect of case volume on outcome is most evident between very-low-volume centers relative to centers with a medium-to-high volume.
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Affiliation(s)
| | | | | | | | | | | | | | - Giuseppe Lanzino
- Departments of1Neurosurgery and.,2Neurointerventional Radiology, Mayo Clinic, Rochester, Minnesota
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Morgan MK, Wiedmann M, Assaad NN, Heller GZ. Complication-Effectiveness Analysis for Unruptured Intracranial Aneurysm Surgery: A Prospective Cohort Study. Neurosurgery 2016; 78:648-59. [PMID: 26562824 DOI: 10.1227/neu.0000000000001113] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND The aim of intervention for unruptured intracranial aneurysms (UIAs) is safe, effective treatment. OBJECTIVE To analyze a prospective database for variables influencing the risk of surgery to produce a risk model adjusting this risk for effectively treated aneurysms. METHODS First, we identified variables to create a model from multiple logistic regression for complications of surgery leading to a 12-month modified Rankin Scale score >1. Second, we established the long-term cumulative incidence of freedom from retreatment or rupture (treated aneurysm) from Kaplan-Meier analysis. Third, we combined these analyses to establish a model of risk of surgery per effective treatment. RESULTS One thousand twelve patients with 1440 UIA underwent 1080 craniotomies. We found that 10.1% (95% confidence interval [CI], 8.4-12.0) of craniotomies resulted in a complication leading to a modified Rankin Scale score >1 at 12 months. Logistic regression found age (odds ratio, 1.04; 95% CI, 1.02-1.06), size (odds ratio, 1.12; 95% CI, 1.09-1.15), and posterior circulation location (odds ratio, 2.95; 95% CI, 1.82-4.78) to be significant. Cumulative 10-year risk of retreatment or rupture was 3.0% (95% CI, 1.3-7.0). The complication-effectiveness model was derived by dividing the complication risk by the 10-year cumulative freedom from retreatment or rupture proportion. Risk per effective treatment ranged from 1% for a 5-mm anterior circulation UIA in a 20-year-old patient to 70% for a giant posterior circulation UIA in a 70-year-old patient. CONCLUSION Complication-effectiveness analyses increase the information available with regard to outcome for the management of UIAs.
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Affiliation(s)
- Michael Kerin Morgan
- Departments of *Clinical Medicine and‡Statistics, Macquarie University, New South Wales, Australia
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Abdulrauf SI, Vuong P, Patel R, Sampath R, Ashour AM, Germany LM, Lebovitz J, Brunson C, Nijjar Y, Dryden JK, Khan MQ, Stefan MG, Wiley E, Cleary RT, Reis C, Walsh J, Buchanan P. "Awake" clipping of cerebral aneurysms: report of initial series. J Neurosurg 2016; 127:311-318. [PMID: 27767401 DOI: 10.3171/2015.12.jns152140] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE Risk of ischemia during aneurysm surgery is significantly related to temporary clipping time and final clipping that might incorporate a perforator. In this study, the authors attempted to assess the potential added benefit to patient outcomes of "awake" neurological testing when compared with standard neurophysiological testing performed under general anesthesia. The procedure is performed after the induction of conscious sedation, and for the neurological testing, the patient is fully awake. METHODS The authors conducted an institutional review board-approved prospective study of clipping unruptured intracranial aneurysms (UIAs) in 30 consecutive adult patients who underwent awake clipping. The end points were the incidence of stroke/cerebrovascular accident (CVA), death, discharge to a long-term facility, length of stay, and 30-day modified Rankin Scale score. All clinical and neurophysiological intraoperative monitoring data were recorded. RESULTS The median patient age was 52 years (range 27-63 years); 19 (63%) female and 11 (37%) male patients were included. Twenty-seven (90%) aneurysms were anterior, and 3 (10%) were posterior circulation aneurysms. Five (17%) had been coiled previously, 3 (10%) had been clipped previously, 2 (7%) were partially calcified, and 2 (7%) were fusiform aneurysms. Three patients developed synchronous clinical neurological and neurophysiological changes during temporary clipping with consequent removal of the temporary clip and reversal of those clinical and neurophysiological changes. Three patients developed asynchronous clinical neurological and neurophysiological changes. These 3 patients developed hemiparesis without changes in neurophysiological monitoring results. One patient developed linked clinical neurological and neurophysiological changes during final clipping that were not reversed by reapplication of the clip, and the patient had a CVA. Four patients with internal carotid artery ophthalmic segment aneurysms underwent visual testing with final clipping, and 1 of these patients required repositioning of the clip. Three patients who required permanent occlusion of a vessel as part of their aneurysm treatment underwent a 10-minute intraoperative clinical respective-vessel test occlusion. The median length of stay was 3 days (range 1-5 days). The median modified Rankin Scale score was 1 (range 0-3). All of the patients were discharged to home from the hospital except for 1 who developed a CVA and was discharged to a rehabilitation facility. There were no deaths in this series. CONCLUSIONS The 3 patients who developed neurological deterioration without a concomitant neurophysiological finding during temporary clipping revealed a potential advantage of awake aneurysm surgery (i.e., in decreasing the risk of ischemic injury).
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Jodi Walsh
- Saint Louis University Hospital Database
| | - Paula Buchanan
- Saint Louis University Center for Outcomes Research, St. Louis University, Missouri
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Patient Age and the Outcomes after Decompressive Hemicraniectomy for Stroke: A Nationwide Inpatient Sample Analysis. Neurocrit Care 2016; 25:371-383. [DOI: 10.1007/s12028-016-0287-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Matsukawa H, Kamiyama H, Tsuboi T, Noda K, Ota N, Miyata S, Takahashi O, Tokuda S, Tanikawa R. Is Age a Risk Factor for Poor Outcome of Surgical Treatment of Unruptured Intracranial Aneurysms? World Neurosurg 2016; 94:222-228. [PMID: 27392889 DOI: 10.1016/j.wneu.2016.06.118] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2016] [Revised: 06/25/2016] [Accepted: 06/27/2016] [Indexed: 12/25/2022]
Abstract
OBJECTIVE Advanced age is known to be a significant risk factor for the rupture of intracranial aneurysms. The impact of age on outcomes of surgically treated patients with unruptured intracranial aneurysms (UIAs) is less clear. METHODS A total of 663 consecutive patients with 823 surgically treated UIAs were evaluated. UIAs, which need bypass surgery including low-flow or high-flow bypass, were defined as complex aneurysms. Aneurysm size was categorized as small (<15 mm), large (15-24 mm), and giant (≥25 mm). In patients without symptoms, a poor outcome is defined as a modified Rankin Scale (mRS) score of 2-6. In those with mRS score higher than 1 as a result of UIA-related symptoms or other comorbidities, a poor outcome is defined as an increase of 1 or more on the mRS. Outcomes were evaluated at the 6-month and 12-month follow-up examinations. RESULTS The mean age was 62 ± 12 years and 650 UIAs (78%) were observed in women. Previously treated aneurysm (P = 0.009), posterior circulation aneurysm (P < 0.0001), complex aneurysm (P < 0.0001), a larger size (P = 0.011), and perforator territory infarction (P < 0.0001) were related to poor outcome at 6 months, and posterior circulation aneurysm (P < 0.0001), complex aneurysm (P < 0.0001), a larger size (P = 0.035), and perforator territory infarction (P = 0.013) were related to poor outcome at 12 months. Age was not associated with poor outcome in patients with UIAs who undertook direct surgery. CONCLUSIONS Although risks and benefits of aneurysm treatment in older patients should be carefully considered, surgical treatment of UIAs in the elderly should be considered positively.
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Affiliation(s)
- Hidetoshi Matsukawa
- Department of Neurosurgery, Stroke Center, Teishinkai Hospital, Sapporo, Japan.
| | - Hiroyasu Kamiyama
- Department of Neurosurgery, Stroke Center, Teishinkai Hospital, Sapporo, Japan
| | - Toshiyuki Tsuboi
- Department of Neurosurgery, Stroke Center, Teishinkai Hospital, Sapporo, Japan
| | - Kosumo Noda
- Department of Neurosurgery, Stroke Center, Teishinkai Hospital, Sapporo, Japan
| | - Nakao Ota
- Department of Neurosurgery, Stroke Center, Teishinkai Hospital, Sapporo, Japan
| | - Shiro Miyata
- Department of Neurosurgery, Stroke Center, Teishinkai Hospital, Sapporo, Japan
| | - Osamu Takahashi
- Center for Clinical Epidemiology, Internal Medicine, St. Luke's International Hospital, Chuo-ku, Tokyo, Japan
| | - Sadahisa Tokuda
- Department of Neurosurgery, Stroke Center, Teishinkai Hospital, Sapporo, Japan
| | - Rokuya Tanikawa
- Department of Neurosurgery, Stroke Center, Teishinkai Hospital, Sapporo, Japan
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McCutcheon BA, Kerezoudis P, Porter AL, Rinaldo L, Murphy M, Maloney P, Shepherd D, Hirshman BR, Carter BS, Lanzino G, Bydon M, Meyer F. Coma and Stroke Following Surgical Treatment of Unruptured Intracranial Aneurysm: An American College of Surgeons National Surgical Quality Improvement Program Study. World Neurosurg 2016; 91:272-8. [PMID: 27108027 DOI: 10.1016/j.wneu.2016.04.039] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2016] [Revised: 04/12/2016] [Accepted: 04/12/2016] [Indexed: 01/08/2023]
Abstract
OBJECTIVE A large national surgical registry was used to establish national benchmarks and associated predictors of major neurologic complications (i.e., coma and stroke) after surgical clipping of unruptured intracranial aneurysms. METHODS The American College of Surgeons National Surgical Quality Improvement Program data set between 2007 and 2013 was used for this retrospective cohort analysis. Demographic, comorbidity, and operative characteristics associated with the development of a major neurologic complication (i.e., coma or stroke) were elucidated using a backward selection stepwise logistic regression analysis. This model was subsequently used to fit a predictive score for major neurologic complications. RESULTS Inclusion criteria were met by 662 patients. Of these patients, 57 (8.61%) developed a major neurologic complication (i.e., coma or stroke) within the 30-day postoperative period. On multivariable analysis, operative time (log odds 0.004 per minute; 95% confidence interval [CI], 0.002-0.007), age (log odds 0.05 per year; 95% CI, 0.02-0.08), history of chronic obstructive pulmonary disease (log odds 1.26; 95% CI, 0.43-2.08), and diabetes (log odds 1.15; 95% CI, 0.38-1.91) were associated with an increased odds of major neurologic complications. When patients were categorized according to quartile of a predictive score generated from the multivariable analysis, rates of major neurologic complications were 1.8%, 4.3%, 6.7%, and 21.2%. CONCLUSIONS Using a large, national multi-institutional cohort, this study established representative national benchmarks and a predictive scoring system for major neurologic complications following operative management of unruptured intracranial aneurysms. The model may assist with risk stratification and tailoring of decision making in surgical candidates.
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Affiliation(s)
- Brandon A McCutcheon
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA; Mayo Clinic Neuro-Informatics Laboratory, Mayo Clinic, Rochester, Minnesota, USA
| | - Panagiotis Kerezoudis
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA; Mayo Clinic Neuro-Informatics Laboratory, Mayo Clinic, Rochester, Minnesota, USA
| | - Amanda L Porter
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA; Mayo Clinic Neuro-Informatics Laboratory, Mayo Clinic, Rochester, Minnesota, USA
| | - Lorenzo Rinaldo
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA; Mayo Clinic Neuro-Informatics Laboratory, Mayo Clinic, Rochester, Minnesota, USA
| | - Meghan Murphy
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA; Mayo Clinic Neuro-Informatics Laboratory, Mayo Clinic, Rochester, Minnesota, USA
| | - Patrick Maloney
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA; Mayo Clinic Neuro-Informatics Laboratory, Mayo Clinic, Rochester, Minnesota, USA
| | - Daniel Shepherd
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA; Mayo Clinic Neuro-Informatics Laboratory, Mayo Clinic, Rochester, Minnesota, USA
| | - Brian R Hirshman
- Department of Neurosurgery, University of California, San Diego, La Jolla, California, USA
| | - Bob S Carter
- Department of Neurosurgery, University of California, San Diego, La Jolla, California, USA
| | - Giuseppe Lanzino
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Mohamad Bydon
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA; Mayo Clinic Neuro-Informatics Laboratory, Mayo Clinic, Rochester, Minnesota, USA.
| | - Fredric Meyer
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
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Falk Delgado A, Andersson T, Falk Delgado A. 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. J Neurointerv Surg 2016; 9:264-277. [PMID: 27053705 DOI: 10.1136/neurintsurg-2016-012292] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2016] [Revised: 03/01/2016] [Accepted: 03/08/2016] [Indexed: 12/27/2022]
Abstract
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.
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Affiliation(s)
| | - Tommy Andersson
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden.,Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden.,Department of Medical Imaging, AZ Groeninge, Kortrijk, Belgium
| | - Anna Falk Delgado
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden.,Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden
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Shimamura N, Naraoka M, Katagai T, Katayama K, Kakuta K, Matsuda N, Ohkuma H. Analysis of Factors That Influence Long-Term Independent Living for Elderly Subarachnoid Hemorrhage Patients. World Neurosurg 2016; 90:504-510. [PMID: 27025452 DOI: 10.1016/j.wneu.2016.03.057] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2016] [Revised: 03/17/2016] [Accepted: 03/18/2016] [Indexed: 12/01/2022]
Abstract
BACKGROUND The number of elderly subarachnoid hemorrhage (SAH) patients has been increasing. The aim of this study was to analyze long-term outcome for elderly (≥75 years) SAH patients and to establish a treatment strategy. METHODS From January 2005 to December 2013, 86 consecutive cases were treated. We used a modified Rankin Scale (mRS) at the outpatient clinic or a telephone interview of patients and/or families. Kaplan-Meier plots were done for mortality and independent (mRS 0 ∼ 2) state. Multivariate analysis was done to distinguish factors that influence on outcome. RESULTS Median age was 79, Hunt-Kosnik grade 1 ∼ 3 was 79%, and the radical intervention (clipping or coiling) rate was 78%. Mean follow-up period was 28.7 ± 3.4 standard error months. Half of deaths occurred during the first two months. The number of cases of independent living gradually decreased to 50% at 28 months after SAH. Half of patients lived independently for 36 months at HK grades 1 to 3, and 3 months at HK grades 4 to 5 (p < 0.05). Half of patients lived independently for 40 months in the radical intervention group, and 14 months in the conservative treatment group (p < 0.05). Multivariate analysis for independent living revealed that gender, pre-morbid condition, HK grade, and postoperative complication were significant (p < 0.05). CONCLUSIONS Good-grade elderly SAH cases that were independent pre-stroke should have radical intervention performed for aneurysm. Avoiding perioperative complications have a positive influence on long-term independent living.
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Affiliation(s)
- Norihito Shimamura
- Department of Neurosurgery, Hirosaki University School of Medicine, Hirosaki, Aomori, Japan.
| | - Masato Naraoka
- Department of Neurosurgery, Hirosaki University School of Medicine, Hirosaki, Aomori, Japan
| | - Takeshi Katagai
- Department of Neurosurgery, Hirosaki University School of Medicine, Hirosaki, Aomori, Japan
| | - Kosuke Katayama
- Department of Neurosurgery, Hirosaki University School of Medicine, Hirosaki, Aomori, Japan
| | - Kiyohide Kakuta
- Department of Neurosurgery, Hirosaki University School of Medicine, Hirosaki, Aomori, Japan
| | - Naoya Matsuda
- Department of Neurosurgery, Hirosaki University School of Medicine, Hirosaki, Aomori, Japan
| | - Hiroki Ohkuma
- Department of Neurosurgery, Hirosaki University School of Medicine, Hirosaki, Aomori, Japan
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Zweifel C, Sacho RH, Tymianski R, Radovanovic I, Tymianski M. Safety, efficacy, and cost of surgery for patients with unruptured aneurysms deemed unsuitable for endovascular therapy. Acta Neurochir (Wien) 2015; 157:2061-70; discussion 2070. [PMID: 26496925 DOI: 10.1007/s00701-015-2606-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Accepted: 10/05/2015] [Indexed: 12/01/2022]
Abstract
BACKGROUND Open surgery is a frequent option given to patients with unruptured intracranial aneurysms (UIAs) unsuitable for endovascular repair. Since the risk of rupture of UIAs is generally low, we determined whether the risks and costs of surgery in this patient subset are warranted. METHODS The safety, efficacy, and costs of minimally invasive surgery by minicraniotomy were evaluated in 102 consecutive patients with anterior circulation UIAs deemed unsuitable for endovascular repair by an interdisciplinary conference of surgeons and neurointerventionalists. Data from 107 UIA patients treated by endovascular means in the same period were used as the standard. RESULTS Surgical patients comprised a different subset of aneurysms, with more MCA and fewer paraophthalmic aneurysms (54 vs. 6, p < 0.0001 and 4 vs. 60, p < 0.0001, for minicraniotomy and endovascular, respectively). However, surgery incurred shorter anesthesia time (197.7 vs. 149.3 min, p < 0.0001), higher rates of complete aneurysm obliteration (94.57 vs. 66.67 %, p < 0.0001), and lower overall hospital costs ($8,287 CAD vs. $17,732 CAD, p < 0.0001) than the endovascular cohort. There were no treatment-related surgical deaths, but one patient had an mRS of 3 after 6 months due to temporal lobe epilepsy and memory problems. This compared favorably with the endovascular cohort in which two patients died due to treatment (mRS = 6) and one suffered a severe stroke (mRS = 5 at 6 months). CONCLUSIONS For patients counseled to undergo treatment but have UIAs unsuitable for endovascular repair, surgery is safe, effective, and cost-efficient.
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Affiliation(s)
- Christian Zweifel
- Division of Neurosurgery, Toronto Western Hospital, University Health Network, 4W-435, 399 Bathurst Street, M5T 2S8, Toronto, ON, Canada
| | - Raphael Hillel Sacho
- Division of Neurosurgery, Toronto Western Hospital, University Health Network, 4W-435, 399 Bathurst Street, M5T 2S8, Toronto, ON, Canada
| | - Rachel Tymianski
- Division of Neurosurgery, Toronto Western Hospital, University Health Network, 4W-435, 399 Bathurst Street, M5T 2S8, Toronto, ON, Canada
| | - Ivan Radovanovic
- Division of Neurosurgery, Toronto Western Hospital, University Health Network, 4W-435, 399 Bathurst Street, M5T 2S8, Toronto, ON, Canada
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Michael Tymianski
- Division of Neurosurgery, Toronto Western Hospital, University Health Network, 4W-435, 399 Bathurst Street, M5T 2S8, Toronto, ON, Canada.
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada.
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Comprehensive Overview of Contemporary Management Strategies for Cerebral Aneurysms. World Neurosurg 2015; 84:1147-60. [DOI: 10.1016/j.wneu.2015.05.064] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2014] [Revised: 05/19/2015] [Accepted: 05/20/2015] [Indexed: 01/06/2023]
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Song J, Kim BS, Shin YS. Treatment outcomes of unruptured intracranial aneurysm; experience of 1,231 consecutive aneurysms. Acta Neurochir (Wien) 2015; 157:1303-10; discussion 1311. [PMID: 26055578 DOI: 10.1007/s00701-015-2460-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Accepted: 05/25/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND The aim of this study was to review our experience with surgical clipping and endovascular treatment (EVT) of unruptured intracranial aneurysms (UIAs), with a special focus on complications. METHODS We retrospectively analyzed clinical and radiological data from patients who underwent surgery or EVT. Surgery was performed by one neurosurgeon, and EVT was performed by two neurointerventionists according to one hybrid neurosurgeon's decision. Adverse events included the following: (1) decline of the modified Rankin Scale (mRS) score from 1 to 2 and (2) any unexpected neurological deficit or imaging finding affecting the prognosis and/or requiring additional procedures, medication, or prolonged hospital stay. RESULTS Of the 1231 UIAs in 1124 patients, 625 (50.7 %) aneurysms were treated with surgery, and 606 (49.3 %) aneurysms were treated with EVT. The overall complication rate of UIA treatment was 3.2 %. The rate of adverse events was 2.4 %, and the rates of morbidity and mortality were 0.6 and 0.2 %, respectively. The rates of adverse events, morbidity, and mortality were not significantly different between surgery and EVT. The rate of hospital use for EVT was stationary over the years of the study. Posterior circulation in surgery, large aneurysms (>15 mm) in EVT, and stent- or balloon-assisted procedures in EVT were associated with the occurrence of complications. Poor clinical outcome (mRS of 3-6) was 0.8 % at hospital discharge. CONCLUSIONS Both UIA treatment modalities decided by one hybrid neurosurgeon showed low complication rates and good clinical outcomes in this study. These results may serve as a point of reference for clinical decision-making for patients with UIA.
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Deshaies EM, Villwock MR, Singla A, Toshkezi G, Padalino DJ. Minimally Invasive Thumb-sized Pterional Craniotomy for Surgical Clip Ligation of Unruptured Anterior Circulation Aneurysms. J Vis Exp 2015:e51661. [PMID: 26325337 DOI: 10.3791/51661] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
Less invasive surgical approaches for intracranial aneurysm clipping may reduce length of hospital stay, surgical morbidity, treatment cost, and improve patient outcomes. We present our experience with a minimally invasive pterional approach for anterior circulation aneurysms performed in a major tertiary cerebrovascular center and compare the results with an aged matched dataset from the Nationwide Inpatient Sample (NIS). From August 2008 to December 2012, 22 elective aneurysm clippings on patients ≤55 years of age were performed by the same dual fellowship-trained cerebrovascular/endovascular neurosurgeon. One patient (4.5%) experienced transient post-operative complications. 18 of 22 patients returned for follow-up imaging and there were no recurrences through an average duration of 22 months. A search in the NIS database from 2008 to 2010, also for patients aged ≤55 years of age, yielded 1,341 hospitalizations for surgical clip ligation of unruptured cerebral aneurysms. Inpatient length of stay and hospital charges at our institution using the minimally invasive thumb-sized pterional technique were nearly half that of NIS (length of stay: 3.2 vs 5.7 days; hospital charges: $52,779 vs. $101,882). The minimally invasive thumb-sized pterional craniotomy allows good exposure of unruptured small and medium-sized supraclinoid anterior circulation aneurysms. Cerebrospinal fluid drainage from key subarachnoid cisterns and constant bimanual microsurgical techniques avoid the need for retractors which can cause contusions, localized venous infarctions, and post-operative cerebral edema at the retractor sites. Utilizing this set of techniques has afforded our patients with a shorter hospital stay at a lower cost compared to the national average.
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Affiliation(s)
- Eric M Deshaies
- Neurovascular and Stroke Center, Crouse Neuroscience Institute; Department of Biology, Syracuse University;
| | - Mark R Villwock
- Neurovascular and Stroke Center, Crouse Neuroscience Institute
| | - Amit Singla
- Department of Neurosurgery, University of Florida
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Bekelis K, Missios S, Coy S, Singer RJ, MacKenzie TA. New York State: Comparison of Treatment Outcomes for Unruptured Cerebral Aneurysms Using an Instrumental Variable Analysis. J Am Heart Assoc 2015; 4:JAHA.115.002190. [PMID: 26169534 PMCID: PMC4608094 DOI: 10.1161/jaha.115.002190] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background There is wide regional variation in the predominant treatment for unruptured cerebral aneurysms. We investigated the association of elective surgical clipping and endovascular coiling with mortality, readmission rate, length of stay, and discharge to rehabilitation. Methods and Results We performed a cohort study involving patients with unruptured cerebral aneurysms, who underwent surgical clipping or endovascular coiling from 2009 to 2013 and were registered in the Statewide Planning and Research Cooperative System database. An instrumental variable analysis was used to investigate the association of treatment technique with outcomes. Of the 4643 patients undergoing treatment, 3190 (68.7%) underwent coiling, and 1453 (31.3%) underwent clipping. Using an instrumental variable analysis, we did not identify a difference in inpatient mortality (marginal effect, 0.13; 95% CI, −0.30, 0.57), or the rate of 30-day readmission (marginal effect, −1.84; 95% CI −4.06, −0.37) between the 2 treatment techniques for patients with unruptured cerebral aneurysms. Clipping was associated with a higher rate of discharge to rehabilitation (marginal effect, 2.31; 95% CI 0.21, 4.41), and longer length of stay (β, 2.01; 95% CI 0.85, 3.04). In sensitivity analysis, mixed-effect regression, and propensity score, adjusted regression models demonstrated identical results. Conclusions Using a comprehensive all-payer cohort of patients in New York State with unruptured cerebral aneurysms, we did not identify an association of treatment method with mortality or 30-day readmission. Clipping was associated with a higher rate of discharge to rehabilitation and longer length of stay.
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Affiliation(s)
- Kimon Bekelis
- Section of Neurosurgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH (K.B., R.J.S.)
| | - Symeon Missios
- Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, LA (S.M.)
| | - Shannon Coy
- Geisel School of Medicine at Dartmouth, Hanover, NH (S.C.)
| | - Robert J Singer
- Section of Neurosurgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH (K.B., R.J.S.)
| | - Todd A MacKenzie
- Department of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH (T.A.M.K.) Department of Community and Family Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH (T.A.M.K.) The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH (T.A.M.K.)
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