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Kissling FJ, Goldberg J, Raabe A, Bervini D. Quality of life in patients with unruptured intracranial aneurysms treated conservatively, before and after occlusion. A single center cohort study. World Neurosurg X 2024; 22:100305. [PMID: 38515528 PMCID: PMC10955403 DOI: 10.1016/j.wnsx.2024.100305] [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: 06/26/2023] [Accepted: 02/21/2024] [Indexed: 03/23/2024] Open
Abstract
Introduction Rupture of intracranial aneurysms is the most frequent cause of subarachnoid hemorrhage and is associated with high morbidity. Recommendations for preventive treatment of unruptured aneurysms (UIAs) remain controversial due to inconsistent data on their natural history and the risks associated with treatment. The awareness of being diagnosed with one or more UIAs can provoke feelings of anxiety and psychosocial distress. Therefore, the impact of management on a patients' health perception and quality of life (QoL) is an essential factor to be considered in the treatment decision-making process. Objective The aim of this study was to assess and compare QoL in patients diagnosed with one or more UIAs depending on their treatment as well as their pre- or postoperative status. Material and methods Demographic and clinical data as well as results of the 15D quality of life (15D QoL) questionnaire of 189 patients were prospectively collected and retrospectively analyzed. Patients were categorized into different subgroups, depending on their treatment modalities (conservative, microsurgery or endovascular treatment) and their pre- or postoperative status at the time of completion of the questionnaire. Statistical analysis was performed to compare the different subgroups. Results Conservatively treated patients had similar mean 15D QoL scores as preoperative patients. Despite an initial postoperative QoL reduction and a trend towards recovery and even an improvement of QoL in the long term after UIA occlusion, neither clinically relevant nor statistically significant differences between preoperative and postoperative mean 15D QoL scores were observed. Conclusions Health-related QoL does not significantly change after treatment of UIAs when compared to the preoperative period. Further studies are needed to confirm long-term postoperative quality of life changes as well as treatment-related influencing factors on patients' quality of life.
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Affiliation(s)
| | - Johannes Goldberg
- Department of Neurosurgery, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Andreas Raabe
- Bern University, Bern, Switzerland
- Department of Neurosurgery, Inselspital, Bern University Hospital, Bern, Switzerland
| | - David Bervini
- Bern University, Bern, Switzerland
- Department of Neurosurgery, Inselspital, Bern University Hospital, Bern, Switzerland
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Park SY, Kim SA, An YH, Kim SW, Kim S, Lee JM, Jung Y. Risk Factor Analysis of Complications and Mortality Following Coil Procedures in Patients with Intracranial Unruptured Aneurysms Using a Nationwide Health Insurance Database. J Clin Med 2024; 13:1094. [PMID: 38398408 PMCID: PMC10889784 DOI: 10.3390/jcm13041094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Revised: 02/08/2024] [Accepted: 02/13/2024] [Indexed: 02/25/2024] Open
Abstract
(1) Background: Unruptured intracranial aneurysm (UIA) occurs in 1-2% of the population and is being increasingly detected. Patients with UIA are treated with close observation, endovascular coiling or surgical clipping. The proportion of endovascular coiling has been rising. However, complications such as cerebral infarction (CI), intracranial hemorrhage (ICRH), and death remain crucial issues after coil treatment. (2) Methods: We analyzed the incidence and risk factors of complications after the use of coil in patients with UIA based on the patients' characteristics. We utilized the Health Insurance Review and Assessment (HIRA) database. Patients treated with coils for UIA between 1 January 2015 and 1 December 2021 were retrospectively analyzed. (3) Results: Of the total 35,140 patients, 1062 developed ICRH, of whom 87 died, with a mortality rate of 8.2%. Meanwhile, 749 patients developed CI, of whom 29 died, with a mortality rate of 3.9%. The overall mortality rate was 1.8%. In a univariate analysis of the risk factors, older age, males, a higher Charlson Comorbidity Index (CCI) score, and diabetes increase the risk of CI. Meanwhile, males with higher CCI scores and hemiplegia or paraplegia show increased ICRH risk. Older age, males and metastatic solid tumors relate to increased mortality risk. (4) Conclusions: This study is significant in that the complications based on the patient's underlying medical condition were analyzed.
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Affiliation(s)
- So Yeon Park
- Department of Medicine, College of Medicine, Yeungnam University, Daegu 42415, Republic of Korea
| | - So An Kim
- Department of Medicine, College of Medicine, Yeungnam University, Daegu 42415, Republic of Korea
| | - Yu Hyeon An
- Department of Medicine, College of Medicine, Yeungnam University, Daegu 42415, Republic of Korea
| | - Sang Won Kim
- Medical Research Center, College of Medicine, Yeungnam University, Daegu 42415, Republic of Korea
| | - Saeyoon Kim
- Department of Pediatrics, College of Medicine, Yeungnam University, Daegu 42415, Republic of Korea;
| | - Jae Min Lee
- Department of Pediatrics, College of Medicine, Yeungnam University, Daegu 42415, Republic of Korea;
| | - Youngjin Jung
- Department of Neurosurgery, Yeungnam University Medical Center, Daegu 42415, Republic of Korea
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Metayer T, Blanc R, Smajda S, Desilles JP, Redjem H, Escalard S, Mazighi M, Tayeb AA, Robichon E, Raaisi AA, Boisseau W, Delvoye F, Piotin M. Treated unruptured cerebral aneurysm in elderly patients: a single center study. Neurochirurgie 2024; 70:101522. [PMID: 38101026 DOI: 10.1016/j.neuchi.2023.101522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Revised: 11/10/2023] [Accepted: 11/21/2023] [Indexed: 12/17/2023]
Abstract
INTRODUCTION The increase in life expectancy raises the question of the treatment of unruptured intracranial aneurysms in extremely old patients (>80 years). We present results in terms of occlusion and complications in both symptomatic and asymptomatic aneurysm. METHODS All patients aged >80 years admitted to the Foundation Adolphe de Rothschild between January 1, 2005 and March, 2023 were included. Aneurysms were grouped as compressive and non-compressive. Procedural complications were grouped as symptomatic (i.e., leading to any temporary or permanent neurological deficit) and severe (defined by modified Rankin Scale (mRS) ≥3 at follow-up). RESULTS Forty-two aneurysms were treated in the study period. Coiling (with or without remodeling) was the treatment of choice in 30 patients. Eighteen patients had compressive aneurysm. Six complications occurred (14.2%), all ischemic. The majority of complications occurred in symptomatic aneurysms, in 4 patients (66.6%). One of the patients treated by flow-diverter had severe complications (mRs ≥3) with hemiplegia. CONCLUSION In extremely specific cases, treatment of unruptured aneurysm in people older than 80 years may be considered. Compressive aneurysm is associated with a high risk of complications. Treatments can be endovascular. Further prospective studies are required to confirm this hypothesis.
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Affiliation(s)
- Thomas Metayer
- Department of Neuroradiology, Rothschild Foundation Hospital, Paris, F-75019, France; Normandie Univ, UNICAEN, INSERM, U1237, PhIND "Physiopathology and Imaging of Neurological Disorders", Institut Blood and Brain @ Caen-Normandie, Cyceron, 14000 Caen, France.
| | - Raphael Blanc
- Department of Neuroradiology, Rothschild Foundation Hospital, Paris, F-75019, France
| | - Stanislas Smajda
- Department of Neuroradiology, Rothschild Foundation Hospital, Paris, F-75019, France
| | - Jean Philippe Desilles
- Department of Neuroradiology, Rothschild Foundation Hospital, Paris, F-75019, France; Laboratory of Vascular Translational Science, U1148 INSERM, Paris, France
| | - Hocine Redjem
- Department of Neuroradiology, Rothschild Foundation Hospital, Paris, F-75019, France
| | - Simon Escalard
- Department of Neuroradiology, Rothschild Foundation Hospital, Paris, F-75019, France
| | - Mikael Mazighi
- Department of Neuroradiology, Rothschild Foundation Hospital, Paris, F-75019, France; Laboratory of Vascular Translational Science, U1148 INSERM, Paris, France
| | - Adnan Al Tayeb
- Department of Neuroradiology, Rothschild Foundation Hospital, Paris, F-75019, France
| | - Erwan Robichon
- Department of Neuroradiology, Rothschild Foundation Hospital, Paris, F-75019, France
| | - Amira Al Raaisi
- Department of Neuroradiology, Rothschild Foundation Hospital, Paris, F-75019, France
| | - William Boisseau
- Department of Neuroradiology, Rothschild Foundation Hospital, Paris, F-75019, France
| | - Francois Delvoye
- Department of Neuroradiology, Rothschild Foundation Hospital, Paris, F-75019, France; University of Liège, Liège, Belgium
| | - Michel Piotin
- Department of Neuroradiology, Rothschild Foundation Hospital, Paris, F-75019, France
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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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Siller S, Kunz M, Lauseker M, Dimitriadis K, Dorn F, Tonn JC, Schichor C. The impact of initial counselling for patients' decision-making and the accuracy of interdisciplinary neurovascular board evaluation in elective treatment of unruptured intracranial aneurysms - a German single-centre retrospective study. Clin Neurol Neurosurg 2023; 232:107896. [PMID: 37454599 DOI: 10.1016/j.clineuro.2023.107896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 07/10/2023] [Accepted: 07/11/2023] [Indexed: 07/18/2023]
Abstract
OBJECTIVE Interdisciplinary-neurovascular-boards (INVB) are deemed to find the patient's optimum treatment-modality in elective unruptured intracranial aneurysm-repair (EUIAR). If INVB judges risk/success estimation similar for microsurgical/endovascular EUIAR, the choice for either modality is up to the informed patient. However, it is unknown if the patients' decision-making might be biased by the discipline of initial counselling prior to INVB and if INVB's equal risk/success estimation is finally accurate. METHODS We analysed all our patients with EUIAR after INVB-discussion between 2007 and 2017 and identified those patients where INVB-recommendation estimated similar risk/success rates for both treatment-modalities. We investigated the procedural/outcome parameters and determined if the mode of initial counselling prior to INVB influenced the patients' choice of EUIAR and if INVB's equal risk/success estimation was accurate. RESULTS Within altogether 572 patients with EUIAR during our study period, we identified 99 patients (agemean:58 yrs; m:f=1:2) in whom pre-treatment INVB-discussion estimated risk/success rates for both modalities of EUIAR to be similar. Prior to INVB-discussion, 80 of the 99 patients had been initially counselled in the neurosurgical discipline and 19 patients in the endovascular discipline. The final patients' decision rates for surgical vs. endovascular EUIAR (after secondary consultation of each patient in both disciplines after INVB-discussion) were 67% vs. 33% in the first and 58% vs. 42% in the latter group (no significant difference: p = 0.345). Uni- and multivariate analysis did not show any hints for a bias in patients' decision-making caused by the discipline of initial counselling prior to INVB/secondary bilateral consultations. Clinical and procedural outcome at last follow-up (median:18mos) did not differ between those 66 patients that eventually decided for microsurgical and those 33 patients that eventually decided for endovascular EUIAR, underlining the high accuracy of INVB's pre-treatment risk/success estimations. CONCLUSION Only in a small number of patients, INVB estimates both disciplines to be of equal value for EUIAR which proves to be highly accurate at long-term outcome measures. Initial contact to one or the other neurovascular discipline does not appear to play a significant role in the final patient's decision-making process.
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Affiliation(s)
- Sebastian Siller
- Neurosurgical Clinic, Clinic of the University of Munich (LMU), Campus Grosshadern, Marchioninistrasse 15, 81377 Munich, Germany; Department of Neuroradiology, Clinic of the University of Munich (LMU), Campus Grosshadern, Marchioninistrasse 15, 81377 Munich, Germany.
| | - Mathias Kunz
- Neurosurgical Clinic, Clinic of the University of Munich (LMU), Campus Grosshadern, Marchioninistrasse 15, 81377 Munich, Germany; Department of Neuroradiology, Clinic of the University of Munich (LMU), Campus Grosshadern, Marchioninistrasse 15, 81377 Munich, Germany
| | - Michael Lauseker
- Institute for Medical Information Processing, Biometry and Epidemiology, Clinic of the University of Munich (LMU), Campus Grosshadern, Marchioninistrasse 15, 81377 Munich, Germany; Department of Neuroradiology, Clinic of the University of Munich (LMU), Campus Grosshadern, Marchioninistrasse 15, 81377 Munich, Germany
| | - Konstantinos Dimitriadis
- Neurological Clinic, Clinic of the University of Munich (LMU), Campus Grosshadern, Marchioninistrasse 15, 81377 Munich, Germany; Department of Neuroradiology, Clinic of the University of Munich (LMU), Campus Grosshadern, Marchioninistrasse 15, 81377 Munich, Germany
| | - Franziska Dorn
- Institute for Medical Information Processing, Biometry and Epidemiology, Clinic of the University of Munich (LMU), Campus Grosshadern, Marchioninistrasse 15, 81377 Munich, Germany; Department of Neuroradiology, Clinic of the University of Munich (LMU), Campus Grosshadern, Marchioninistrasse 15, 81377 Munich, Germany; Department of Neuroradiology, University Hospital of Bonn, Venusberg Campus 1, 53127 Bonn, Germany
| | - Joerg-Christian Tonn
- Neurosurgical Clinic, Clinic of the University of Munich (LMU), Campus Grosshadern, Marchioninistrasse 15, 81377 Munich, Germany; Department of Neuroradiology, Clinic of the University of Munich (LMU), Campus Grosshadern, Marchioninistrasse 15, 81377 Munich, Germany
| | - Christian Schichor
- Neurosurgical Clinic, Clinic of the University of Munich (LMU), Campus Grosshadern, Marchioninistrasse 15, 81377 Munich, Germany; Department of Neuroradiology, Clinic of the University of Munich (LMU), Campus Grosshadern, Marchioninistrasse 15, 81377 Munich, Germany
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Chen R, Wen D, Xiao A, Guo R, You C, Liu Y. Clinical characteristics of intracranial aneurysms in elderly patents over 70 years old: a retrospective observational study. BMC Neurol 2022; 22:255. [PMID: 35820817 PMCID: PMC9275156 DOI: 10.1186/s12883-022-02786-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 07/06/2022] [Indexed: 02/08/2023] Open
Abstract
Background Although the characteristics of intracranial aneurysms (IAs) in different age groups have been well documented, they remain relatively unclear in elderly patients due to a lack of large sample studies. Methods Data from IA patients aged more than 70 years who were treated in our centre from January 2016 to January 2020 were retrospectively collected. Results A total of 290 elderly patients (75.9% female) with a mean age of 74.0 ± 4.7 years were analysed. Rupture occurred in 60.7% of patients, 38.6% of whom presented with meningeal irritation, and seizures were noted in 2.3%. A total of 48.9% of the patients with ruptured IAs had initial symptoms presenting with slow development, and the mean delay from ictus was prolonged to 264.2 ± 914.0 hours. In addition, 61.9% of the patients with ruptured IAs had lesions with a maximum diameter of less than 5 mm. A total of 30.3% of the patients had multiple aneurysms, 35.5% had aneurysms with irregular shapes and 54.8% had cerebrovascular atherosclerotic stenosis (CAS). Pulmonary infection (n = 138, 47.6%), hydrocephalus (n = 72, 24.8%), and thrombosis (n = 35, 12.1%) were common complications during hospitalization. By the end of the 1-year follow-up, 22.1% of the patients had unfavourable clinical outcomes, and the mortality rate was 23.4%. Conclusions Several characteristics regarding IAs in elderly patients were reported, including an obvious female predominance; mild, slow initial symptom development causing prolonged admission delay; a low incidence of meningeal irritation and seizures due to decreased electrophysiological activity of the neurons; increased percentages of CAS, multiple aneurysms, and aneurysms with daughter sacs causing a high risk of rupture even for small lesions; a high risk of complications during hospitalization; and relatively poor clinical outcomes.
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Affiliation(s)
- Ruiqi Chen
- Department of Neurosurgery, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang, Chengdu, Sichuan, 610041, P.R. China
| | - Dingke Wen
- Department of Neurosurgery, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang, Chengdu, Sichuan, 610041, P.R. China
| | - Anqi Xiao
- Department of Neurosurgery, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang, Chengdu, Sichuan, 610041, P.R. China
| | - Rui Guo
- Department of Neurosurgery, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang, Chengdu, Sichuan, 610041, P.R. China
| | - Chao You
- Department of Neurosurgery, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang, Chengdu, Sichuan, 610041, P.R. China
| | - Yi Liu
- Department of Neurosurgery, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang, Chengdu, Sichuan, 610041, P.R. China.
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Spiriev T, Laleva L, Alioski N, Dobrikov R, Gelev V, Milev M, Nakov V. Contrast-induced neurotoxicity presented as transient cortical blindness after stent-assisted coiling of a medium-sized unruptured basilar artery aneurysm: A case report and review of the literature. Surg Neurol Int 2022; 13:48. [PMID: 35242414 PMCID: PMC8888313 DOI: 10.25259/sni_1143_2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 01/20/2022] [Indexed: 11/04/2022] Open
Abstract
Background:
Contrast-induced neurotoxicity is a rare event after endovascular diagnostic procedures or interventions and presents as transient neurological deficit. Herewith, we present a case of reversible complete cortical blindness after uneventful stent-assisted coiling of a medium-sized unruptured basilar artery aneurysm.
Case Description:
A 70-year-old woman with a medium-sized 10 mm/6 mm wide neck basilar tip aneurysm was planned for endovascular obliteration of the lesion. The procedure was done under general anesthesia. The contrast agent was iso-osmolar, nonionic. The aneurysm was coiled, and a stent was placed in the left posterior cerebral artery achieving sufficient aneurysm packing. No signs of vessel obliteration were observed during the procedure. On awakening of anesthesia, the patient reported complete visual loss. Ophthalmological examination was normal. The patient was brought back to the angio-suite but there were no signs of parent vessel compromise from the endovascular implants or distal vessel occlusion. An MRI of the brain was done showing no signs of brain ischemia, just mild brain edema in both occipital lobes. Given the results of the radiological studies and clinical presentation, the diagnosis of contrast-induced neurotoxicity was accepted. In 72 h, the patient had complete resolution of the visual loss and was discharged home with no additional neurological worsening.
Conclusion:
Contrast-induced neurotoxicity is a rare event that can occur after uneventful endovascular interventions of the brain vessels. Knowledge of this rare complication, after exclusion of all other possible reversible causes, is important for the treatment and prognosis of the patient.
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Affiliation(s)
- Toma Spiriev
- Department of Neurosurgery, Acibadem CityClinic University Hospital Tokuda, Sofia, Bulgaria
| | - Lili Laleva
- Department of Neurosurgery, Acibadem CityClinic University Hospital Tokuda, Sofia, Bulgaria
| | - Nurfet Alioski
- Department of Neurosurgery, Acibadem CityClinic University Hospital Tokuda, Sofia, Bulgaria
| | - Raicho Dobrikov
- Department of Imaging Diagnostics Acibadem CityClinic University Hospital Tokuda, Sofia, Bulgaria
| | - Valeri Gelev
- Department of Cardiology, Acibadem CityClinic University Hospital Tokuda, Sofia, Bulgaria
| | - Milko Milev
- Department of Neurosurgery, Acibadem CityClinic University Hospital Tokuda, Sofia, Bulgaria
| | - Vladimir Nakov
- Department of Neurosurgery, Acibadem CityClinic University Hospital Tokuda, Sofia, Bulgaria
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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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Lee SH, Lee SU, Kwon OK, Bang JS, Ban SP, Kim T, Kim YD, Byoun HS, Oh CW. Clinical Outcomes of Clipping and Coiling in Elderly Patients with Unruptured Cerebral Aneurysms: a National Cohort Study in Korea. J Korean Med Sci 2021; 36:e178. [PMID: 34227262 PMCID: PMC8258241 DOI: 10.3346/jkms.2021.36.e178] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 06/06/2021] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND We aimed to analyze outcomes of clipping and coiling in treating unruptured intracranial aneurysms (UIAs) in elderly patients and to identify the age at which perioperative risk increases based on national cohort data in South Korea. METHODS The incidence of perioperative intracranial hemorrhage (ICRH), perioperative cerebral infarction (CI), mortality, and moderate to severe disability data of the patients who underwent coiling or clipping for UIAs were retrieved. Estimated breakpoint (EBP) was calculated to identify the age at which the risk of treatment increases. RESULTS A total of 38,207 patients were treated for UIAs. Among these, 22,093 (57.8%) patients underwent coiling and 16,114 (42.2%) patients underwent clipping. The incidence of ICRH, requiring a secondary operation, within 3 months in patients ≥ 65 years that underwent coiling and clipping was 1.13% and 4.81%, respectively, and that of both groups assessed were significantly higher in patients ≥ 75 years (coiling, P = 0.013, relative risk (RR) 1.81; clipping, P = 0.015) than younger patients. The incidence of CI within 3 months in patients aged ≥ 65 was 13.90% and 9.19% in the coiling and clipping groups, respectively. The incidence of CI after coiling in patients aged ≥ 75 years (P < 0.001, RR 1.96) and after clipping in patients aged ≥ 70 years (P < 0.001, RR 1.76) was significantly higher than that in younger patients. The mortality rates within 1 year in patients with perioperative ICRH or CI were 2.41% and 3.39% for coiling and clipping groups, respectively, in patients ≥ 65. These rates increased significantly at age 70 in the coiling group and at age 75 for the clipping group (P = 0.012 and P < 0.001, respectively). CONCLUSION The risk of treatment increases with age, and this risk increases dramatically in patients aged ≥ 70 years. Therefore, the treatment decisions in patients aged ≥ 70 years should be made with utmost care.
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Affiliation(s)
- Sang Hyo Lee
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Si Un Lee
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seongnam, Korea
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea.
| | - O Ki Kwon
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seongnam, Korea
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea
| | - Jae Seung Bang
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seongnam, Korea
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea
| | - Seung Pil Ban
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seongnam, Korea
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea
| | - Tackeun Kim
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seongnam, Korea
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea
| | - Young Deok Kim
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seongnam, Korea
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea
| | - Hyoung Soo Byoun
- Department of Neurosurgery, Chungnam University Sejong Hospital, Sejong, Korea
| | - Chang Wan Oh
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seongnam, Korea
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea.
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Daou BJ, Muhlestein WE, Palmateer G, Thompson BG, Pandey AS. Clipping of unruptured intracranial aneurysms in patients older than sixty: An age-based analysis. Clin Neurol Neurosurg 2021; 207:106737. [PMID: 34134009 DOI: 10.1016/j.clineuro.2021.106737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 06/03/2021] [Accepted: 06/05/2021] [Indexed: 11/19/2022]
Abstract
OBJECTIVE The diagnosis of unruptured intracranial aneurysms (UIAs) is being made more frequently in elderly patients. The goal of this study is to evaluate complications and clinical outcome in patients ≥ 60 years-old who underwent clipping of UIAs. METHODS We performed a retrospective cohort study. Clinical outcome (modified Rankin scale score) was determined at the latest clinical follow-up. Complications and outcomes were compared between age groups (60-69, 70-80) and subgroups (60-64, 65-69, 70-74, and >75). RESULTS The study population consisted of 255 patients (range 60-80 years-old) who underwent 262 clipping procedures for UIAs. Mean follow-up duration was 15.6 months (± 27.5). Major complications occurred in 20 patients (7.6%) and mortality in 3 patients (1.1%). Medical complications occurred in 26 patients (10%). Mean length of hospital-stay was 4.7 days (± 5.8). 89.6% were discharged to home. 87.8% had a favorable clinical outcome. The 70-80 age group had significantly more complications (P = 0.03) than the 60-69 group and a significantly longer hospital stay (6.02 vs. 4.3 days, P = 0.04). The older group was less likely to discharge to home and more likely to require rehabilitation (P = 0.002). Favorable clinical outcome did not significantly differ between the two groups (85.7% vs. 88.4%, P = 0.56). There was a trend for increasing complications from the younger to older subgroups (P = 0.008) and a reduction in the likelihood to discharge to home (P < 0.0001). The rate of ultimate favorable clinical outcome did not differ significantly between subgroups (P = 0.79). CONCLUSION Although complications, length of hospital-stay, and discharge to non-home destinations increase with older age, the majority of patients ≥ 60 may have favorable clinical outcomes.
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Affiliation(s)
- Badih J Daou
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, United States
| | - Whitney E Muhlestein
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, United States
| | - Gregory Palmateer
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, United States
| | - B Gregory Thompson
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, United States
| | - Aditya S Pandey
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, United States.
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11
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Sun Z, Yan X, Li X, Wu J. Evaluation of Surgical Clipping and Endovascular Coiling on Oculomotor Nerve Palsy Caused by Internal Carotid Artery Aneurysm. Front Neurol 2020; 11:609003. [PMID: 33362706 PMCID: PMC7759633 DOI: 10.3389/fneur.2020.609003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 11/05/2020] [Indexed: 11/13/2022] Open
Abstract
Objectives: Internal carotid artery (ICA) aneurysm often leads to oculomotor nerve palsy (ONP) that impairs eye movement. Currently, microsurgical clipping and endovascular coiling are the two major options to treat ONP. The purpose of the current study is to compare the clinical outcomes of the two methods in patients with ONP caused by ICA aneurysm. Patients and Methods: In the present study, we assessed the prognostic factors and recovery outcomes of a total of 90 ICA aneurysm-induced ONP patients, where 50 of them were treated with microsurgical clipping and 40 of them were treated with endovascular coiling. Within the endovascular coiling group, 20 of the patients were treated with balloon-assisted coiling and the other 20 were treated with stent-assisted coiling. Results: Overall, we achieved a 59% (53 out of 90) full recovery rate. Both surgical clipping and endovascular coiling treatment methods achieved similar recovery outcomes in the tested patients. However, within the endovascular coiling group, balloon-assisted coiling treatment demonstrated a significantly higher full recovery rate (17 out of 20) compared to stent-assisted coiling treatment (eight out of 20). Conclusion: In general, no significant difference was identified between the surgical and coiling treatments, and both procedures were considered as beneficial for ICA aneurysm-induced ONP.
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Affiliation(s)
- Zhenqing Sun
- Department of Neurosurgery, Guangdong 999 Brain Hospital, Guangzhou, China
| | - Xueqiang Yan
- Department of Neurosurgery, Guangdong 999 Brain Hospital, Guangzhou, China
| | - Xiaolong Li
- Department of Neurosurgery, Guangdong 999 Brain Hospital, Guangzhou, China
| | - Jie Wu
- Department of Neurosurgery, Guangdong 999 Brain Hospital, Guangzhou, China
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12
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Ruigrok YM. Management of Unruptured Cerebral Aneurysms and Arteriovenous Malformations. Continuum (Minneap Minn) 2020; 26:478-498. [PMID: 32224762 DOI: 10.1212/con.0000000000000835] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE OF REVIEW Unruptured intracranial aneurysms and brain arteriovenous malformations (AVMs) may be detected as incidental findings on cranial imaging. This article provides a practical approach to the management of unruptured intracranial aneurysms and unruptured brain AVMs and reviews the risk of rupture, risk factors for rupture, preventive treatment options with their associated risks, and the approach of treatment versus observation for both types of vascular malformations. RECENT FINDINGS For unruptured intracranial aneurysms, scoring systems on the risk of rupture can help with choosing preventive treatment or observation with follow-up imaging. Although the literature provides detailed information on the complication risks of preventive treatment of unruptured intracranial aneurysms, individualized predictions of these procedural complication risks are not yet available. With observation with imaging, growth of unruptured intracranial aneurysms can be monitored, and prediction scores for growth can help determine the optimal timing of monitoring. The past years have revealed more about the risk of complications of the different treatment modalities for brain AVMs. A randomized clinical trial and prospective follow-up data have shown that preventive interventional therapy in patients with brain AVMs is associated with a higher rate of neurologic morbidity and mortality compared with observation. SUMMARY The risk of hemorrhage from both unruptured intracranial aneurysms and brain AVMs varies depending on the number of risk factors associated with hemorrhage. For both types of vascular malformations, different preventive treatment options are available, and all carry risks of complications. For unruptured intracranial aneurysms, the consideration of preventive treatment versus observation is complex, and several factors should be included in the decision making. Overall, it is recommended that patients with unruptured asymptomatic brain AVMs should be observed.
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13
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Thavara BD, Yamada Y, Joshi G, Tanaka R, Miyatani K, Devareddy G, Nakao K, Kawase T, Kato Y. Analysis of the Surgical Outcome of Unruptured Intracranial Saccular Aneurysms in Octogenarians (80-89 Years). Asian J Neurosurg 2020; 15:640-643. [PMID: 33145219 PMCID: PMC7591182 DOI: 10.4103/ajns.ajns_44_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Revised: 04/07/2020] [Accepted: 04/25/2020] [Indexed: 11/28/2022] Open
Abstract
Background: The prevalence of unruptured intracranial aneurysms is increasing in elderly population in Japan. Octogenarians (80–89 years) are more prone to complications due to increased age, comorbidities, increased risk of vasospasm, and treatment risks. Aim: The aim is to study the surgical outcome of unruptured intracranial saccular aneurysms in elderly patients aged between 80 and 89 years. Patients and Methods: A retrospective study was conducted involving all the cases of unruptured intracranial saccular aneurysms operated surgically in elderly patients aged between 80 and 89 years. All the cases operated between January 2017 and October 2019 were included in the study. The preoperative neurological status was assessed using the Glasgow Coma Scale (GCS). The comorbidities and risk factors involved were assessed. Postoperative neurological status was assessed by (1) postoperative GCS score and by the (2) presence or absence of the motor weakness of limbs. Results: Thirty-three aneurysms were operated in 27 patients. Two patients were operated two times at separate occasions for different aneurysms during the study period and hence making a total of 29 surgeries. The age range was 80–88 years, with a mean of 82.4 years ± 2.64 standard deviation (SD). There were 7 (24.1%) males and 22 (75.86%) females. All the patients had a preoperative GCS score of 15/15 without focal neurological deficit. The mean size (mm) of the aneurysms was 6.57 ± 4.04 SD. There were 31 (93.94%) aneurysms in the anterior circulation and 2 (6.06%) aneurysms in the posterior circulation. The comorbidities and risk factors were analyzed and found to be not influencing the outcome of the patients. Clipping was done in 32 aneurysms. One case of posterior inferior cerebellar artery (PICA) aneurysm underwent occipital artery to PICA bypass surgery. The postoperative complications include chronic subdural hematoma (CSDH) in 7 (24.13%) patients, extradural hematoma in 1 (3.4%), meningitis in 1 (3.4%), and lower cranial nerve palsy in 1 (3.4%) patient. All the patients were discharged with GCS score 15/15 without motor weakness of the limbs. The mean duration of stay was 16.62 days ± 9.98 SD. Conclusion: Surgery for unruptured saccular aneurysms in octogenarians has got a good result in the tertiary care facility. Advanced age alone should not be considered for preferring coiling over clipping. Octogenarians are more prone to developing postoperative CSDH.
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Affiliation(s)
- Binoy Damodar Thavara
- Department of Neurosurgery, Government Medical College, Thrissur, Kerala, India.,Department of Neurosurgery, Fujita Health University Bantane Hospital, Nagoya, Aichi, Japan
| | - Yasuhiro Yamada
- Department of Neurosurgery, Fujita Health University Bantane Hospital, Nagoya, Aichi, Japan
| | - Girish Joshi
- Department of Neurosurgery, Fujita Health University Bantane Hospital, Nagoya, Aichi, Japan.,Department of Neurosurgery, Apollo Speciality Hospital, Bengaluru, Karnataka, India
| | - Riki Tanaka
- Department of Neurosurgery, Government Medical College, Thrissur, Kerala, India
| | - Kyosuke Miyatani
- Department of Neurosurgery, Government Medical College, Thrissur, Kerala, India
| | - Gowtham Devareddy
- Department of Neurosurgery, Fujita Health University Bantane Hospital, Nagoya, Aichi, Japan.,Department of Neurosurgery, Dr. Rela Institute and Medical Centre, Chennai, Tamil Nadu, India
| | - Kazutaka Nakao
- Department of Neurosurgery, Fujita Health University Bantane Hospital, Nagoya, Aichi, Japan
| | - Tsukasa Kawase
- Department of Neurosurgery, Fujita Health University Bantane Hospital, Nagoya, Aichi, Japan
| | - Yoko Kato
- Department of Neurosurgery, Fujita Health University Bantane Hospital, Nagoya, Aichi, Japan
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14
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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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15
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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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16
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Kang XK, Guo SF, Lei Y, Wei W, Liu HX, Huang LL, Jiang QL. Endovascular coiling versus surgical clipping for the treatment of unruptured cerebral aneurysms: Direct comparison of procedure-related complications. Medicine (Baltimore) 2020; 99:e19654. [PMID: 32221092 PMCID: PMC7220217 DOI: 10.1097/md.0000000000019654] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Endovascular coiling and surgical clipping are routinely used to treat unruptured cerebral aneurysms (UCAs). However, the evidence to support the efficacy of these approaches is limited. We aimed to analyze the efficacy of endovascular coiling compared with surgical clipping in patients with UCAs. METHOD A systematic search of 4 databases was conducted to identify comparative articles involving endovascular coiling and surgical clipping in patients with UCAs. We conducted a meta-analysis using the random-effects model when I> 50%. Otherwise, a meta-analysis using the fixed-effects model was performed. RESULTS Our results showed that endovascular coiling was associated with a shorter length of stay (WMD: -4.14, 95% CI: (-5.75, -2.531), P < .001) and a lower incidence of short-term complications compared with surgical clipping (OR: 0.518; 95% CI (0.433, 0.621); P < .001), which seems to be a result of ischemia complications (OR: 0.423; 95% CI (0.317, 0.564); P < .001). However, surgical clipping showed a higher rate of complete occlusion after surgery, in both short-term (OR: 0.179, 95% CI (0.064, 0.499), P = .001) and 1-year follow-ups (OR: 0.307, 95% CI (0.146, 0.646), P = .002), and a lower rate of short-term retreatment (OR: 0.307, 95% CI (0.146, 0.646), P = .002). Meanwhile, there was no significant difference in postoperative death, bleeding, and modified Rankin Scale (mRS) > 2 between the 2 groups. CONCLUSIONS The latest evidence illustrates that surgical clipping resulted in lower retreatment rates and was associated with a higher incidence of complete occlusion, while endovascular coiling was associated with shorter LOS and a lower rate of complications, especially ischemia.
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Affiliation(s)
- Xiao-kui Kang
- Department of Neurosurgery, Liaocheng People's Hospital, Liaocheng, Shandong
| | - Sheng-fu Guo
- Department of Neurosurgery, Liaocheng People's Hospital, Liaocheng, Shandong
| | - Yi Lei
- Department of Gynaecology and Obstetrics, Anyi County People's Hospital, Nanchang
| | - Wei Wei
- Department of Neurology, Mianyang Central Hospital, Sichuan
| | | | - Li-li Huang
- Department of Endocrinology, Liaocheng People's Hospital, Liaocheng, Shandong, China
| | - Qun-long Jiang
- Department of Neurosurgery, Liaocheng People's Hospital, Liaocheng, Shandong
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17
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A Propensity Score-Matched Comparison of Readmission Rates Associated With Microsurgical Clipping and Endovascular Treatment of Ruptured Intracranial Aneurysms. J Stroke Cerebrovasc Dis 2020; 29:104696. [PMID: 32089437 DOI: 10.1016/j.jstrokecerebrovasdis.2020.104696] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2019] [Revised: 01/08/2020] [Accepted: 01/25/2020] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND In the treatment of aneurysmal subarachnoid hemorrhage (aSAH), microsurgical clipping, and endovascular therapy (EVT) with coiling are modalities for securing the ruptured aneurysm. Little data is available regarding associated readmission rates. We sought to determine whether readmission rates differed according to treatment modality for ruptured intracranial aneurysms. METHODS The Nationwide Readmissions Database (NRD) was used to identify adults who experienced aSAH and underwent clipping or EVT. Primary outcomes of interest were the incidences of 30- and 90-day readmissions (30dRA, 90dRA). Propensity score matching was used to generate matched pairs based on age, comorbidities, hospital volume, and hemorrhage severity. RESULTS We identified 13,623 and 11,160 patients who were eligible for 30dRA and 90dRA analyses, respectively. Among the patients eligible for 30dRA and 90dRA, we created 4282 and 3518 propensity score-matched pairs, respectively. There was no difference in the incidence of 30dRA (12.4% for clipping versus 11.2% for EVT; P = .094). However, 90dRA occurred more frequently after clipping (22.5%) compared to EVT (19.7%; P = .003). Clipping was associated with poor outcome after 30dRA (odds ratio [OR] = 1.51, 95% confidence interval [CI] 1.21-1.88, P < .001) and after 90dRA (OR = 1.60, 95% CI 1.34-1.91, P = .001). Mean duration to readmission and cost of readmission did not vary, but clipping was associated with longer lengths of stay during readmission. CONCLUSIONS Microsurgical clipping of ruptured aneurysms is associated with a greater incidence of 90dRA, but not 30dRA, compared to EVT. Poor outcomes after readmission are more common following clipping.
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18
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Hoffman H, Protas M, Chin LS. Causes, Predictors, and Trends of Unplanned Readmissions after Elective Endovascular Embolization of Cerebral Aneurysms. J Stroke Cerebrovasc Dis 2019; 28:104396. [PMID: 31540783 DOI: 10.1016/j.jstrokecerebrovasdis.2019.104396] [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: 08/02/2019] [Accepted: 09/04/2019] [Indexed: 10/26/2022] Open
Abstract
BACKGROUND 30- and 90-day readmissions (dRA) are being increasingly scrutinized as quality metrics for hospital and provider performances. Little information regarding risk factors for readmission after elective endovascular treatment (EVT) of an unruptured cerebral aneurysm (UCA) is available. METHODS The Nationwide Readmissions Database was used to identify patients who underwent elective endovascular embolization of an unruptured aneurysm between 2010 and 2014. The primary outcomes of interest were unplanned readmissions occurring within 30 or 90 days of discharge. Binary logistic regressions were used to identify variables related to patients' demographics, comorbidities, and index hospital admission that were associated with 30dRA and 90dRA. RESULTS A total of 8588 patients met the inclusion criteria for 30dRA analysis and 7289 patients were eligible for 90dRA analysis. The 5-year 30dRA and 90dRA readmission rates were 7.1% and 13.5%, respectively. The annual incidences of 30dRAs and 90dRAs between 2010 and 2014 decreased significantly (pooled odds ratio (OR) for 30dRA: .874, 95% confidence interval (CI) .765-.998; pooled OR for 90dRA: .841, 95% CI .755-.938). Patients in higher income quartiles experienced decreased odds of 30dRA and 90dRA. Nonroutine disposition following the index admission and greater comorbidity burdens were associated with higher likelihoods of both 30dRA and 90dRA. The presence of pulmonary or cardiac complications was associated with increased odds of 90dRA. CONCLUSION Readmission rates after elective EVT of UCAs decreased between 2010 and 2014. We identified several novel risk factors for both 30dRAs and 90dRAs that can be used to identify patients who are at highest risk of readmission.
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Affiliation(s)
- Haydn Hoffman
- Department of Neurosurgery, State University of New York Upstate Medical University, Syracuse, NY, USA.
| | - Matthew Protas
- Department of Neurosurgery, State University of New York Upstate Medical University, Syracuse, NY, USA
| | - Lawrence S Chin
- Department of Neurosurgery, State University of New York Upstate Medical University, Syracuse, NY, USA
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Rojas Concha HA, Simões RT, Dellaretti M, Rubatino FVM. Trends for in-hospital metrics in the treatment of intracranial aneurysms in Minas Gerais, Brazil. Hosp Pract (1995) 2019; 47:163-169. [PMID: 31340694 DOI: 10.1080/21548331.2019.1646073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Background: Aneurysmal subarachnoid hemorrhage (ASAH) and unruptured aneurysm (URA) are particularly important because of the high mortality rates, and physical and cognitive impairment, which affect the economically active population. The present work aims at describing the scenario regarding in-hospital indicators related to the following therapeutic approaches: vascular microsurgery (VMS) and endovascular therapy (EVT) in the state of Minas Gerais, Brazil, in order to gather information to construct hypotheses and plan actions. Methods: The study has an ecological design and it is also analytical for the time trends of 2008-2014. Trends for VMS and EVT therapies and mortality are estimated using linear regression, followed by the Prais-Winsten procedure. Data were obtained through Hospital Information System (Sistema de Informações Hospitalares - SIH) of Brazilian Public Health System (Sistema Único de Saúde - SUS). Results: In 2014, 601 procedures were performed, and out of these, 373 (62%) were triggered by SAH and 228 (38%) by URA. The frequency of procedures performed in males and in females results in a ratio of 1:2 for SAH procedures and 1:3 for URA procedures. A heterogeneous distribution of therapeutic approaches was seen among the hospital studied, suggesting a technological preference, which determines the therapeutic approach. Conclusion: Technological bias was observed for aneurysm treatment in Minas Gerais's hospitals. EVT is seen to have a growing trend to detriment of VMS (β1 = 0.024; p = 0.025), with a stable mortality for both therapeutics in both pathologies (SAH and URA). EVT has been associated with a shorter hospital stay, with higher expenses for both ASAH and URA treatment. EVT showed an inverse correlation with in-hospital fatality for ASAH treatment.
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Affiliation(s)
| | - Renata Toscano Simões
- Instituto de Ensino e Pesquisa da Santa Casa de Belo Horizonte , Belo Horizonte , Brazil
| | - Marcos Dellaretti
- Instituto de Ensino e Pesquisa da Santa Casa de Belo Horizonte , Belo Horizonte , Brazil
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20
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Malhotra A, Wu X, Forman HP, Matouk CC, Hughes DR, Gandhi D, Sanelli P. Management of Unruptured Intracranial Aneurysms in Older Adults: A Cost-effectiveness Analysis. Radiology 2019; 291:411-417. [PMID: 30888931 DOI: 10.1148/radiol.2019182353] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Background Unruptured intracranial aneurysms (UIAs) are relatively common and are being increasingly diagnosed, with a significant proportion in older patients (˃ 65 years old). Serial imaging is often performed to assess change in size or morphology of UIAs since growing aneurysms are known to be at high risk for rupture. However, the frequency and duration of surveillance imaging have not been established. Purpose To evaluate the cost-effectiveness of routine treatment (aneurysm coil placement) versus four different strategies for imaging surveillance of UIAs in adults older than 65 years. Materials and Methods A Markov decision-analytic model was constructed from a societal perspective. Age-dependent input parameters were obtained from published literature. Analysis included adults older than 65 years, with incidental detection of UIA and no prior history of subarachnoid hemorrhage. Five different management strategies for UIAs in older adults were evaluated: (a) annual MR angiography, (b) biennial MR angiography, (c) MR angiography every 5 years, (d) coil placement and follow-up, and (e) limited MR angiography follow-up for the first 2 years after detection only. Outcomes were assessed in terms of quality-adjusted life-years (QALYs). Probabilistic, one-way, and two-way sensitivity analyses were performed. Results Imaging follow-up for the first 2 years after detection is the most cost-effective strategy (cost = $24 572, effectiveness = 13.73 QALYs), showing the lowest cost and highest effectiveness. The conclusion remains robust in probabilistic and one-way sensitivity analyses. Time-limited imaging follow-up remains the optimal strategy when the annual growth rate and rupture risk of growing aneurysms are varied. If annual rupture risk of nongrowing aneurysms is greater than 7.1%, coil placement should be performed directly. Conclusion Routine preventive treatment or periodic, indefinite imaging follow-up is not a cost-effective strategy in all adults older than 65 years with unruptured intracranial aneurysms. More aggressive management strategies should be reserved for patients with high risk of rupture, such as those with aneurysms larger than 7 mm and those with aneurysms in the posterior circulation. © RSNA, 2019 Online supplemental material is available for this article. See also the editorial by Cloft in this issue.
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Affiliation(s)
- Ajay Malhotra
- From the Departments of Radiology and Biomedical Imaging (A.M., X.W., H.P.F., C.C.M.), Economics (H.P.F.), Management (H.P.F.), Public Health (H.P.F.), and Neurosurgery (C.C.M.), Yale School of Medicine, 333 Cedar St, Box 208042, Tompkins East 2, New Haven, CT 06520-8042; Harvey L. Neiman Health Policy Institute, Reston, VA (D.R.H.); Department of Radiology, University of Maryland School of Medicine, Baltimore, MD (D.G.); and Department of Radiology, Northwell Health, Manhasset, NY (P.S.)
| | - Xiao Wu
- From the Departments of Radiology and Biomedical Imaging (A.M., X.W., H.P.F., C.C.M.), Economics (H.P.F.), Management (H.P.F.), Public Health (H.P.F.), and Neurosurgery (C.C.M.), Yale School of Medicine, 333 Cedar St, Box 208042, Tompkins East 2, New Haven, CT 06520-8042; Harvey L. Neiman Health Policy Institute, Reston, VA (D.R.H.); Department of Radiology, University of Maryland School of Medicine, Baltimore, MD (D.G.); and Department of Radiology, Northwell Health, Manhasset, NY (P.S.)
| | - Howard P Forman
- From the Departments of Radiology and Biomedical Imaging (A.M., X.W., H.P.F., C.C.M.), Economics (H.P.F.), Management (H.P.F.), Public Health (H.P.F.), and Neurosurgery (C.C.M.), Yale School of Medicine, 333 Cedar St, Box 208042, Tompkins East 2, New Haven, CT 06520-8042; Harvey L. Neiman Health Policy Institute, Reston, VA (D.R.H.); Department of Radiology, University of Maryland School of Medicine, Baltimore, MD (D.G.); and Department of Radiology, Northwell Health, Manhasset, NY (P.S.)
| | - Charles C Matouk
- From the Departments of Radiology and Biomedical Imaging (A.M., X.W., H.P.F., C.C.M.), Economics (H.P.F.), Management (H.P.F.), Public Health (H.P.F.), and Neurosurgery (C.C.M.), Yale School of Medicine, 333 Cedar St, Box 208042, Tompkins East 2, New Haven, CT 06520-8042; Harvey L. Neiman Health Policy Institute, Reston, VA (D.R.H.); Department of Radiology, University of Maryland School of Medicine, Baltimore, MD (D.G.); and Department of Radiology, Northwell Health, Manhasset, NY (P.S.)
| | - Danny R Hughes
- From the Departments of Radiology and Biomedical Imaging (A.M., X.W., H.P.F., C.C.M.), Economics (H.P.F.), Management (H.P.F.), Public Health (H.P.F.), and Neurosurgery (C.C.M.), Yale School of Medicine, 333 Cedar St, Box 208042, Tompkins East 2, New Haven, CT 06520-8042; Harvey L. Neiman Health Policy Institute, Reston, VA (D.R.H.); Department of Radiology, University of Maryland School of Medicine, Baltimore, MD (D.G.); and Department of Radiology, Northwell Health, Manhasset, NY (P.S.)
| | - Dheeraj Gandhi
- From the Departments of Radiology and Biomedical Imaging (A.M., X.W., H.P.F., C.C.M.), Economics (H.P.F.), Management (H.P.F.), Public Health (H.P.F.), and Neurosurgery (C.C.M.), Yale School of Medicine, 333 Cedar St, Box 208042, Tompkins East 2, New Haven, CT 06520-8042; Harvey L. Neiman Health Policy Institute, Reston, VA (D.R.H.); Department of Radiology, University of Maryland School of Medicine, Baltimore, MD (D.G.); and Department of Radiology, Northwell Health, Manhasset, NY (P.S.)
| | - Pina Sanelli
- From the Departments of Radiology and Biomedical Imaging (A.M., X.W., H.P.F., C.C.M.), Economics (H.P.F.), Management (H.P.F.), Public Health (H.P.F.), and Neurosurgery (C.C.M.), Yale School of Medicine, 333 Cedar St, Box 208042, Tompkins East 2, New Haven, CT 06520-8042; Harvey L. Neiman Health Policy Institute, Reston, VA (D.R.H.); Department of Radiology, University of Maryland School of Medicine, Baltimore, MD (D.G.); and Department of Radiology, Northwell Health, Manhasset, NY (P.S.)
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Cheikh A, Kasinathan S, Yasuhiro Y, Kawase T, Kato Y. Surgical Management of Unruptured Cerebral Aneurysms in the Elderly: An Institution Experience. Asian J Neurosurg 2019; 14:730-736. [PMID: 31497093 PMCID: PMC6703043 DOI: 10.4103/ajns.ajns_233_18] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Background and Purpose: The elderly population is increasing in the world, especially in developed countries. The gain in life expectancy is remarkable in Japan, consequently incidence of aneurysms increases in this population. The purpose of this study is to evaluate the surgical treatment and outcome of patients aged more than 75 years treated for unruptured intracranial aneurysms. Patients and Methods: We conducted a retrospective study for unruptured cerebral aneurysms operated between September 2014 and August 31, 2018, in Fujita Health University, Banbuntane Hotokukai Hospital, for people aged more than 75 years. A demographic study was done. We also studied aneurysm location, aneurysm size, outcome, duration of stay, and complications. Results: About 61 patients aged more than 75 years were operated in 4 years, comprising 12 males and 45 females. The mean age was 79.32 ± 3.29 years. Mean size of the aneurysm was 6.22 ± 3.28. Aneurysm location (P = 0.0037), associated risk factors (P = 0.006), and association of hypertension and diabetes (P = 0.0362) influence outcome. Length of stay is directly correlated with outcome (P = 0.009). Conclusions: Elder patients with hypertension and diabetes or associated risk factors having a posterior circulation aneurysm have a poor diagnosis.
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Affiliation(s)
- Abderrahmane Cheikh
- Department of Neurosurgery, Ali Ait Idir Hospital and Medical School of Algiers - Algiers University 1, Algiers, Algeria
| | - Sudhakar Kasinathan
- Department of Neurosurgery, Institute of Neurosurgery, Madras Medical College and Rajiv Gandhi Government General Hospital, Chennai, Tamil Nadu, India
| | - Yamada Yasuhiro
- Department of Neurosurgery, Banbutane Hotkukai Hospital, Fujita Health University, Toyoake, Nagoya, Aichi Prefecture, Japan
| | - Tsukasa Kawase
- Department of Neurosurgery, Banbutane Hotkukai Hospital, Fujita Health University, Toyoake, Nagoya, Aichi Prefecture, Japan
| | - Yoko Kato
- Department of Neurosurgery, Banbutane Hotkukai Hospital, Fujita Health University, Toyoake, Nagoya, Aichi Prefecture, Japan
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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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Abstract
Advances in neuroimaging and its widespread use for screening have increased the diagnosis of unruptured intracranial aneurysms (UIAs), including small-sized UIAs. The clinical management of these small-sized UIAs requires a patient-specific judgment of the risk of aneurysm rupture, if not treated, versus the risk of complications from surgical or endovascular treatment. Experienced cerebrovascular teams recommend treating small UIAs in young patients or in patients with more than one aneurysm rupture risk factor who also have a reasonable life expectancy. However, individual overall assessment of risk is critical for patients with UIAs to decide the next steps of care.
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Affiliation(s)
- Jan-Karl Burkhardt
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Arnau Benet
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Michael T Lawton
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, USA.
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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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Bekelis K, Missios S, MacKenzie TA, Tjoumakaris S, Jabbour P. Anesthesia Technique and Outcomes of Mechanical Thrombectomy in Patients With Acute Ischemic Stroke. Stroke 2017; 48:361-366. [PMID: 28070000 DOI: 10.1161/strokeaha.116.015343] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2016] [Revised: 11/28/2016] [Accepted: 11/30/2016] [Indexed: 01/05/2023]
Abstract
BACKGROUND AND PURPOSE The impact of anesthesia technique on the outcomes of mechanical thrombectomy for acute ischemic stroke remains an issue of debate. We investigated the association of general anesthesia with outcomes in patients undergoing mechanical thrombectomy for ischemic stroke. METHODS We performed a cohort study involving patients undergoing mechanical thrombectomy for ischemic stroke from 2009 to 2013, who were registered in the New York Statewide Planning and Research Cooperative System database. An instrumental variable (hospital rate of general anesthesia) analysis was used to simulate the effects of randomization and investigate the association of anesthesia technique with case-fatality and length of stay. RESULTS Among 1174 patients, 441 (37.6%) underwent general anesthesia and 733 (62.4%) underwent conscious sedation. Using an instrumental variable analysis, we identified that general anesthesia was associated with a 6.4% increased case-fatality (95% confidence interval, 1.9%-11.0%) and 8.4 days longer length of stay (95% confidence interval, 2.9-14.0) in comparison to conscious sedation. This corresponded to 15 patients needing to be treated with conscious sedation to prevent 1 death. Our results were robust in sensitivity analysis with mixed effects regression and propensity score-adjusted regression models. CONCLUSIONS Using a comprehensive all-payer cohort of acute ischemic stroke patients undergoing mechanical thrombectomy in New York State, we identified an association of general anesthesia with increased case-fatality and length of stay. These considerations should be taken into account when standardizing acute stroke care.
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Affiliation(s)
- Kimon Bekelis
- From the Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, PA (K.B., S.T., P.J.); The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH (K.B., T.A.M.); Neuroscience Institute, Cleveland Clinic/Akron General Hospital, OH (S.M.); and Department of Medicine (T.A.M.) and Department of Community and Family Medicine (T.A.M.), Dartmouth-Hitchcock Medical Center, Lebanon, NH.
| | - Symeon Missios
- From the Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, PA (K.B., S.T., P.J.); The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH (K.B., T.A.M.); Neuroscience Institute, Cleveland Clinic/Akron General Hospital, OH (S.M.); and Department of Medicine (T.A.M.) and Department of Community and Family Medicine (T.A.M.), Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Todd A MacKenzie
- From the Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, PA (K.B., S.T., P.J.); The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH (K.B., T.A.M.); Neuroscience Institute, Cleveland Clinic/Akron General Hospital, OH (S.M.); and Department of Medicine (T.A.M.) and Department of Community and Family Medicine (T.A.M.), Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Stavropoula Tjoumakaris
- From the Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, PA (K.B., S.T., P.J.); The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH (K.B., T.A.M.); Neuroscience Institute, Cleveland Clinic/Akron General Hospital, OH (S.M.); and Department of Medicine (T.A.M.) and Department of Community and Family Medicine (T.A.M.), Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Pascal Jabbour
- From the Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, PA (K.B., S.T., P.J.); The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH (K.B., T.A.M.); Neuroscience Institute, Cleveland Clinic/Akron General Hospital, OH (S.M.); and Department of Medicine (T.A.M.) and Department of Community and Family Medicine (T.A.M.), Dartmouth-Hitchcock Medical Center, Lebanon, NH
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