TREATMENT OF RUPTURED INTRACRANIAL ANEURYSMS

Cost Comparison of Microsurgery vs Endovascular Treatment for Ruptured Intracranial Aneurysms: A Propensity-Adjusted Analysis

BACKGROUND

In specialized neurosurgical centers, open microsurgery is routinely performed for aneurysmal subarachnoid hemorrhage (aSAH).

OBJECTIVE

To compare the cost of endovascular vs microsurgical treatment for aSAH at a single quaternary center.

METHODS

All patients undergoing aSAH treatment from July 1, 2014, to July 31, 2019, were retrospectively reviewed. Patients were grouped based on primary treatment (microsurgery vs endovascular treatment). The primary outcome was the difference in total cost (including hospital, discharge facility, and all follow-up) using a propensity-adjusted analysis.

RESULTS

Of 384 patients treated for an aSAH, 234 (61%) were microsurgically treated and 150 (39%) were endovascularly treated. The mean cost of index hospitalization for these patients was marginally higher ($9504) for endovascularly treated patients ($103 980) than for microsurgically treated patients ($94 476) ( P = .047). For the subset of patients with follow-up data available, the mean total cost was $45 040 higher for endovascularly treated patients ($159 406, n = 59) than that for microsurgically treated patients ($114 366, n = 105) ( P < .001). After propensity scoring (adjusted for age, sex, comorbidities, Glasgow Coma Scale score, Hunt and Hess grade, Fisher grade, aneurysms, and type/size/location), linear regression analysis of patients with follow-up data available revealed that microsurgery was independently associated with healthcare costs that were $37 244 less than endovascular treatment costs ( P < .001). An itemized cost analysis suggested that this discrepancy was due to differences in the rates of aneurysm retreatment and long-term surveillance.

CONCLUSION

Microsurgical treatment for aSAH is associated with lower total healthcare costs than endovascular therapy. Aneurysm surveillance after endovascular treatments, retreatment, and device costs warrants attention in future studies.

Cost-Effective Analysis of Different Diagnostic Strategies in Screening for Aneurysms After Spontaneous Subarachnoid Hemorrhage

PURPOSE

With an increasing number of patients being treated by coiling for aneurysms, using computed tomographic angiography (CTA) or magnetic resonance angiography (MRA) as an initial screening test becomes less important because digital subtraction angiography (DSA) is the first step of endovascular treatment procedure. The objective of this study is to investigate whether CTA or MRA remained to be the optimal screening strategy in patients with spontaneous subarachnoid hemorrhage (SAH).

METHODS

CTA, MRA, and DSA strategy were evaluated in a decision tree model created with TreeAge Pro Suite 2011. Input parameters were derived from published literature and our institutional database. Base case and sensitivity analyses were conducted to assess the cost-effectiveness of each strategy. A Monte Carlo simulation was performed with all parameters ranged among their distributions to evaluate the validation of results.

RESULTS

The base case scenario showed that MRA was the most cost-effective strategy. Using a willingness-to-pay threshold of ¥70,892/quality adjusted life year, MRA remained to be most cost-effective when its sensitivity is >0.907. DSA was not cost-effective compared to CTA or MRA unless over 91.56% of patients were treated by coiling. The Monte Carlo simulation reported DSA not to be a cost-effective strategy at willingness-to-pay of ¥70,892 in 99.99% of the iterations.

CONCLUSION

DSA is not cost-effective compared to CTA or MRA and should not be used as the initial diagnostic tool for spontaneous SAH.

Management of Ruptured Intracranial Aneurysms in the Post-International Subarachnoid Aneurysm Trial Era: A Single-Centre Prospective Series

BACKGROUND

Aneurysmal subarachnoid haemorrhage (aSAH) is associated with significant morbidity and mortality. The International Subarachnoid Aneurysm Trial (ISAT) reported reduced morbidity in patients treated with endovascular coiling versus surgical clipping. However, recent studies suggest that there is no significant difference in clinical outcomes. This study examines the outcomes of either technique for treating aSAH during the 15 years post-ISAT at a Canadian quaternary centre.

METHODS

We reviewed prospectively collected data of patients admitted with aSAH from January 2002 to December 2017. Glasgow Outcome Scale (GOS) was compared at discharge, 6 months and 12 months' follow-up using univariate and multivariable ordinal logistic regression. Post-operative complications were assessed using binary logistic regression.

RESULTS

Two-hundred and eighty-seven patients were treated with coiling and 95 patients with clipping. The mean age of clipped patients was significantly younger, and hypertension was significantly commoner in coiled patients. A greater proportion of coiled aneurysms were located in the posterior circulation. No difference in the odds of having a favourable GOS was seen between patients who were clipped versus coiled at any of follow-up time points on univariate or multivariable analysis. In both treatment groups, patient recovery to independence (GOS 4-5) was seen from discharge to 6 months, but not from 6 to 12 months' follow-up, without difference between clipping and coiling.

CONCLUSION

These real-world findings suggest clipping remains an effective and important treatment option for patients with aSAH who do not meet ISAT inclusion criteria. The results can assist in clinical decision-making processes and understanding of the natural recovery progression of aSAH.

Subarachnoid hemorrhage in C57BL/6J mice increases motor stereotypies and compulsive-like behaviors

OBJECTIVE

Long-term behavioral, mood, and cognitive deficits affect over 30% of patients with subarachnoid hemorrhage (SAH). The aim of the present study was to examine the neurobehavioral outcomes following endovascular perforation induced SAH in mice.

METHODS

C57BL/6 J (B6) mice were exposed to endovascular perforation induced SAH or control surgery. Three weeks later, mice received a series of behavioral tests, e.g. motor function, stereotypy, learning, memory, behavioral flexibility, depression and anxiety. The immunohistologic experiment examined neuronalloss in the cortex following SAH.

RESULTS

SAH mice exhibited increased marble burying and nestlet shredding compared to that of control mice. Although SAH did not affect memory, learning or reversal learning,mice displayed greater overall object exploration in the novel object recognition test, as well as elevated perseveration during probabilistic reversal learning.In the forced swim and open field tests, SAH mice performed comparably to that of control mice. However, SAH mice exhibited an increased frequency in 'jumping' behavior in the open field test. Histological analyses revealed reduced neuron density in the parietal-entorhinal cortices of SAH mice on the injured side compared to that of control mice.

DISCUSSION

The findings suggest that parietal-entorhinal damage from SAH increases stereotyped motor behaviors and 'compulsive-like' behaviors without affecting cognition (learning and memory) or mood (anxiety and depression). This model can be used to better understand the neuropathophysiology following SAH that contributes to behavioral impairments in survivors with no gross sensory-motor deficits.

[A comparative study of the efficacy and safety of the eyebrow supraorbital approach in cerebral aneurysm surgery]

OBJECTIVE

The study objective was to compare the efficacy and safety of supraorbital eyebrow (SEA) and pterional (PA) approaches in surgery of anterior circle of Willis (ACW) aneurysms and to determine the advantages and disadvantages of SEA in aneurysm clipping.

MATERIAL AND METHODS

The analysis included 166 patients with ACW aneurysms aged 18 to 70 years who were treated in the Neurosurgery Department of the Interregional Clinical Diagnostic Center (Kazan) in the period from 2013 to 2016. At the first stage of the study, factors affecting surgical outcomes were compared (by using the Glasgow outcome scale (GOS)) in subpopulations of patients operated on using SEA (n=49) and PA (n=117). At the second stage, we compared the efficacy and safety of approaches using a case-control subanalysis in appropriate subgroups of the SEA (n=37) and PA (n=37) groups. The subgroups were comparable in the following factors: gender, age, severity of subarachnoid hemorrhage (SAH) on (Fisher scale), severity of the patient's condition (Hunt-Hess scale), size and location of the aneurysm, surgery duration, intraoperative aneurysm rupture (IOAR), amount of blood loss, rate of frontal sinus surgery, rate of nasal CSF leak, rate of intraoperative and postoperative complications, hemorrhagic and ischemic complications according to postoperative CT, patient's satisfaction with the cosmetic result of surgery (visual analogue scale - VAS), and treatment outcomes (GOS). Treatment outcomes (GOS) and patient's satisfaction with the cosmetic result of surgery (VAS) were considered as the efficacy parameters. The safety parameters included the amount of blood loss, rate of frontal sinus surgery, rate of nasal CSF leak, and rate of intraoperative and postoperative (hemorrhagic and ischemic) complications.

RESULTS

At the first stage of the study, we found that the amount of intraoperative blood loss in the subpopulation of patients with ACW aneurysms who were operated on using SEA was statistically significantly less than that in the PA group (p=0.0000002). In the postoperative period, patients who underwent surgery using SEA less frequently experienced neurological deficit (p=0.003), less frequently developed first epileptic seizures (p=0.035), and had a lower rate of hemorrhagic complications (p=0.003) and better treatment outcomes (GOS) (p=0.01). Comparison of appropriate subgroups in the SEA and PA groups, which were selected according to the case-control methodology and were comparable in the main factors affecting treatment outcomes, confirmed statistically significantly lower blood loss for SEA (p=0.0000002) than for PA. Compared to the SEA group, the PA group was characterized by more frequent, but not statistically significantly different, IOAR (p=1), postoperative worsening of neurological deficit (p=0.115), newly developed epileptic seizures (p=0.493), and hemorrhagic complications (p=0.0557). There were no deaths in both groups. In the SEA group, the treatment outcome was scored 4 and 5 (GOS, favorable outcome); in the PA group, the treatment outcome was scored 3 (GOS) in 2 (5.4%) patients and 4 or 5 in 35 (94.6%) patients (p=0.063). The mean subjective score of satisfaction with the treatment result (VAS) in the SEA group was significantly higher (9.4±1) than in the PA group (8.8±1; p=0.01).

CONCLUSION

SEA is an adequate approach for clipping ACW aneurysms, in particular ACA-AComA and MCA aneurysms, which is as effective and safe as the pterional approach.

Small Aneurysms Should Be Clipped?

Background:

Cerebral aneurysm prevalence may vary from 0.4% to 10%. The decision to treat or not incidental aneurysms remains controversial, especially when the lesions are small (<5 mm). Many recent publications are demonstrating that these lesions often bleed.

Methods:

We reviewed admitted patients with angiographic studies submitted to intracranial aneurysm surgical treatment from April 2012 to July 2013 in the Neurosurgery Department of São Paulo Medical School University (15 months), to define the rate and risk of bleeding. In addition, we proceeded literature review with collected 357 papers (past 5 years) which were selected 50 that were focused on our research. Clinical patients’ status at the time of discharge was evaluated with the modified Rankin scale.

Results:

A series of 118 cases of surgically clipped aneurysms was analyzed: 73.7% woman; Ruptured (61 cases, 51%); middle cerebral artery (51 cases, 43%) was the more common aneurysm. Small size (<5 mm) was 25 cases (21%); that 2 died (16%), 3 (25%) with severe disability,restricted to bed and dependent on nursing care; blood pressure was the main risk factors (56%); and an aneurysm <2 mm (100%) was ruptured.

Conclusion:

The number of small aneurysms in our series was significant (25 cases, 21%), and its rate of bleeding was high (25 cases, 48%), resulting in death and disability in a significant number of cases. Our tendency is for surgical treatment when it is associated with risk factors.

The influence of clinical and radiological parameters in treatment of ruptured intracranial aneurysms: a single center 7-year retrospective cohort study

BACKGROUND

In many clinical trials endovascular procedures are suggested as the treatment of choice for aneurysmal Subarachnoid Hemorrhage (aSAH) whenever possible. However, in clinical practice this management is often controversial. The aim of this study was to analyze factors involved in this decision.

METHODS

Our study included 317 consecutive cases of aSAH between 2010 and 2016, assessing clinical and neuroradiological features to evaluate their role in this choice.

RESULTS

In our series coiling was preferred in 119 (37.6%) patients, while 198 (62.4%) were treated surgically. On univariate analysis location of aneurysms (P<0.001), GCS score on admission (P=0.105), degree of midline shift (P=0.015), Fisher' score (P=0.002) and presence of vessels in the aneurysmal neck (P=0.071) proved the most relevant factors in the choice. Also, multivariate analysis confirmed the location and Fisher' grade as influential factors. Conversely, other radiological parameters, such as morphology, aspect and dome-neck ratio, presence of pre-operative vasospasm or hydrocephalus were not associated with this decision.

CONCLUSIONS

The decision process in aSAH requires a multidisciplinary team, to singularly evaluate each patient. We found that the location of aneurysms in vertebro-basilar circulation, PcomA and ICA, greater GCS score, absence of vessels in the aneurysmal neck, lower midline shift and Fisher' score are factors influencing in choosing coiling. Conversely, morphology, Aspect and Dome-Neck ratio proved not relevant to this decision, due to technological improvement and increasing skills in the endovascular treatment.

The Benefits of Navien™ Intracranial Support Catheter for Endovascular Treatment

Objective

Endovascular treatment is one of the most important treatments along with open craniotomy for cerebrovascular surgery. The successful treatment of endovascular disease relies on appropriate instruments and the surgeon's skill. Endovascular treatment needs to provide safe and stable access to the catheter cavity. Additionally, it is important to maintain a round shape without changing to an oval shape. The catheter for endovascular treatment has to be flexible and accommodate at least 0.027 inches of inner diameter. The 6-Fr Navien™ Intracranial Support Catheter (formerly the ReFlex Intracranial Catheter; Covidien Vascular Therapies, Mansfield, MA, USA) provides 0.072 inches of inner diameter.

Materials and Methods

We reviewed 61 cases for 56 cases of endovascular treatment with a Navien catheter. A triaxial system was used for all procedures with femoral arterial access. The Navien catheter was placed in the petrous segment of the internal carotid artery or third segment of the vertebral artery. The patients had various shapes of intracranial arteries, including tortuous vessels.

Results

The Navien catheter was used for 61 cases of endovascular treatment. We had 59 cases of coil embolization at unruptured and ruptured aneurysms and two cases of stent insertion into the middle cerebral artery. All the cases were successful without any catheter-related complications.

Conclusion

The Navien catheter is a recently developed catheter that has several strengths compared with previously developed catheters. It provides a more stable environment for endovascular treatment. It provides a cavity sufficient for endovascular treatment devices. Additionally, it is sufficiently flexible to approach tortuous vessels.

Complications and follow up of subarachnoid hemorrhages

Complications of subarachnoid hemorrhage are the major life threatening and functional components of the follow up of a ruptured aneurysm. Knowing how to identify these is a key challenge. They vary in type throughout the postoperative follow up period. The aim of this article is firstly to list the main complications of the acute phase (rebleeding, acute hydrocephalus, acute ischemic injury and non-neurological complications), the subacute phase (vasospasm) and the chronic phase of subarachnoid hemorrhages: (chronic hydrocephalus and cognitive disorders) and to describe their major clinical and radiological features. Secondly, we describe the long-term follow up strategy for patients who have suffered a subarachnoid hemorrhage and have been treated endovascularly or by surgery. This follow up involves a combination of clinical consultations, cerebral MRI and at least one review angiogram.

Motor evoked potential monitoring during surgery of middle cerebral artery aneurysms: a cohort study

BACKGROUND

Motor evoked potential (MEP) monitoring has been widely used in brain or spine surgery to recognize potential damage of the pyramidal motor system. However, its ability to detect ischemic injury during middle cerebral artery (MCA) aneurysm surgery remains unclear. A prospective cohort study was designed to evaluate MEP changes during MCA aneurysm surgery.

METHODS

From January 2009 to August 2011, 89 patients underwent MCA aneurysm surgery and were prospectively divided into 2 groups: MEP monitoring group and control group. Based on an amplitude decrement of >50% or loss, a 2-stage warning criterion of MEP changes was established. Concomitant somatosensory evoked potential changes were also recorded. MEP changes occurred in 15 patients, and various methods were used to avoid continued brain ischemia. Indocyanine green angiography and Doppler ultrasonography were performed if needed. A head computed tomography scan was performed immediately and the day after the operation.

RESULTS

At discharge, neither motor status nor Glasgow Coma Scale score was significantly different between the 2 groups. However, at the latest follow-up (mean, 31.9 months), motor status of the patients in the monitoring group was better (P = 0.037). MEP monitoring was identified as an independent prognostic factor for motor outcome in long-term results by multivariate analysis (P = 0.042). Both wave loss and >50% amplitude decrement of MEP monitoring showed good predictive value when used as part of a 2-stage warning criterion.

CONCLUSIONS

MEP monitoring is reliable for evaluation of the ischemic status of the pyramidal motor system during MCA aneurysm surgery and can improve surgical outcomes when used appropriately.

Is a high initial World Federation of Neurosurgery (WFNS) grade really associated with a poor clinical outcome in elderly patients with ruptured intracranial aneurysms treated with coiling?

BACKGROUND

Coiling of ruptured intracranial aneurysms in elderly patients remains debatable in terms of technical feasibility and clinical outcome.

AIMS

In this observational cohort study we aimed to assess the technical feasibility, complication profile and clinical outcomes of elderly patients with subarachnoid hemorrhage (SAH) treated with endovascular therapy.

METHODS

The study included 59 consecutive patients (47 women) aged ≥70 years (mean age 76 years, range 71-84) admitted to our institution with SAH from January 2002 to July 2011. The patients were treated for 66 aneurysms (regular coiling: n=62 (94%), balloon-assisted technique: n=2 (3%), stent and coil technique: n=2 (3%)). World Federation of Neurosurgery (WFNS) grade at admission was 1 in 13 patients, 2 in 23 patients, 3 in 8 patients, 4 in 11 patients and 5 in 4 patients. We analysed data by univariate and multivariate statistical analyses with an emphasis on the initial clinical situation, complications and clinical outcome.

RESULTS

The technical success rate was 98% with a procedure-related deficit rate of 10% and procedure-related death rate of 5%. The Glasgow Outcome Scale score at 6 months was 1 in 15 patients (25.4%), 2 in 8 patients (13.6%), 3 in 14 patients (23.7%), 4 in 11 patients (18.6%) and 5 in 11 patients (18.6%). Patients admitted with a high initial WFNS grade did not differ statistically in terms of clinical outcome. The final clinical outcome was not significantly correlated with age, initial Fisher score or procedure-related complications.

CONCLUSIONS

Endovascular treatment of elderly patients with ruptured cerebral aneurysms is feasible, safe and beneficial regardless of the presenting WFNS score.

Clipping versus coiling for ruptured intracranial aneurysms: a systematic review and meta-analysis

BACKGROUND AND PURPOSE

Endovascular treatment has increasingly been used for aneurismal subarachnoid aneurismal hemorrhage. The aim of this analysis is to assess the current evidence regarding safety and efficiency of clipping compared with coiling.

METHODS

We conducted a meta-analysis of studies that compared clipping with coiling between January 1999 and July 2012. Comparison of binary outcomes between treatment groups was described using odds ratios (OR; clip versus coil).

RESULTS

Four randomized controlled trials and 23 observational studies were included. Randomized controlled trials showed that coiling reduced the 1-year unfavorable outcome rate (OR, 1.48; 95% confidence interval [CI], 1.24-1.76). However, there was no statistical deference in nonrandomized controlled trials (OR, 1.11; 95% CI, 0.96-1.28). Subgroup analysis revealed coiling yielded better outcomes for patients with good preoperative grade (OR, 1.51; 95% CI, 1.24-1.84) than for poor preoperative patients (OR, 0.88; 95% CI 0.56-1.38). Additionally, the incidence of rebleeding is higher after coiling (OR, 0.43; 95% CI, 0.28-0.66), corresponding to a better complete occlusion rate of clipping (OR, 2.43; 95% CI, 1.88-3.13). The 1-year mortality showed no significant difference (OR, 1.07; 95% CI, 0.88-1.30). Vasospasm was more common after clipping (OR, 1.43; 95% CI, 1.07-1.91), whereas the ischemic infarct (OR, 0.74; 95% CI, 0.52-1.06), shunt-dependent hydrocephalus (OR, 0.84; 95% CI, 0.66-1.07), and procedural complication rates (OR, 1.19; 95% CI, 0.67-2.11) did not differ significantly between techniques.

CONCLUSIONS

Coiling yields a better clinical outcome, the benefit being greater in those with a good preoperative grade than those with a poor preoperative grade. However, coiling leads to a greater risk of rebleeding. Well-designed randomized trials with special considerations to the aspect are needed.

Intracranial aneurysms: optimized diagnostic tools call for thorough interdisciplinary treatment strategies

OBJECTIVE

Intracranial aneurysms (IAs) require deliberately selected treatment strategies as they are incrementally found prior to rupture and deleterious subarachnoid haemorrhage (SAH). Multiple and recurrent aneurysms necessitate both neurointerventionalists and neurosurgeons to optimize aneurysmal occlusion in an interdisciplinary effort. The present study was conducted to condense essential strategies from a single neurovascular centre with regard to the lessons learned.

METHOD

Medical charts of 321 consecutive patients treated for IAs at our centre from September 2008 until December 2010 were retrospectively analysed for clinical presentation of the aneurysms, multiplicity and treatment pathways. In addition, a selective Medline search was performed.

RESULTS

A total of 321 patients with 492 aneurysms underwent occlusion of their symptomatic aneurysm: 132 (41.1%) individuals were treated surgically, 189 (58.2%) interventionally; 138 patients presented with a SAH, of these 44.2% were clipped and 55.8% were coiled. Aneurysms of the middle cerebral artery were primarily occluded surgically (88), whereas most of the aneurysms of the internal carotid artery and anterior communicating artery (114) were treated endovascularly. Multiple aneurysms (range 2-5 aneurysms/individual) were diagnosed in 98 patients (30.2%). During the study period 12 patients with recurrent aneurysms were allocated to another treatment modality (previously clip to coil and vice versa).

CONCLUSIONS

Our data show that successful interdisciplinary occlusion of IAs is based on both neurosurgical and neurointerventional therapy. In particular, multiple and recurrent aneurysms require tailored individual approaches to aneurysmal occlusion. This is achieved by a consequent interdisciplinary pondering of the optimal strategy to occlude IAs in order to prevent SAH.

The keyhole concept in aneurysm surgery: results of the past 20 years

BACKGROUND

Improvements in preoperative imaging and intraoperative visualization have led to a refinement in surgical techniques.

OBJECTIVE

Report of a 20-year experience with application of the keyhole technique as a contribution to the ongoing debate on the impact of limited craniotomies in aneurysm surgery.

METHODS

Over a 20-year period, 1000 consecutive patients with 1297 aneurysms were surgically treated in 1062 operations: 651 in the acute stage after SAH and 411 with unruptured aneurysms. The outcome was assessed with the modified Rankin scale and approach-related complications.

RESULTS

The majority of the cases were treated by 4 different keyhole approaches: The supraorbital approach was used in 793 patients for 989 aneurysms, the subtemporal in 48 patients for 50 aneurysms, the interhemispheric in 46 patients for 51 aneurysms, and the retromastoidal in 55 patients for 55 aneurysms. In 120 patients, the classic pterional approach was applied to treat 152 aneurysms. The results of unruptured aneurysms were good (modified Rankin scale ≤ 2) in 96.52%. The complication rates of the keyhole approaches were less than in the pterional group, although the difference did not reach statistical significance.

CONCLUSION

The overall outcome, rate of retreatment, and approach-related complications with keyhole approaches for the management of ruptured and unruptured aneurysms are comparable to recently published conventional surgical aneurysm series. In addition to the common benefits of limited-exposure approaches, this series demonstrates appropriate safety and applicability of the keyhole technique in aneurysm surgery.

In-stent thrombosis and stenosis after neck-remodeling device-assisted coil embolization of intracranial aneurysms

BACKGROUND

Intrinsic thrombosis and stenosis are complications associated with the use of neck-remodeling devices in the treatment of intracranial aneurysms.

OBJECTIVE

To examine the technical and anatomic factors that predict short- and long-term stent patency.

METHODS

We undertook a retrospective review of 161 patients who underwent coil embolization of 168 ruptured and unruptured aneurysms assisted by the use of a neck-remodeling device. One hundred twenty-seven patients had catheter-based angiographic follow-up to evaluate 133 stent-coil constructs (mean, 15.4 months; median, 12.7 months). The technique of microcatheter jailing was used in a majority of patients; nonstandard stent configurations were also used.

RESULTS

Clinical follow-up for all patients who had catheter-based angiograms demonstrated that among 133 stent constructs, a total of 9 (6.8%) had an in-stent event: 6 acute or subacute thrombosis (4.5%) and 3 delayed stenosis or occlusion (2.3%). Seven of these constructs were associated with a symptomatic event (5.3%). A significantly higher rate of in-stent events was seen with the use of constructs to treat anterior communicating artery aneurysms. When all patients are considered, including those who did not receive catheter-based follow-up imaging, 2 of 168 procedures (1.2%) resulted in the death of a patient, and procedural morbidity was 14.9%.

CONCLUSION

From these results and those in the published literature, in-stent complication rates are low in carefully selected patients. The use of dual antiplatelet therapy, sensitivity assays, and glycoprotein IIb/IIIa inhibitors may decrease the rate of acute and chronic in-stent complications.

Impact of International Subarachnoid Aneurysm Trial results on treatment of ruptured intracranial aneurysms in the United States

Object

The utilization of endovascular treatment for ruptured intracranial aneurysms is expected to change since the publication of the International Subarachnoid Aneurysm Trial (ISAT) in 2002. The authors performed this analysis to determine the impact of ISAT results on treatment selection for ruptured intracranial aneurysms and associated in-hospital outcomes using nationally representative data.

Methods

We determined the national estimates of treatments used for ruptured intracranial aneurysms and associated in-hospital outcomes, length of stay, mortality, and cost incurred using the Nationwide Inpatient Survey (NIS) data. The NIS is the largest all-payer inpatient care database in the US and contains data from 986 hospitals approximating a 20% stratified sample of US hospitals. All the variables pertaining to hospitalization were compared between 2000–2002 and 2004–2006, and in-hospital outcomes were analyzed using multivariate analysis.

Results

In the 3-year periods prior to and after the ISAT, there were 70,637 and 77,352 admissions for ruptured intracranial aneurysms, respectively. There was a significant increase in endovascular treatment after publication of the ISAT (trend test, p < 0.0001) The in-hospital mortality for ruptured intracranial aneurysm admissions decreased from 27% to 24% (odds ratio [OR] 0.89, 95% CI 0.83–0.96, p = 0.003) after the publication of the ISAT. The cost of hospitalization after adjusting for procedures practices was not significantly higher after the publication of the ISAT ($21,437 vs $22,817, p < 0.89), but cost of hospitalization was higher in the post-ISAT period for patients undergoing endovascular procedure.

Conclusions

The results of the ISAT have been associated with a prominent change in practice patterns related to the treatment of ruptured aneurysms. The cost of hospitalization has increased and the mortality has decreased, presumably due to a larger proportion of patients receiving any treatment and endovascular treatment.

The combined approach to intracranial aneurysm treatment

BACKGROUND

A consecutive series of patients with intracranial aneurysms in the practice of one neurovascular surgeon was retrospectively reviewed to illustrate that one physician can become proficient in microneurosurgery as well as endovascular surgery and achieve favorable outcomes in both disciplines. This supports one model of training for cerebrovascular surgeons that includes the complimentary practice of open microneurovascular surgery with endovascular surgery.

METHODS

The senior author (HAR) treated 351 patients with 413 aneurysms between July 2001 and March 2007. Of these, 172 patients (216 aneurysms) were treated with open microneurosurgical techniques and 179 patients (197 aneurysms) were treated using endovascular techniques.

RESULTS

Complete obliteration was attained in 94.3% of clipped aneurysms, and 61.9% and 65.9% of coiled aneurysms immediately and after at least 6 months of follow-up, respectively. At latest evaluation, 93% of endovascular patients and 90% of microneurosurgical patients had good clinical outcomes (GOS, 4 or 5; mean follow-up, 23 months; combines ruptured and unruptured cohorts). Procedure-related mortality included 1 surgical patient and 2 endovascular patients.

CONCLUSIONS

Because the fields of microvascular and endovascular surgeries are both technically complex, there has been concern that hybrid cerebrovascular surgeons cannot perform each technique with the skill necessary to achieve good outcomes. When compared to clipping and coiling reviews in the neurosurgical literature, we illustrate that one hybrid neurovascular surgeon is capable of attaining great facility in both techniques and that this type of physician will represent one practice model of cerebrovascular specialist in the future. This has potential implications for the training of hybrid cerebrovascular surgeons.

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

BACKGROUND

Endovascular coil treatment is being used increasingly as an alternative to clipping for some ruptured intracranial aneurysms. The relative benefits of these 2 approaches have yet to be fully established. The aim of this study was to compare the clinical outcome, resource consumption, and cost-effectiveness of endovascular treatment vs surgical clipping in a developing country.

METHODS

The study population consisted of 55 patients with aneurysmal subarachnoid hemorrhage (SAH) identified prospectively from January 2004 to June 2007. Of the 55 patients with ruptured intracranial aneurysms, 31 underwent surgical clipping, whereas 24 were treated via interventional coils. Clinical outcome at 6 months, using the modified Rankin Scale, and cost of treatment related to all aspects of the inpatient stay were evaluated in both groups.

RESULTS

The average age of the patients in the endovascular group was 38 years, whereas in the surgical group, it was 45 years. Most patients (43) were found to be in grades (1 and 2). Of these patients, 18 received coils and 25 were clipped. The remaining 12 patients were of poor grades (3 and 4), of which 6 had coiling and 6 underwent clipping. Most the patients (46/55) had anterior circulation aneurysms, and the rest of the patients (9/55) had posterior circulation aneurysms. The clinical outcome was similar in comparison (good in 81% for clipping and 83% for coiling). The average total cost for patients undergoing endovascular treatment of the aneurysms was $5080, whereas the average total cost of surgical clipping was $3127.

CONCLUSION

Patients with aneurysmal SAH whom we judged to require coiling had higher charges than patients who could be treated by clipping. The benefits of apparent decrease in length of stay in the endovascular group were offset by higher procedure price and cost of consumables. There was no significant difference in clinical outcome at 6 months. We have proposed a risk scoring system to give guidelines regarding the choice of treatment considering size of aneurysm and resource allocation.

Outcomes of ruptured intracranial aneurysms treated by microsurgical clipping and endovascular coiling in a high-volume center

BACKGROUND AND PURPOSE

The purpose of this study was to analyze the 3-month outcomes of patients with aneurysmal subarachnoid hemorrhage (SAH) treated from January 2005 to June 2006. This paper describes the outcomes after treatment of aneurysmal SAH and comparison between patients treated by clipping or coiling in a high volume center.

MATERIALS AND METHODS

A retrospective chart review was performed of records of 195 consecutive patients with SAH. The overall outcome and the pretreatment variables predicting outcomes and the difference between the clipping and coiling groups were analyzed by logistic regression analysis.

RESULTS

A total of 105 (55%) patients had microsurgical clipping and 87 (45%) had endovascular coiling. At 3 months, 69% of patients recovered with no or mild disability. The predictors of a 3-month modified Rankin Scale (mRS) were Hunt and Hess (HH) grade on admission and the presence of intracerebral hemorrhage (ICH). Patients in the coiling group had worse admission grades; they had worse 3-month mRS (2.28 vs 1.73), but this was not significant when the groups were matched (P = .38). Vasospasm rate was significantly higher in the clipping group (66% vs 52%). The immediate incomplete occlusion rate of aneurysms was higher (21.7% vs 7.6%) in the coiling group.

CONCLUSION

The overall results of treatment of aneurysmal SAH have improved. There is no significant difference in the outcomes between the patients in the clipping and coiling groups.

Stenting and Coil Embolization of a Surgically Treated Residual Aneurysm of the Middle Cerebral Artery Bifurcation Associated with Coil Embolization of a Communicating Artery Aneurysm

We describe the case of a 76-year-old man admitted to our hospital for mild subarachnoid haemorrhage detected by CT scan in an aneurysm of the left middle cerebral artery bifurcation treated surgically 29 years earlier and not completely occluded. Angiography disclosed a further aneurysm in the anterior communicating artery. During the same procedure we treated the residual aneurysm in the left middle cerebral artery bifurcation positioning a Neuroform3 stent (Boston) and embolization deploying two biologically active Cerecyte coils (Balt) for a total of 10 cm and excluding the communicating artery aneurysm from the circulation releasing two active Cerecyte coils for a total length of 30.9 cm. The procedure was well tolerated by the patient and did not give rise to neurological deficits.