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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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2
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Ishikawa T, Ikawa F, Ichihara N, Yamaguchi K, Funatsu T, Nakatomi H, Shiokawa Y, Sorimachi T, Murayama Y, Suzuki K, Kurita H, Fukuda H, Ueba T, Shimamura N, Ohkuma H, Morioka J, Nakahara I, Uezato M, Chin M, Kawamata T. Superiority of Endovascular Coiling Over Surgical Clipping for Clinical Outcomes at Discharge in Patients With Poor-Grade Subarachnoid Hemorrhage: A Registry Study in Japan. Neurosurgery 2023:00006123-990000000-00980. [PMID: 38038438 DOI: 10.1227/neu.0000000000002782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 10/11/2023] [Indexed: 12/02/2023] Open
Abstract
BACKGROUND AND OBJECTIVES The differences in clinical outcomes between endovascular coiling (EC) and surgical clipping (SC) in patients with poor-grade aneurysmal subarachnoid hemorrhage (aSAH) are controversial. Therefore, this study aimed to evaluate whether EC is superior to SC and identify risk factors in patients with poor-grade aSAH. METHODS We used data from the "Predict for Outcome Study of aneurysmal SubArachnoid Hemorrhage." World Federation of Neurological Societies (WFNS) grade III-V aSAH was defined as poor-grade aSAH, and unfavorable clinical outcomes (modified Rankin Scale scores 3-6) were compared between SC and EC after propensity score matching (PSM). In-hospital mortality was similarly evaluated. Predictors of unfavorable clinical outcomes were identified using multivariable analysis. RESULTS Ultimately, 1326 (SC: 847, EC: 479) and 632 (SC: 316, EC: 316) patients with poor-grade aSAH were included before and after PSM, respectively. Unfavorable clinical outcomes at discharge were significantly different between SC and EC before (72.0% vs 66.2%, P = .026) and after PSM (70.6% vs 63.3%, P = .025). In-hospital mortality was significantly different between groups before PSM (10.5% vs 16.1%, P = .003) but not after PSM (10.4% vs 12.7%, P = .384). Predictors of unfavorable clinical outcomes in both SC and EC were WFNS grade V, older than 70 years, and Fisher computed tomography (CT) grade 4. Predictors of unfavorable clinical outcomes only in SC were WFNS grade IV (odds ratio: 2.46, 95% CI: 1.22-4.97, P = .012) and Fisher CT grade 3 (4.90, 1.42-16.9, P = .012). Predictors of unfavorable clinical outcome only in EC were ages of 50s (3.35, 1.37-8.20, P = .008) and 60s (3.28, 1.43-7.52, P = .005). CONCLUSION EC resulted in significantly more favorable clinical outcomes than SC in patients with poor-grade aSAH, without clear differences in in-hospital mortality. The benefit of EC over SC might be particularly remarkable in patients with WFNS grade IV and Fisher CT grade 3.
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Affiliation(s)
- Tatsuya Ishikawa
- Department of Neurosurgery, Tokyo Women's Medical University, Shinjuku, Tokyo, Japan
| | - Fusao Ikawa
- Department of Neurosurgery, Shimane Prefectural Central Hospital, Izumo, Shimane, Japan
| | - Nao Ichihara
- Department of Healthcare Quality Assessment, University of Tokyo, Tokyo, Japan
- Department of Cardiovascular Surgery, Jikei University, Tokyo, Japan
| | - Koji Yamaguchi
- Department of Neurosurgery, Tokyo Women's Medical University, Shinjuku, Tokyo, Japan
| | - Takayuki Funatsu
- Department of Neurosurgery, Tokyo Women's Medical University, Shinjuku, Tokyo, Japan
| | | | | | | | - Yuichi Murayama
- Department of Neurosurgery, The Jikei University School of Medicine, Minato, Tokyo, Japan
| | - Kaima Suzuki
- Department of Cerebrovascular Surgery, Saitama Medical University International Medical Center, Hidaka, Saitama, Japan
| | - Hiroki Kurita
- Department of Cerebrovascular Surgery, Saitama Medical University International Medical Center, Hidaka, Saitama, Japan
| | - Hitoshi Fukuda
- Department of Neurosurgery, Kochi Medical School, Kochi University, Nankoku, Kochi, Japan
| | - Tetsuya Ueba
- Department of Neurosurgery, Kochi Medical School, Kochi University, Nankoku, Kochi, Japan
| | - Norihito Shimamura
- Department of Neurosurgery, Hirosaki University, Hirosaki, Aomori, Japan
- Department of Neurosurgery, Hirosaki General Medical Center, National Hospital Organization, Hirosaki, Aomori, Japan
| | - Hiroki Ohkuma
- Department of Neurosurgery, Hirosaki University, Hirosaki, Aomori, Japan
- Department of Neurosurgery, Hirosaki General Medical Center, National Hospital Organization, Hirosaki, Aomori, Japan
| | - Jun Morioka
- Department of Comprehensive Strokology, Fujita Health University, Toyoake, Aichi, Japan
| | - Ichiro Nakahara
- Department of Comprehensive Strokology, Fujita Health University, Toyoake, Aichi, Japan
| | - Minami Uezato
- Department of Neurosurgery, Kurashiki Central Hospital, Kurashiki, Okayama, Japan
| | - Masaki Chin
- Department of Neurosurgery, Kurashiki Central Hospital, Kurashiki, Okayama, Japan
| | - Takakazu Kawamata
- Department of Neurosurgery, Tokyo Women's Medical University, Shinjuku, Tokyo, Japan
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3
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Charalambous LT, Adil SM, Rajkumar S, Gramer R, Kirsch E, Liu B, Zomorodi A, McClellan M, Lad SP. A Nationwide Analysis of Aneurysmal Subarachnoid Hemorrhage Mortality, Complications, and Health Economics in the USA. Transl Stroke Res 2023; 14:347-356. [PMID: 35881231 PMCID: PMC10149048 DOI: 10.1007/s12975-022-01065-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 06/21/2022] [Accepted: 07/13/2022] [Indexed: 11/25/2022]
Abstract
Aneurysmal subarachnoid hemorrhage (aSAH) is a devastating neurological condition. Endovascular coiling or surgical clipping have equivocal success rates, but relatively little is known regarding the health economics and complications of these procedures at the population level. We aimed to analyze the complication profiles and healthcare resource utilization (HRCU) associated with the treatment of aSAH in the USA. We performed a retrospective analysis utilizing the IBM MarketScan database between 2008 and 2015. Primary outcomes included economic analysis stratified by post-operative complication; determination of the effect of several factors on total cost by multivariable regression; and analysis of the incidence, timing, and associated HCRU of aSAH-related post-operative complications. Of the 2374 patients meeting inclusion criteria for economic analysis, 1783 (75.1%) patients had at least one of the ten complications. The most common complications included hydrocephalus (43.8%), transient cerebral ischemia (including vasospasm) (30.6%), ischemic stroke (29.1%), syndrome of inappropriate antidiuretic hormone (SIADH)/hyposmolarity/hyponatremia (22.1%), and seizures (14.9%). Patients who experienced complications had higher median 90-day total costs [$161,127 (Q1 to Q3, $101,411 to $257,662)] than those who did not [$97,376 (Q1 to Q3, $55,692 to $147,447)]. Length of stay was longest for those with pulmonary embolism and pneumonia (27 days) and shortest for those with SIADH/hyposmolarity/hyponatremia (16 days). Brain compression/herniation had the highest mortality rate (19.5%). In total, 14.6% of all patients experienced a readmission within 30 days. In conclusion, patients with aSAH have high post-operative complication rates and costs. Development of novel interventions to reduce complications and improve outcomes is crucial.
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Affiliation(s)
- Lefko T Charalambous
- Department of Neurosurgery, Duke University Medical Center, Duke University, Box 3807, Durham, NC, 27710, USA.
| | - Syed M Adil
- Department of Neurosurgery, Duke University Medical Center, Duke University, Box 3807, Durham, NC, 27710, USA
| | - Shashank Rajkumar
- Department of Neurosurgery, Duke University Medical Center, Duke University, Box 3807, Durham, NC, 27710, USA
| | - Robert Gramer
- Department of Neurosurgery, Duke University Medical Center, Duke University, Box 3807, Durham, NC, 27710, USA
| | - Elayna Kirsch
- Department of Neurosurgery, Duke University Medical Center, Duke University, Box 3807, Durham, NC, 27710, USA
| | - Beiyu Liu
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, NC, USA
| | - Ali Zomorodi
- Department of Neurosurgery, Duke University Medical Center, Duke University, Box 3807, Durham, NC, 27710, USA
| | - Mark McClellan
- Duke-Robert J. Margolis Center for Health Policy, Duke University, Box 3807, Durham, NC, 27710, USA
| | - Shivanand P Lad
- Department of Neurosurgery, Duke University Medical Center, Duke University, Box 3807, Durham, NC, 27710, USA.
- Duke-Robert J. Margolis Center for Health Policy, Duke University, Box 3807, Durham, NC, 27710, USA.
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Kurogi R, Kada A, Ogasawara K, Nishimura K, Kitazono T, Iwama T, Matsumaru Y, Sakai N, Shiokawa Y, Miyachi S, Kuroda S, Shimizu H, Yoshimura S, Osato T, Horie N, Nagata I, Nozaki K, Date I, Hashimoto Y, Hoshino H, Nakase H, Kataoka H, Ohta T, Fukuda H, Tamiya N, Kurogi AI, Ren N, Nishimura A, Arimura K, Shimogawa T, Yoshimoto K, Onozuka D, Ogata S, Hagihara A, Saito N, Arai H, Miyamoto S, Tominaga T, Iihara K. National trends in the outcomes of subarachnoid haemorrhage and the prognostic influence of stroke centre capability in Japan: retrospective cohort study. BMJ Open 2023; 13:e068642. [PMID: 37037619 PMCID: PMC10111904 DOI: 10.1136/bmjopen-2022-068642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/12/2023] Open
Abstract
OBJECTIVES To examine the national, 6-year trends in in-hospital clinical outcomes of patients with subarachnoid haemorrhage (SAH) who underwent clipping or coiling and the prognostic influence of temporal trends in the Comprehensive Stroke Center (CSC) capabilities on patient outcomes in Japan. DESIGN Retrospective study. SETTING Six hundred and thirty-one primary care institutions in Japan. PARTICIPANTS Forty-five thousand and eleven patients with SAH who were urgently hospitalised, identified using the J-ASPECT Diagnosis Procedure Combination database. PRIMARY AND SECONDARY OUTCOME MEASURES Annual number of patients with SAH who remained untreated, or who received clipping or coiling, in-hospital mortality and poor functional outcomes (modified Rankin Scale: 3-6) at discharge. Each CSC was assessed using a validated scoring system (CSC score: 1-25 points). RESULTS In the overall cohort, in-hospital mortality decreased (year for trend, OR (95% CI): 0.97 (0.96 to 0.99)), while the proportion of poor functional outcomes remained unchanged (1.00 (0.98 to 1.02)). The proportion of patients who underwent clipping gradually decreased from 46.6% to 38.5%, while that of those who received coiling and those left untreated gradually increased from 16.9% to 22.6% and 35.4% to 38%, respectively. In-hospital mortality of coiled (0.94 (0.89 to 0.98)) and untreated (0.93 (0.90 to 0.96)) patients decreased, whereas that of clipped patients remained stable. CSC score improvement was associated with increased use of coiling (per 1-point increase, 1.14 (1.08 to 1.20)) but not with short-term patient outcomes regardless of treatment modality. CONCLUSIONS The 6-year trends indicated lower in-hospital mortality for patients with SAH (attributable to better outcomes), increased use of coiling and multidisciplinary care for untreated patients. Further increasing CSC capabilities may improve overall outcomes, mainly by increasing the use of coiling. Additional studies are necessary to determine the effect of confounders such as aneurysm complexity on outcomes of clipped patients in the modern endovascular era.
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Affiliation(s)
- Ryota Kurogi
- Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Akiko Kada
- Department of Clinical Research Management, National Hospital Organization Nagoya Medical Center, Nagoya, Japan
| | - Kuniaki Ogasawara
- Department of Neurosurgery, Iwate Medical University, Morioka, Japan
| | - Kunihiro Nishimura
- Department of Preventive Medicine and Epidemiology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Takanari Kitazono
- Department of Medicine and Clinical Science, Graduate School of Medical Science, Kyushu University, Fukuoka, Japan
| | - Toru Iwama
- Department of Neurosurgery, Gifu University Graduate School of Medicine, Yanagido, Japan
| | - Yuji Matsumaru
- Division of Stroke Prevention and Treatment, Department of Neurosurgery, University of Tsukuba, Tsukuba, Japan
| | - Nobuyuki Sakai
- Department of Neurosurgery, Kobe City General Hospital, Kobe, Japan
| | | | - Shigeru Miyachi
- Department of Neurosurgery, Neuroendovascular Therapy Center, Aichi Medical University, Nagakute, Japan
| | - Satoshi Kuroda
- Department of Neurosurgery, Toyama University, Toyama, Japan
| | - Hiroaki Shimizu
- Department of Neurosurgery, Akita University Graduate School of Medicine, Akita, Japan
| | - Shinichi Yoshimura
- Department of Neurosurgery, Hyogo College of Medicine, Nishinomiya, Japan
| | - Toshiaki Osato
- Department of Neurosurgery, Nakamura Memorial Hospital, Sapporo, Japan
| | - Nobutaka Horie
- Department of Neurosurgery, Hiroshima University Hospital, Hiroshima, Japan
| | - Izumi Nagata
- Department of Neurosurgery, Kokura Memorial Hospital, Kita-kyushu, Japan
| | - Kazuhiko Nozaki
- Department of Neurosurgery, Shiga University of Medical Science, Otsu, Japan
| | - Isao Date
- Department of Neurological Surgery, Okayama University Graduate School of Medicine, Okayama, Japan
| | | | - Haruhiko Hoshino
- Department of Neurology, Tokyo Saiseikai Central Hospital, Tokyo, Japan
| | - Hiroyuki Nakase
- Department of Neurosurgery, Nara Medical University, Nara, Japan
| | - Hiroharu Kataoka
- Department of Neurosurgery, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Tsuyoshi Ohta
- Department of Neurosurgery, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Hitoshi Fukuda
- Department of Neurosurgery, Kochi Medical School, Nankoku, Japan
| | - Nanako Tamiya
- Department of Health Services Research, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - A I Kurogi
- Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Nice Ren
- Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Ataru Nishimura
- Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Koichi Arimura
- Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Takafumi Shimogawa
- Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Koji Yoshimoto
- Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Daisuke Onozuka
- Department of Preventive Medicine and Epidemiology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Soshiro Ogata
- Department of Preventive Medicine and Epidemiology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Akihito Hagihara
- Department of Preventive Medicine and Epidemiology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Nobuhito Saito
- Department of Neurosurgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Hajime Arai
- Department of Neurosurgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Susumu Miyamoto
- Department of Neurosurgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Teiji Tominaga
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Koji Iihara
- Director General, National Cerebral and Cardiovascular Center Hospital, Suita, Japan
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Gaub M, Kromenacker B, Avila MJ, Gonzales-Portillo GS, Aguilar-Salinas P, Dumont TM. Evolution of open surgery for unruptured intracranial aneurysms over a fifteen year period-increased difficulty and morbidity. J Clin Neurosci 2023; 107:178-183. [PMID: 36443125 DOI: 10.1016/j.jocn.2022.10.010] [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: 05/01/2022] [Revised: 09/27/2022] [Accepted: 10/10/2022] [Indexed: 11/27/2022]
Abstract
OBJECTIVE The approach to intervention for unruptured intracranial aneurysms (UIAs) remains controversial. Utilization of endovascular techniques for aneurysm repair increased dramatically during the last decade. We sought to analyze recent national trends for electively treated (open and endovascular) UIAs focusing on pre-existing patient disease burden and intervention modality selection. METHODS The Nationwide Inpatient Sample (NIS) national database was used to identify patients with primary diagnosis codes of unruptured intracranial aneurysm between 1999 and 2014. Patients were dichotomized by intervention into endovascular or open surgical treatment. Analysis of pre-existing disease severity were calculated using the Elixhauser comorbidity index. Complications of combined peri-procedural stroke or death during admission and hospital length of stay were used as primary endpoints for comparison. RESULTS The percent of total UIAs treated electively with open approach decreased from more than 95 % of cases in 1999 to less than 25 % in 2014. Patients undergoing clipping were 3 years younger than those in the endovascular group (p < 0.001). The rate of primary endpoint complications (stroke and death) and length of stay for open cases saw a decrease throughout the study but remained statistically higher when compared to the endovascular group over the study period (p < 0.001). Additionally, non-neurologic complications increased over the time period for open cases. The average preoperative co-morbid disease severity for all groups treated increased over this interval. Conversely, the relative volume of endovascular cases increased but the rate of complications and average group disease remained statistically lower than the surgical clipping group (p < 0.05). CONCLUSION The percent of UIAs treated electively with open approach has decreased since 1999 with a concomitant increase in complication rate in particular compared to endovascular cases. However, the health characteristics of patients treated with surgical clipping show an increase in severity of pre-existing co-morbidities. Further research into factors contributing to this finding, including potential socioeconomic differences and changes in surgeon experience are needed.
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Affiliation(s)
- Michael Gaub
- The University of Arizona, College of Medicine, Tucson, AZ, United States; UT Health San Antonio, United States
| | - Bryan Kromenacker
- The University of Arizona, College of Medicine, Tucson, AZ, United States
| | - Mauricio J Avila
- The University of Arizona, College of Medicine, Tucson, AZ, United States; Department of Neurosurgery, University of Arizona, Tucson, AZ, United States
| | | | - Pedro Aguilar-Salinas
- The University of Arizona, College of Medicine, Tucson, AZ, United States; Department of Neurosurgery, University of Arizona, Tucson, AZ, United States
| | - Travis M Dumont
- The University of Arizona, College of Medicine, Tucson, AZ, United States; Department of Neurosurgery, University of Arizona, Tucson, AZ, United States.
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Balcerzak A, Tubbs RS, Zielinska N, Olewnik Ł. Clinical analysis of cavernous sinus anatomy, pathologies, diagnostics, surgical management and complications - comprehensive review. Ann Anat 2022; 245:152004. [PMID: 36183938 DOI: 10.1016/j.aanat.2022.152004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Revised: 09/02/2022] [Accepted: 09/05/2022] [Indexed: 11/24/2022]
Abstract
For decades, the cavernous sinus (CS) has been the subject of debates and scientific studies aimed at elucidating its anatomical variability, and at choosing the best method for accessing it so that optimal diagnoses and related surgical treatments can be decided. The present review considers a series of issues related to the CS. The anatomy of the CS and its features is explored first, and the most important structures, spaces and morphological variations are considered. This is followed by CS pathology and selected diagnostic methods that have proved useful in therapy, and then the management of these pathologies is discussed. Examples of therapeutic steps that have proved helpful in specific cases are taken from the literature. Finally, the various surgical accesses and complications that can be encountered during invasive interventions in the CS area are discussed. The aim of this study is to summarize up-to-date anatomical and clinical knowledge about the CS, citing the most informative scientific papers and aggregating their results. Morphological variations of the CS are common but have not been well described in the literature.
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Affiliation(s)
- Adrian Balcerzak
- Department of Anatomical Dissection and Donation, Medical University of Lodz, Poland
| | - R Shane Tubbs
- Department of Neurosurgery, Tulane University School of Medicine, New Orleans, LA, USA; Department of Neurosurgery and Ochsner Neuroscience Institute, Ochsner Health System, New Orleans, LA, USA; Department of Anatomical Sciences, St. George's University, Grenada; Department of Structural and Cellular Biology, Tulane University School of Medicine, New Orleans, LA, USA; Department of Surgery, Tulane University School of Medicine, New Orleans, LA, USA; University of Queensland, Brisbane, Australia
| | - Nicol Zielinska
- Department of Anatomical Dissection and Donation, Medical University of Lodz, Poland
| | - Łukasz Olewnik
- Department of Anatomical Dissection and Donation, Medical University of Lodz, Poland.
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7
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Yarahmadi P, Kabiri A, Bavandipour A, Jabbour P, Yousefi O. Intra-procedural complications, success rate, and need for retreatment of endovascular treatments in anterior communicating artery aneurysms: a systematic review and meta-analysis. Neurosurg Rev 2022; 45:3157-3170. [PMID: 36029421 DOI: 10.1007/s10143-022-01853-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 07/30/2022] [Accepted: 08/19/2022] [Indexed: 11/28/2022]
Abstract
In recent years, intracranial aneurysms have been widely treated with endovascular methods. The anterior communicating artery (Acom) is the most common site of intracranial aneurysms. Despite its effectiveness, endovascular interventions can be associated with various intra-procedural and post-procedural complications. A systematic review of the literature was performed through PubMed, Embase, Scopus, and Web of Sciences databases up to March 18, 2022. The pooled rates of intra-procedural complications, mortality, procedure-related morbidities, the immediate and late aneurysm occlusion, and also the necessity for retreatment were calculated by applying random-effects models. A total of 41 articles with 4583 patients were included in the meta-analysis. The pooled rate of overall intra-procedural complications was 9.6% (95% CI: 7.7 to 11.8%). The initial rupture status and also type of EVT procedure did not affect the overall complication rate. The pooled rate of intra-procedural thrombosis, aneurysm rupture, coil prolapse, and early aneurysm rebleeding were 6.1% (95% CI: 4.5 to 8.2%); 4.2% (95% CI: 3.4 to 5.2%), 4.7% (95% CI: 3.2 to 6.7%), and 2.2% (95% CI: 1.5 to 3.2%), respectively. Our analysis showed that intra-procedural mortality occurred in 1.7% (95% CI: 1.1 to 2.5%) and procedure-related permanent morbidities in 3.3% (95% CI: 2.3 to 4.7%) of patients. Endovascular methods achieved complete and near to complete aneurysm occlusion (Raymond-Roy occlusion classification 1 and 2) in 89.2% (95% CI: 86.4 to 92.5%) of cases post-procedure, and 9.5% (95% CI: 7.3 to 12.4%) of patients needed retreatment due to recanalization in follow-ups. Endovascular treatment can serve as an acceptable method for Acom aneurysms. However, improved endovascular treatment equipment and new techniques provide more satisfactory outcomes for complicated cases.
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Affiliation(s)
- Pourya Yarahmadi
- Faculty of Medicine, Tehran University of Medical Sciences, Medicine, Tehran, Iran
| | - Ali Kabiri
- Faculty of Medicine, Iran University of Medical Sciences, Medicine, Tehran, Iran
| | | | - Pascal Jabbour
- Division of Neurovascular Surgery and Endovascular Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA, USA
| | - Omid Yousefi
- Trauma Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.
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8
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Belavadi R, Gudigopuram SVR, Raguthu CC, Gajjela H, Kela I, Kakarala CL, Hassan M, Sange I. Surgical Clipping Versus Endovascular Coiling in the Management of Intracranial Aneurysms. Cureus 2021; 13:e20478. [PMID: 35047297 PMCID: PMC8760002 DOI: 10.7759/cureus.20478] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/17/2021] [Indexed: 01/16/2023] Open
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9
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Huang JY, Lin HY, Wei QQ, Pan XH, Liang NC, Gao W, Shi SL. Relationship between annualized case volume and in-hospital motality in subarachnoid hemorrhage: A systematic review and meta-analysis. Medicine (Baltimore) 2021; 100:e27852. [PMID: 35049186 PMCID: PMC9191364 DOI: 10.1097/md.0000000000027852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Accepted: 11/01/2021] [Indexed: 11/25/2022] Open
Abstract
Studies on the relationship between hospital annualized case volume and in-hospital mortality in patients with subarachnoid hemorrhage (SAH) have shown conflicting results. Therefore, we performed a meta-analysis to further examine this relationship.The authors searched the PubMed and Embase databases from inception through July 2020 to identify studies that assessed the relationship between hospital annualized SAH case volume and in-hospital SAH mortality. Studies that reported in-hospital mortality in SAH patients and an adjusted odds ratio (OR) comparing mortality between low-volume and high-volume hospitals or provided core data to calculate an adjusted OR were eligible for inclusion. No language or human subject restrictions were imposed.Five retrospective cohort studies with 46,186 patients were included for analysis. The pooled estimate revealed an inverse relationship between annualized case volume and in-hospital mortality (OR, 0.53; 95% confidence interval, 0.42-0.68, P < .0001). This relationship was consistent in almost all subgroup analyses and was robust in sensitivity analyses.This meta-analysis confirms an inverse relationship between hospital annualized SAH case volume and in-hospital SAH mortality. Higher annualized case volume was associated with lower in-hospital mortality.
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Affiliation(s)
- Jian-Yi Huang
- Department of Neurology, People's Hospital of Chongzuo city, Chongzuo, Guangxi Zhuang Autonomous Region, China
| | - Hong-Yu Lin
- Department of Neurology, People's Hospital of Chongzuo city, Chongzuo, Guangxi Zhuang Autonomous Region, China
| | - Qing-Qing Wei
- Department of Neurology, People's Hospital of Chongzuo city, Chongzuo, Guangxi Zhuang Autonomous Region, China
| | - Xing-Hua Pan
- Department of Neurology, People's Hospital of Chongzuo city, Chongzuo, Guangxi Zhuang Autonomous Region, China
| | - Ning-Chao Liang
- Department of Neurology, People's Hospital of Chongzuo city, Chongzuo, Guangxi Zhuang Autonomous Region, China
| | - Wen Gao
- Department of Neurology, People's Hospital of Liuzhou city, Liuzhou, Guangxi Zhuang Autonomous Region, China
| | - Sheng-Liang Shi
- Department of Neurology, Second Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi Zhuang Autonomous Region, China
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10
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Pontes FGDB, da Silva EM, Baptista-Silva JC, Vasconcelos V. Treatments for unruptured intracranial aneurysms. Cochrane Database Syst Rev 2021; 5:CD013312. [PMID: 33971026 PMCID: PMC8109849 DOI: 10.1002/14651858.cd013312.pub2] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Unruptured intracranial aneurysms are relatively common lesions in the general population, with a prevalence of 3.2%, and are being diagnosed with greater frequency as non-invasive techniques for imaging of intracranial vessels have become increasingly available and used. If not treated, an intracranial aneurysm can be catastrophic. Morbidity and mortality in aneurysmal subarachnoid hemorrhage are substantial: in people with subarachnoid hemorrhage, 12% die immediately, more than 30% die within one month, 25% to 50% die within six months, and 30% of survivors remain dependent. However, most intracranial aneurysms do not bleed, and the best treatment approach is still a matter of debate. OBJECTIVES To assess the risks and benefits of interventions for people with unruptured intracranial aneurysms. SEARCH METHODS We searched CENTRAL (Cochrane Library 2020, Issue 5), MEDLINE Ovid, Embase Ovid, and Latin American and Caribbean Health Science Information database (LILACS). We also searched ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform from inception to 25 May 2020. There were no language restrictions. We contacted experts in the field to identify further studies and unpublished trials. SELECTION CRITERIA Unconfounded, truly randomized trials comparing conservative treatment versus interventional treatments (microsurgical clipping or endovascular coiling) and microsurgical clipping versus endovascular coiling for individuals with unruptured intracranial aneurysms. DATA COLLECTION AND ANALYSIS Two review authors independently selected trials for inclusion according to the above criteria, assessed trial quality and risk of bias, performed data extraction, and applied the GRADE approach to the evidence. We used an intention-to-treat analysis strategy. MAIN RESULTS We included two trials in the review: one prospective randomized trial involving 80 participants that compared conservative treatment to endovascular coiling, and one randomized controlled trial involving 136 participants that compared microsurgical clipping to endovascular coiling for unruptured intracranial aneurysms. There was no difference in outcome events between conservative treatment and endovascular coiling groups. New perioperative neurological deficits were more common in participants treated surgically (16/65, 24.6%; 15.8% to 36.3%) versus 7/69 (10.1%; 5.0% to 19.5%); odds ratio (OR) 2.87 (95% confidence interval (CI) 1.02 to 8.93; P = 0.038). Hospitalization for more than five days was more common in surgical participants (30/65, 46.2%; 34.6% to 58.1%) versus 6/69 (8.7%; 4.0% to 17.7%); OR 8.85 (95% CI 3.22 to 28.59; P < 0.001). Clinical follow-up to one year showed 1/48 clipped versus 1/58 coiled participants had died, and 1/48 clipped versus 1/58 coiled participants had become disabled (modified Rankin Scale > 2). All the evidence is of very low quality. AUTHORS' CONCLUSIONS There is currently insufficient good-quality evidence to support either conservative treatment or interventional treatments (microsurgical clipping or endovascular coiling) for individuals with unruptured intracranial aneurysms. Further randomized trials are required to establish if surgery is a better option than conservative management, and if so, which surgical approach is preferred for which patients. Future studies should include consideration of important characteristics such as participant age, gender, aneurysm size, aneurysm location (anterior circulation and posterior circulation), grade of ischemia (major stroke), and duration of hospitalizations.
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Affiliation(s)
| | - Edina Mk da Silva
- Emergency Medicine and Evidence Based Medicine, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Jose Cc Baptista-Silva
- Evidence Based Medicine, Cochrane Brazil, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Vladimir Vasconcelos
- Department of Surgery, Division of Vascular and Endovascular Surgery, Universidade Federal de São Paulo, São Paulo, Brazil
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11
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Kurogi R, Kada A, Ogasawara K, Kitazono T, Sakai N, Hashimoto Y, Shiokawa Y, Miyachi S, Matsumaru Y, Iwama T, Tominaga T, Onozuka D, Nishimura A, Arimura K, Kurogi A, Ren N, Hagihara A, Nakaoku Y, Arai H, Miyamoto S, Nishimura K, Iihara K. Effects of case volume and comprehensive stroke center capabilities on patient outcomes of clipping and coiling for subarachnoid hemorrhage. J Neurosurg 2021; 134:929-939. [DOI: 10.3171/2019.12.jns192584] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Accepted: 12/30/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVEImproved outcomes in patients with subarachnoid hemorrhage (SAH) treated at high-volume centers have been reported. The authors sought to examine whether hospital case volume and comprehensive stroke center (CSC) capabilities affect outcomes in patients treated with clipping or coiling for SAH.METHODSThe authors conducted a nationwide retrospective cohort study in 27,490 SAH patients who underwent clipping or coiling in 621 institutions between 2010 and 2015 and whose data were collected from the Japanese nationwide J-ASPECT Diagnosis Procedure Combination database. The CSC capabilities of each hospital were assessed by use of a validated scoring system based on answers to a previously reported 25-item questionnaire (CSC score 1–25 points). Hospitals were classified into quartiles based on CSC scores and case volumes of clipping or coiling for SAH.RESULTSOverall, the absolute risk reductions associated with high versus low case volumes and high versus low CSC scores were relatively small. Nevertheless, in patients who underwent clipping, a high case volume (> 14 cases/yr) was significantly associated with reduced in-hospital mortality (Q1 as control, Q4 OR 0.71, 95% CI 0.55–0.90) but not with short-term poor outcome. In patients who underwent coiling, a high case volume (> 9 cases/yr) was associated with reduced in-hospital mortality (Q4 OR 0.69, 95% CI 0.53–0.90) and short-term poor outcomes (Q3 [> 5 cases/yr] OR 0.75, 95% CI 0.59–0.96 vs Q4 OR 0.65, 95% CI 0.51–0.82). A high CSC score (> 19 points) was significantly associated with reduced in-hospital mortality for clipping (OR 0.68, 95% CI 0.54–0.86) but not coiling treatment. There was no association between CSC capabilities and short-term poor outcomes.CONCLUSIONSThe effects of case volume and CSC capabilities on in-hospital mortality and short-term functional outcomes in SAH patients differed between patients undergoing clipping and those undergoing coiling. In the modern endovascular era, better outcomes of clipping may be achieved in facilities with high CSC capabilities.
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Affiliation(s)
- Ryota Kurogi
- 1Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka
| | - Akiko Kada
- 2Department of Clinical Trials and Research, National Hospital Organization, Nagoya Medical Center, Nagoya
| | | | - Takanari Kitazono
- 4Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka
| | - Nobuyuki Sakai
- 5Department of Neurosurgery, Kobe City Medical Centre General Hospital, Kobe
| | | | - Yoshiaki Shiokawa
- 7Department of Neurosurgery, Kyorin University School of Medicine, Mitaka
| | - Shigeru Miyachi
- 8Department of Neurosurgery, Aichi Medical University, Nagakute
| | - Yuji Matsumaru
- 9Department of Neurosurgery, University of Tsukuba, Tsukuba
| | - Toru Iwama
- 10Department of Neurosurgery, Gifu University Graduate School of Medicine, Gifu
| | - Teiji Tominaga
- 11Department of Neurosurgery, Tohoku University School of Medicine, Sendai
| | - Daisuke Onozuka
- 12Department of Preventive Medicine and Epidemiology, National Cerebral and Cardiovascular Center, Suita
| | - Ataru Nishimura
- 1Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka
| | - Koichi Arimura
- 1Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka
| | - Ai Kurogi
- 1Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka
| | - Nice Ren
- 1Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka
| | - Akihito Hagihara
- 12Department of Preventive Medicine and Epidemiology, National Cerebral and Cardiovascular Center, Suita
| | - Yuriko Nakaoku
- 12Department of Preventive Medicine and Epidemiology, National Cerebral and Cardiovascular Center, Suita
| | - Hajime Arai
- 13Department of Neurosurgery, Juntendo University School of Medicine, Tokyo; and
| | - Susumu Miyamoto
- 14Department of Neurosurgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Kunihiro Nishimura
- 12Department of Preventive Medicine and Epidemiology, National Cerebral and Cardiovascular Center, Suita
| | - Koji Iihara
- 1Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka
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12
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Salem MM, Maragkos GA, Gomez-Paz S, Ascanio LC, Ngo LH, Ogilvy CS, Thomas AJ, Moore JM. Trends of Ruptured and Unruptured Aneurysms Treatment in the United States in Post-ISAT Era: A National Inpatient Sample Analysis. J Am Heart Assoc 2021; 10:e016998. [PMID: 33559478 PMCID: PMC7955327 DOI: 10.1161/jaha.120.016998] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background The ISAT (International Subarachnoid Aneurysm Trial) has generated a paradigm shift towards endovascular treatment for intracranial aneurysms but remains unclear if this has led to a true reduction in the risk for aneurysmal subarachnoid hemorrhage (aSAH). We sought to study the association between the treatment burden of unruptured and ruptured aneurysms in the post-ISAT era. Methods and Results Admissions data from the National Inpatient Sample (2004-2014) were extracted, including patients with a primary diagnosis of aSAH or unruptured intracranial aneurysms treated by clipping or coiling. Within each year, this combined group was randomly matched to non-aneurysmal control group, based on age, sex, and Elixhauser comorbidity index. Multinomial regression was performed to calculate the relative risk ratio of undergoing treatment for either ruptured or unruptured aneurysms in comparison with the reference control group, adjusted for time. After adjusting for National Inpatient Sample sampling effects, 243 754 patients with aneurysm were identified, 174 580 (71.6%) were women; mean age, 55.4±13.2 years. A total of 121 882 (50.01%) patients were treated for unruptured aneurysms, 79 627 (65.3%) endovascularly and 42 256 (34.7%) surgically. A total of 121 872 (49.99%) patients underwent procedures for aSAH, 68 921 (56.6%) endovascular, and 52 951 (43.5%) surgically. Multinomial regression revealed a significant year-to-year decrease in aSAH procedures compared with the control group of non-aneurysmal hospitalizations (relative risk ratio, 0.963 per year; P<0.001), while there was no statistical significance for unruptured aneurysms procedures (relative risk ratio, 1.012 per year; P=0.35). Conclusions With each passing year, there is a significant decrease in relative risk ratio of undergoing treatment for aSAH, concomitant with a stable annual risk of undergoing treatment for unruptured intracranial aneurysms.
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Affiliation(s)
- Mohamed M Salem
- Neurosurgery Service Beth Israel Deaconess Medical CenterHarvard Medical School Boston MA
| | - Georgios A Maragkos
- Neurosurgery Service Beth Israel Deaconess Medical CenterHarvard Medical School Boston MA
| | - Santiago Gomez-Paz
- Neurosurgery Service Beth Israel Deaconess Medical CenterHarvard Medical School Boston MA
| | - Luis C Ascanio
- Neurosurgery Service Beth Israel Deaconess Medical CenterHarvard Medical School Boston MA
| | - Long H Ngo
- Department of Medicine Beth Israel Deaconess Medical CenterHarvard Medical School Boston MA
| | - Christopher S Ogilvy
- Neurosurgery Service Beth Israel Deaconess Medical CenterHarvard Medical School Boston MA
| | - Ajith J Thomas
- Neurosurgery Service Beth Israel Deaconess Medical CenterHarvard Medical School Boston MA
| | - Justin M Moore
- Neurosurgery Service Beth Israel Deaconess Medical CenterHarvard Medical School Boston MA
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13
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Effect of treatment modality and cerebral vasospasm agent on patient outcomes after aneurysmal subarachnoid hemorrhage in the elderly aged 75 years and older. PLoS One 2020; 15:e0230953. [PMID: 32271814 PMCID: PMC7145106 DOI: 10.1371/journal.pone.0230953] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2020] [Accepted: 03/11/2020] [Indexed: 12/14/2022] Open
Abstract
Objective We sought to examine whether the effect of treatment modality and drugs for cerebral vasospasm on clinical outcomes differs between elderly and non-elderly subarachnoid hemorrhage (SAH) patients in Japan. Methods We analyzed the J-ASPECT Study Diagnosis Procedure Combination database (n = 17,343) that underwent clipping or coiling between 2010 and 2014 in 579 hospitals. We stratified patients into two groups according to their age (elderly [≥75 years old], n = 3,885; non-elderly, n = 13,458). We analyzed the effect of treatment modality and anti-vasospasm agents (fasudil hydrochloride, ozagrel sodium, cilostazol, statin, eicosapentaenoic acid [EPA], and edaravone) on in-hospital poor outcomes (mRS 3–6 at discharge) and mortality using multivariable analysis. Results The elderly patients were more likely to be female, have impaired levels of consciousness and comorbidity, and less likely to be treated with clipping and anti-vasospasm agents, except for ozagrel sodium and statin. In-hospital mortality and poor outcomes were higher in the elderly (15.8% vs. 8.5%, 71.7% vs. 36.5%). Coiling was associated with higher mortality (odds ratio 1.43, 95% confidence interval 1.2–1.7) despite a lower proportion of poor outcomes (0.84, 0.75–0.94) in the non-elderly, in contrast to no effect on clinical outcomes in the elderly. A comparable effect of anti-vasospasm agents on mortality was observed between non-elderly and elderly for fasudil hydrochloride (non-elderly: 0.20, 0.17–0.24), statin (0.63, 0.50–0.79), ozagrel sodium (0.72, 0.60–0.86), and cilostazol (0.63, 0.51–0.77). Poor outcomes were inversely associated with fasudil hydrochloride (0.59, 0.51–0.68), statin (0.84, 0.75–0.94), and EPA (0.83, 0.72–0.94) use in the non-elderly. No effect of these agents on poor outcomes was observed in the elderly. Conclusions In contrast to the non-elderly, no effect of treatment modality on clinical outcomes were observed in the elderly. A comparable effect of anti-vasospasm agents was observed on mortality, but not on functional outcomes, between the non-elderly and elderly.
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14
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Luther E, McCarthy DJ, Brunet MC, Sur S, Chen SH, Sheinberg D, Hasan D, Jabbour P, Yavagal DR, Peterson EC, Starke RM. Treatment and diagnosis of cerebral aneurysms in the post-International Subarachnoid Aneurysm Trial (ISAT) era: trends and outcomes. J Neurointerv Surg 2020; 12:682-687. [PMID: 31959634 DOI: 10.1136/neurintsurg-2019-015418] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Revised: 12/02/2019] [Accepted: 12/04/2019] [Indexed: 11/03/2022]
Abstract
BACKGROUND Following publication of the International Subarachnoid Aneurysm Trial (ISAT), treatment paradigms for cerebral aneurysms (CAs) shifted from open surgical clipping to endovascular embolization as primary therapy in a majority of cases. However, comprehensive analyses evaluating more recent CA diagnosis patterns, patient populations and outcomes as a function of treatment modality remain rare. METHODS The National Inpatient Sample from 2004 to 2014 was reviewed. Aneurysmal subarachnoid hemorrhages (aSAHs) and unruptured intracranial aneurysms (UIAs) with a treatment of surgical clipping or endovascular therapy (EVT) were identified. Time trend series plots were created. Linear and logistic regressions were utilized to quantify treatment changes. RESULTS 114 137 aSAHs and 122 916 UIAs were reviewed. aSAH (+732/year, p=0.014) and UIA (+2550/year, p<0.0001) discharges increased annually. The annual caseload of surgical clippings for aSAH decreased (-264/year, p=0.0002) while EVT increased (+366/year, p=0.0003). For UIAs, the annual caseload for surgical clipping remained stable but increased for EVT (+615/year, p<0.0001). The rate of incidentally diagnosed UIAs increased annually (+1987/year; p<0.0001). Inpatient mortality decreased for clipping (p<0.0001) and EVT in aSAH (p<0.0001) (2004 vs 2014-clipping 13% vs 11.7%, EVT 15.8% vs 12.7%). Mortality rates for clipped UIAs decreased over time (p<0.0001) and remained stable for EVT (2004 vs 2014-clipping 1.57% vs 0.40%, EVT 0.59% vs 0.52%). CONCLUSION Ruptured and unruptured CAs are increasingly being treated with EVT over clipping. Incidental unruptured aneurysm diagnoses are increasing dramatically. Mortality rates of ruptured aneurysms are improving regardless of treatment modality, whereas mortality in unruptured aneurysms is only improving for surgical clipping.
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Affiliation(s)
- Evan Luther
- Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - David J McCarthy
- Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA .,Neurosurgery, University of Miami School of Medicine, Miami, Florida, USA
| | - Marie-Christine Brunet
- Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Samir Sur
- Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Stephanie H Chen
- Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Dallas Sheinberg
- Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - David Hasan
- Neurological Surgery, University of Iowa, Iowa City, Iowa, USA
| | - Pascal Jabbour
- Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Dileep R Yavagal
- Neurology, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Eric C Peterson
- Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Robert M Starke
- Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
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15
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Pontes FGDB, Vasconcelos V, Baptista-Silva JCC, da Silva EMK. Treatments for unruptured intracranial aneurysms. Hippokratia 2019. [DOI: 10.1002/14651858.cd013312] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Felipe Gomes de Barros Pontes
- University Hospital Prof. Alberto Antunes (Federal University of Alagoas); Department of Surgery; Maceio Alagoas Brazil 57036-730
| | - Vladimir Vasconcelos
- Universidade Federal de São Paulo; Department of Surgery, Division of Vascular and Endovascular Surgery; Rua Borges Lagoa, 754 São Paulo Brazil 04038-001
| | - Jose CC Baptista-Silva
- Universidade Federal de São Paulo; Evidence Based Medicine, Cochrane Brazil; Rua Borges Lagoa, 564, cj 124 São Paulo São Paulo Brazil 04038-000
| | - Edina MK da Silva
- Universidade Federal de São Paulo; Emergency Medicine and Evidence Based Medicine; Rua Borges Lagoa 564 cj 64 Vl. Clementino São Paulo São Paulo Brazil 04038-000
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16
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Ikawa F, Michihata N, Matsushige T, Abiko M, Ishii D, Oshita J, Okazaki T, Sakamoto S, Kurogi R, Iihara K, Nishimura K, Morita A, Fushimi K, Yasunaga H, Kurisu K. In-hospital mortality and poor outcome after surgical clipping and endovascular coiling for aneurysmal subarachnoid hemorrhage using nationwide databases: a systematic review and meta-analysis. Neurosurg Rev 2019; 43:655-667. [PMID: 30941595 DOI: 10.1007/s10143-019-01096-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Revised: 03/12/2019] [Accepted: 03/19/2019] [Indexed: 11/24/2022]
Abstract
There has never been evidence for aneurysmal subarachnoid hemorrhage (aSAH) by endovascular coiling compared to surgical clipping with all grade. The present study and meta-analysis aimed to clarify the in-hospital mortality and poor outcome in the nationwide databases of patients with all grade aSAH between them. The outcome of modified Rankin scale (mRS) at discharge was investigated according to the comprehensive nationwide database in Japan. The propensity score-matched analysis was conducted among patients with aSAH in this database registered between 2010 and 2015. Meta-analysis of studies was conducted based on the nationwide databases published from 2007 to 2018. According to this propensity score-matched analysis, no significant association for poor outcome of mRS > 2 was shown between surgical clipping and endovascular coiling (47.7% vs 48.3%, p = 0.48). However, significantly lower in-hospital mortality was revealed after surgical clipping than endovascular coiling (7.1% vs 12.2%, p < 0.001). Meta-analysis of propensity score-matched analysis in the nationwide database showed no significant association for poor outcome at discharge between them (odds ratio [OR], 1.08; 95% confidence interval [CI], 0.93 to 1.26; p = 0.31). Meta-analysis of propensity score-matched analysis for in-hospital mortality was lower after surgical clipping than after endovascular coiling, however, without significant difference (OR, 0.74; 95% CI, 0.52 to 1.04; p = 0.08). Further prospective randomized controlled study with all grade aSAH should be necessary to validate the in-hospital mortality and poor outcome.
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Affiliation(s)
- Fusao Ikawa
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan.
| | - Nobuaki Michihata
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Toshinori Matsushige
- Department of Neurosurgery and Interventional Neuroradiology, Hiroshima City Asa Citizens Hospital, Hiroshima, Japan
| | - Masaru Abiko
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Daizo Ishii
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Jumpei Oshita
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Takahito Okazaki
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Shigeyuki Sakamoto
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Ryota Kurogi
- Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Koji Iihara
- Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Kunihiro Nishimura
- Department of Preventive Medicine and Epidemiologic Informatics, National Cerebral and Cardiovascular Centre, Suita, Osaka, Japan
| | - Akio Morita
- Department of Neurological Surgery, Nippon Medical School Hospital, Tokyo, Japan
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Tokyo Medical and Dental University Graduate School of Medicine, Tokyo, Japan
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Kaoru Kurisu
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
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17
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Wu J, Tong X, Liu Q, Cao Y, Zhao Y, Wang S. Microsurgical ligation for incompletely coiled or recurrent intracranial aneurysms: a 17-year single-center experience. Chin Neurosurg J 2019; 5:7. [PMID: 32922907 PMCID: PMC7398258 DOI: 10.1186/s41016-019-0153-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Accepted: 01/30/2019] [Indexed: 11/10/2022] Open
Abstract
Background In this retrospective single-center study, we presented our experience in the microsurgical management of incompletely coiled or recurrent aneurysms after initial endovascular coiling. Methods During a 17-year period, 48 patients underwent microsurgical clipping of incompletely coiled or recurrent aneurysms after coiling (Gurian group B). The clinical data, surgical technique, and postoperative outcome were recorded and analyzed. Results Before coiling, 42 patients (87.5%) experienced aneurysm rupture. Most of the aneurysms (46/48, 96%) were located in the anterior circulation. After coiling, 6 patients had incompletely coiled aneurysms and 42 patients had recurrent aneurysms, with a mean time of 20.2 months from coiling to recurrence. Coil extrusion occurred in none of the incompletely coiled aneurysms and 71% (30/42) of the recurrent aneurysms. Clipping techniques are direct microsurgical clipping without coil removal in 16 patients, partial coil removal in 14 patients, and total coil removal in 18 patients. Postoperative and follow-up angiography revealed complete occlusion of the aneurysms in all patients. No patient died during postoperative follow-up period (mean, 78.9 months; range, 10-190 months). Good outcomes (GOS of 4 or 5) were achieved in 87.5% (42/48) of the patients at the final follow-up. Conclusions Microsurgical clipping is effective for incompletely coiled or recurrent aneurysms after initial coiling. For recurrent aneurysms that have coils in the neck, have no adequate neck for clipping, or cause mass effects on surrounding structures, partial or total removal of coiled mass can facilitate surgical clipping and lead to successful obliteration of the aneurysms.
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Affiliation(s)
- Jun Wu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100050 China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Diseases, Beijing, People's Republic of China
| | - Xianzeng Tong
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Qingyuan Liu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100050 China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Diseases, Beijing, People's Republic of China
| | - Yong Cao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100050 China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Diseases, Beijing, People's Republic of China
| | - Yuanli Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100050 China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Diseases, Beijing, People's Republic of China
| | - Shuo Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100050 China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Diseases, Beijing, People's Republic of China
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Sharma M, Ugiliweneza B, Fortuny EM, Khattar NK, Andaluz N, James RF, Williams BJ, Boakye M, Ding D. National trends in cerebral bypass for unruptured intracranial aneurysms: a National (Nationwide) Inpatient Sample analysis of 1998–2015. Neurosurg Focus 2019; 46:E15. [DOI: 10.3171/2018.11.focus18504] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Accepted: 11/08/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVEThe development and recent widespread dissemination of flow diverters may have reduced the utilization of surgical bypass procedures to treat complex or giant unruptured intracranial aneurysms (UIAs). The aim of this retrospective cohort study was to observe trends in cerebral revascularization procedures for UIAs in the United States before and after the introduction of flow diverters by using the National (Nationwide) Inpatient Sample (NIS).METHODSThe authors extracted data from the NIS database for the years 1998–2015 using the ICD-9/10 diagnostic and procedure codes. Patients with a primary diagnosis of UIA with a concurrent bypass procedure were included in the study. Outcomes and hospital charges were analyzed.RESULTSA total of 216,212 patients had a primary diagnosis of UIA during the study period. The number of patients diagnosed with a UIA increased by 128% from 1998 (n = 7718) to 2015 (n = 17,600). Only 1328 of the UIA patients (0.6%) underwent cerebral bypass. The percentage of patients who underwent bypass in the flow diverter era (2010–2015) remained stable at 0.4%. Most patients who underwent bypass were white (51%), were female (62%), had a median household income in the 3rd or 4th quartiles (57%), and had private insurance (51%). The West (33%) and Midwest/North Central regions (30%) had the highest volume of bypasses, whereas the Northeast region had the lowest (15%). Compared to the period 1998–2011, bypass procedures for UIAs in 2012–2015 shifted entirely to urban teaching hospitals (100%) and to an elective basis (77%). The median hospital stay (9 vs 3 days, p < 0.0001), median hospital charges ($186,746 vs $66,361, p < 0.0001), and rate of any complication (51% vs 17%, p < 0.0001) were approximately threefold higher for the UIA patients with bypass than for those without bypass.CONCLUSIONSDespite a significant increase in the diagnosis of UIAs over the 17-year study period, the proportion of bypass procedures performed as part of their treatment has remained stable. Therefore, advances in endovascular aneurysm therapy do not appear to have affected the volume of bypass procedures performed in the UIA population. The authors’ findings suggest a potentially ongoing niche for bypass procedures in the contemporary treatment of UIAs.
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Lin N, Cahill KS, Frerichs KU, Friedlander RM, Claus EB. Treatment of ruptured and unruptured cerebral aneurysms in the USA: a paradigm shift. J Neurointerv Surg 2018; 10:i69-i76. [DOI: 10.1136/jnis.2011.004978.rep] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2011] [Revised: 04/24/2011] [Accepted: 05/06/2011] [Indexed: 11/04/2022]
Abstract
BackgroundIntegration of data from clinical trials and advancements in technology predict a change in selection for treatment of patients with cerebral aneurysm.ObjectiveTo describe patterns of use and in-hospital mortality associated with surgical and endovascular treatments of cerebral aneurysms over the past decade.Materials and methodsThe data are 34 899 hospital discharges with a diagnosis of ruptured or unruptured cerebral aneurysm from 1998 to 2007 identified from the Nationwide Inpatient Sample (NIS). The rates of endovascular coiling and surgical clipping and in-hospital mortality among patients with an aneurysm are examined over a decade by hospital and patient demographic characteristics.ResultsFrom 1998 to 2007, 20 134 discharges with a ruptured aneurysm and 14 765 discharges with an unruptured aneurysm were identified. Over this decade, the number of patients discharged with a ruptured aneurysm was stable while the number discharged with an unruptured aneurysm increased significantly. The use of endovascular coiling increased at least twofold for both groups of patient (p<0.001) with the majority of unruptured aneurysms treated with coiling by 2007. Although whites were more likely than non-whites to undergo coiling versus clipping for a ruptured aneurysm (OR=1.30; 95% CI 1.13 to 1.48) and men with unruptured aneurysms were more likely than women to undergo coiling (OR=1.26; 95% CI 1.13 to 1.40), by 2007 differences in treatment selection by gender and racial subgroups were decreased or statistically non-significant. Over time the use of coiling spread from primarily large, teaching hospitals to smaller, non-teaching hospitals.ConclusionsThe majority of unruptured aneurysms in the USA are now treated with endovascular coiling. Although surgical clipping is used for treatment of most ruptured aneurysms, its use is decreasing over time. Dissemination of endovascular procedures appears widespread across patient and hospital subgroups.
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20
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Shamloo A, Nejad MA, Saeedi M. Fluid–structure interaction simulation of a cerebral aneurysm: Effects of endovascular coiling treatment and aneurysm wall thickening. J Mech Behav Biomed Mater 2017; 74:72-83. [DOI: 10.1016/j.jmbbm.2017.05.020] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Revised: 05/09/2017] [Accepted: 05/12/2017] [Indexed: 12/01/2022]
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21
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Bender MT, Wendt H, Monarch T, Lin LM, Jiang B, Huang J, Coon AL, Tamargo RJ, Colby GP. Shifting Treatment Paradigms for Ruptured Aneurysms from Open Surgery to Endovascular Therapy Over 25 Years. World Neurosurg 2017; 106:919-924. [DOI: 10.1016/j.wneu.2017.07.074] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Revised: 07/12/2017] [Accepted: 07/13/2017] [Indexed: 12/11/2022]
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22
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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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23
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Kurogi R, Kada A, Nishimura K, Kamitani S, Nishimura A, Sayama T, Nakagawara J, Toyoda K, Ogasawara K, Ono J, Shiokawa Y, Aruga T, Miyachi S, Nagata I, Matsuda S, Yoshimura S, Okuchi K, Suzuki A, Nakamura F, Onozuka D, Hagihara A, Iihara K. Effect of treatment modality on in-hospital outcome in patients with subarachnoid hemorrhage: a nationwide study in Japan (J-ASPECT Study). J Neurosurg 2017; 128:1318-1326. [PMID: 28548595 DOI: 10.3171/2016.12.jns161039] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Although heterogeneity in patient outcomes following subarachnoid hemorrhage (SAH) has been observed across different centers, the relative merits of clipping and coiling for SAH remain unknown. The authors sought to compare the patient outcomes between these therapeutic modalities using a large nationwide discharge database encompassing hospitals with different comprehensive stroke center (CSC) capabilities. METHODS They analyzed data from 5214 patients with SAH (clipping 3624, coiling 1590) who had been urgently hospitalized at 393 institutions in Japan in the period from April 2012 to March 2013. In-hospital mortality, modified Rankin Scale (mRS) score, cerebral infarction, complications, hospital length of stay, and medical costs were compared between the clipping and coiling groups after adjustment for patient-level and hospital-level characteristics by using mixed-model analysis. RESULTS Patients who had undergone coiling had significantly higher in-hospital mortality (12.4% vs 8.7%, OR 1.3) and a shorter median hospital stay (32.0 vs 37.0 days, p < 0.001) than those who had undergone clipping. The respective proportions of patients discharged with mRS scores of 3-6 (46.4% and 42.9%) and median medical costs (thousands US$, 35.7 and 36.7) were not significantly different between the groups. These results remained robust after further adjustment for CSC capabilities as a hospital-related covariate. CONCLUSIONS Despite the increasing use of coiling, clipping remains the mainstay treatment for SAH. Regardless of CSC capabilities, clipping was associated with reduced in-hospital mortality, similar unfavorable functional outcomes and medical costs, and a longer hospital stay as compared with coiling in 2012 in Japan. Further study is required to determine the influence of unmeasured confounders.
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Affiliation(s)
- Ryota Kurogi
- 1Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka
| | - Akiko Kada
- 2Department of Clinical Trials and Research, National Hospital Organization Nagoya Medical Centre, Nagoya
| | - Kunihiro Nishimura
- 3Department of Preventive Medicine and Epidemiologic Informatics, National Cerebral and Cardiovascular Centre, Suita
| | - Satoru Kamitani
- 4Department of Public Health/Health Policy, Graduate School of Medicine, University of Tokyo
| | - Ataru Nishimura
- 1Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka
| | - Tetsuro Sayama
- 1Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka
| | | | - Kazunori Toyoda
- 6Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Centre, Suita
| | | | - Junichi Ono
- 8Department of Neurosurgery, Chiba Cerebral and Cardiovascular Centre, Chiba
| | | | - Toru Aruga
- 10Department of Emergency and Critical Care Medicine, Showa University Hospital, Shinagawa
| | - Shigeru Miyachi
- 11Department of Neurosurgery, Osaka Medical College, Takatsuki
| | - Izumi Nagata
- 12Department of Neurosurgery, Kokura Memorial Hospital, Kitakyushu
| | - Shinya Matsuda
- 13Department of Preventive Medicine and Community Health, School of Medicine, University of Occupational and Environmental Health, Kitakyushu
| | | | - Kazuo Okuchi
- 15Department of Emergency and Critical Care Medicine, Nara Medical University, Kashihara
| | - Akifumi Suzuki
- 16Department of Surgical Neurology, Research Institute for Brain and Blood Vessels-Akita; and
| | - Fumiaki Nakamura
- 4Department of Public Health/Health Policy, Graduate School of Medicine, University of Tokyo
| | - Daisuke Onozuka
- 17Department of Health Communication, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Akihito Hagihara
- 17Department of Health Communication, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Koji Iihara
- 1Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka
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Beneš V, Jurák L, Brabec R, Nechanická N, Šercl M, Endrych L, Buchvald P, Suchomel P. Causes of poor outcome in patients admitted with good-grade subarachnoid haemorrhage. Acta Neurochir (Wien) 2017; 159:559-565. [PMID: 28108855 DOI: 10.1007/s00701-017-3081-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2016] [Accepted: 01/10/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND Surgical risk in patients with unruptured aneurysms is well known. The relative impact of surgery and natural history of subarachnoid haemorrhage (SAH) on patients in good clinical condition (World Federation of Neurological Surgeons [WFNS] grades 1 and 2) is less well quantified. The aim of this study was to determine causes of poor outcome in patients admitted in good grade SAH. METHODS A retrospective study of prospectively collected data among WFNS-1 and -2 patients: demographics, SAH and aneurysm-related data, surgical complications and outcome as assesed by the Glasgow Outcome Scale (GOS). Causes of poor outcome (GOS 1-3) were determined. RESULTS During a 7-year period (2009-15), 56 patients with SAH WFNS-1 (39 patients) or WFNS-2 (17 patients) were treated surgically (21 men, 35 women; mean age, 52.4 years). According to the Fisher scale, 19 patients were grade 1 or 2; 37 patients were grade 3 or 4. Most aneurysms were located at anterior communicating (26) or middle cerebral (15) artery. Altogether, 11 patients (19.6%) achieved GOS 1-3. This was attributed to SAH-related complications in six patients (rebleeding, vasospasm), surgery in four patients (postoperative ischaemia in two, haematoma and ventriculitis in one patient each), grand-mal seizure with aspiration in one patient. Age over 60 years (p = 0.017) and presence of hydrocephalus (p < 0.001) were statistically significant predictors of poor GOS; other variables (e.g. sex, Fisher grade, aneurysm size or location, use of temporary clips, intraoperative rupture, vasospasm) were not significant. CONCLUSIONS Patients admitted in good-grade SAH achieve favourable outcome following surgical aneurysm repair in the majority of cases. Negative factors include age over 60 years and presence of hydrocephalus. Aneurysm surgery following good-grade SAH still carries a small but significant risk similar to that shown in large multi-institutional trials.
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Affiliation(s)
- Vladimír Beneš
- Department of Neurosurgery, Regional Hospital Liberec, Husova 10, Liberec, 46001, Czech Republic.
| | - Lubomír Jurák
- Department of Neurosurgery, Regional Hospital Liberec, Husova 10, Liberec, 46001, Czech Republic
| | - Radim Brabec
- Department of Neurosurgery, Regional Hospital Liberec, Husova 10, Liberec, 46001, Czech Republic
| | - Nina Nechanická
- Department of Neurosurgery, Regional Hospital Liberec, Husova 10, Liberec, 46001, Czech Republic
| | - Miroslav Šercl
- Department of Radiology, Regional Hospital Liberec, Husova 10, Liberec, 46001, Czech Republic
| | - Ladislav Endrych
- Department of Radiology, Regional Hospital Liberec, Husova 10, Liberec, 46001, Czech Republic
| | - Pavel Buchvald
- Department of Neurosurgery, Regional Hospital Liberec, Husova 10, Liberec, 46001, Czech Republic
| | - Petr Suchomel
- Department of Neurosurgery, Regional Hospital Liberec, Husova 10, Liberec, 46001, Czech Republic
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Walendy V, Stang A. Clinical management of unruptured intracranial aneurysm in Germany: a nationwide observational study over a 5-year period (2005-2009). BMJ Open 2017; 7:e012294. [PMID: 28096250 PMCID: PMC5253577 DOI: 10.1136/bmjopen-2016-012294] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Our aim was to provide nationwide age-standardised rates (ASR) on the usage of endovascular coiling and neurosurgical clipping for unruptured intracranial aneurysm (UIA) treatment in Germany. SETTING Nationwide observational study using the Diagnosis-Related-Groups (DRG) statistics for the years 2005-2009 (overall 83 million hospitalisations). PARTICIPANTS From 2005 to 2009, overall 39 155 hospitalisations with a diagnosis of UIA occurred in Germany. PRIMARY OUTCOME MEASURES Age-specific and age-standardised hospitalisation rates for UIA with the midyear population of Germany in 2007 as the standard. RESULTS Of the 10 221 hospitalisations with UIA during the observation period, 6098 (59.7%) and 4123 (40.3%) included coiling and clipping, respectively. Overall hospitalisation rates for UIA increased by 39.5% (95% CI 24.7% to 56.0%) and 50.4% (95% CI 39.6% to 62.1%) among men and women, respectively. In 2005, the ASR per 100 000 person years for coiling was 0.7 (95% CI 0.62 to 0.78) for men and 1.7 (95% CI 1.58 to 1.82) for women. In 2009, the ASR was 1.0 (95% CI 0.90 to 1.10) and 2.4 (95% CI 2.24 to 2.56), respectively. Similarly, the ASR for clipping in 2005 amounted to 0.6 (95% CI 0.52 to 0.68) for men and 1.1 (95% CI 1.00 to 1.20) for women. These rates increased in 2009 to 0.8 (95% CI 0.72 to 0.88) and 1.7 (95% CI 1.58 to 1.82), respectively. We observed a marked geographical variation of ASR for coiling and less pronounced for clipping. For the federal state of Saarland, the ASR for coiling was 5.64 (95% CI 4.76 to 6.52) compared with 0.68 (95% CI 0.48 to 0.88; per 100 000 person years) in Saxony-Anhalt, whereas, ASR for clipping were highest in Rhineland-Palatinate (2.48, 95% CI 2.17 to 4.75) and lowest in Saxony-Anhalt (0.52, 95% CI 0.34 to 0.70). CONCLUSIONS To the best of our knowledge, we presented the first representative, nationwide analysis of the clinical management of UIA in Germany. The ASR increased markedly and showed substantial geographical variation among federal states for all treatment modalities during the observation period.
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Affiliation(s)
- Victor Walendy
- Zentrum für Klinische Epidemiologie, Universitätsklinikum Essen, Universität Duisburg-Essen, Essen, Germany
| | - Andreas Stang
- Zentrum für Klinische Epidemiologie, Universitätsklinikum Essen, Universität Duisburg-Essen, Essen, Germany
- Department of Epidemiology, School of Public Health, Boston University, Boston, Massachusetts, USA
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Wang HW, Sun ZH, Wu C, Xue Z, Yu XG. Surgical management of recurrent aneurysms after coiling treatment. Br J Neurosurg 2016; 31:96-100. [PMID: 27596271 DOI: 10.1080/02688697.2016.1226255] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Aneurysms that recur after coiling treatment are difficult to manage. The microsurgical technique in these cases differs significantly from that in regular aneurysm clipping. We present our experience in surgical management of aneurysms that recurred more than 1 month after coiling in a series of 19 patients. MATERIALS AND METHODS Between January 2004 and December 2014, 1437 patients were treated surgically for intracranial aneurysms in our institution. We performed a retrospective review of the clinical records, operation videos, and cerebral angiograms. We focused on patients in whom the initial aneurysm was treated by coiling, but the results were incomplete or the aneurysm recurred. RESULTS Nineteen patients underwent surgical clipping for recurrent aneurysm more than 1 month after initial coiling treatment. The sex ratio (male:female) was 0.9, and the average age was 51.3 years (range 35-72 years). One aneurysm was classified as giant (≥ 25 mm), two as large (10-25 mm), and 18 as small (≤ 10 mm). A good outcome (Glasgow Outcome Scale 4 or 5) was observed in 16 of 19 patients (84.2%). CONCLUSION Microsurgical clipping can be safe and effective in the management of previously coiled residual and recurrent aneurysms.
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Affiliation(s)
- Hua-Wei Wang
- a Department of Neurosurgery , Chinese PLA General Hospital , Beijing , PR China
| | - Zheng-Hui Sun
- a Department of Neurosurgery , Chinese PLA General Hospital , Beijing , PR China
| | - Chen Wu
- a Department of Neurosurgery , Chinese PLA General Hospital , Beijing , PR China
| | - Zhe Xue
- a Department of Neurosurgery , Chinese PLA General Hospital , Beijing , PR China
| | - Xin-Guang Yu
- a Department of Neurosurgery , Chinese PLA General Hospital , Beijing , PR China
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Delgado Lopez PD, Castilla Díez JM, Martín Velasco V. Aneurismas cerebrales no rotos: controversias sobre el cribado poblacional. Neurocirugia (Astur) 2016; 27:237-44. [DOI: 10.1016/j.neucir.2015.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Revised: 12/18/2015] [Accepted: 12/21/2015] [Indexed: 10/22/2022]
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Chung BS, Ahn YH, Park JS. Ten Triangles around Cavernous Sinus for Surgical Approach, Described by Schematic Diagram and Three Dimensional Models with the Sectioned Images. J Korean Med Sci 2016; 31:1455-63. [PMID: 27510391 PMCID: PMC4974189 DOI: 10.3346/jkms.2016.31.9.1455] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2016] [Accepted: 05/13/2016] [Indexed: 11/20/2022] Open
Abstract
For the surgical approach to lesions around the cavernous sinus (CS), triangular spaces around CS have been devised. However, educational materials for learning the triangles were insufficient. The purpose of this study is to present educational materials about the triangles, consisting of a schematic diagram and 3-dimensional (3D) models with sectioned images. To achieve the purposes, other studies were analyzed to establish new definitions and names of the triangular spaces. Learning materials including schematic diagrams and 3D models with cadaver's sectioned images were manufactured. Our new definition was attested by observing the sectioned images and 3D models. The triangles and the four representative surgical approaches were stereoscopically indicated on the 3D models. All materials of this study were put into Portable Document Format file and were distributed freely at our homepage (anatomy.dongguk.ac.kr/triangles). By using our schematic diagram and the 3D models with sectioned images, ten triangles and the related structures could be understood and observed accurately. We expect that our data will contribute to anatomy education, surgery training, and radiologic understanding of the triangles and related structures.
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Affiliation(s)
- Beom Sun Chung
- Department of Anatomy, Ajou University School of Medicine, Suwon, Korea
| | - Young Hwan Ahn
- Department of Neurosurgery, Ajou University School of Medicine, Suwon, Korea
| | - Jin Seo Park
- Department of Anatomy, Dongguk University School of Medicine, Gyeongju, Korea.
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Rumalla K, Mittal MK. Acute Renal Failure in Aneurysmal Subarachnoid Hemorrhage: Nationwide Analysis of Hospitalizations in the United States. World Neurosurg 2016; 91:542-547.e6. [DOI: 10.1016/j.wneu.2016.03.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Revised: 03/02/2016] [Accepted: 03/03/2016] [Indexed: 11/26/2022]
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30
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Chua MH, Griessenauer CJ, Stapleton CJ, He L, Thomas AJ, Ogilvy CS. Documentation of Improved Outcomes for Intracranial Aneurysm Management Over a 15-Year Interval. Stroke 2016; 47:708-12. [PMID: 26839350 DOI: 10.1161/strokeaha.115.011959] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2015] [Accepted: 12/31/2015] [Indexed: 01/08/2023]
Abstract
BACKGROUND AND PURPOSE Despite rapid advancements in intracranial aneurysm management, there is no evidence as of yet that this has translated into improvement in overall prognosis. METHODS We compared 2 periods of aneurysm management, 1998 to 2003 (n=1023 aneurysms) and 2007 to 2013 (n=1499 aneurysms), at a single, high-volume neurovascular center. Our outcome of interest was low or moderate disability (Glasgow Outcome Scale score of 4 or 5) at 6 months or more post treatment. RESULTS There were significant improvements in outcome for surgical, endovascular, and overall treatment of unruptured (adjusted odds ratio [OR], 2.33; P=0.0091; adjusted OR, 4.40; P=0.0271; and adjusted OR, 2.58; P=0.0008, respectively) and ruptured (adjusted OR, 3.18; P=0.0004; adjusted OR, 3.54; P=0.0001; and adjusted OR, 3.11; P<0.0001, respectively) aneurysms from the first to the second time period. In 2007 to 2013, the proportion of cases with low or moderate disability at 6 months post subarachnoid hemorrhage was 75.6% for surgical clipping and 76.6% for endovascular therapy. CONCLUSIONS We report significantly improved outcomes over time for overall aneurysm management and for multiple patient subgroups, associated with increased usage of endovascular therapy.
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Affiliation(s)
- Michelle H Chua
- From the Neurosurgical Service, Beth Israel Deaconess Medical Center, Brain Aneurysm Institute, Harvard Medical School, Boston, MA (M.H.C., C.J.G., L.H., A.J.T., C.S.O.); and Department of Neurosurgery, Massachusetts General Hospital, Boston (C.J.S.)
| | - Christoph J Griessenauer
- From the Neurosurgical Service, Beth Israel Deaconess Medical Center, Brain Aneurysm Institute, Harvard Medical School, Boston, MA (M.H.C., C.J.G., L.H., A.J.T., C.S.O.); and Department of Neurosurgery, Massachusetts General Hospital, Boston (C.J.S.)
| | - Christopher J Stapleton
- From the Neurosurgical Service, Beth Israel Deaconess Medical Center, Brain Aneurysm Institute, Harvard Medical School, Boston, MA (M.H.C., C.J.G., L.H., A.J.T., C.S.O.); and Department of Neurosurgery, Massachusetts General Hospital, Boston (C.J.S.)
| | - Lucy He
- From the Neurosurgical Service, Beth Israel Deaconess Medical Center, Brain Aneurysm Institute, Harvard Medical School, Boston, MA (M.H.C., C.J.G., L.H., A.J.T., C.S.O.); and Department of Neurosurgery, Massachusetts General Hospital, Boston (C.J.S.)
| | - Ajith J Thomas
- From the Neurosurgical Service, Beth Israel Deaconess Medical Center, Brain Aneurysm Institute, Harvard Medical School, Boston, MA (M.H.C., C.J.G., L.H., A.J.T., C.S.O.); and Department of Neurosurgery, Massachusetts General Hospital, Boston (C.J.S.)
| | - Christopher S Ogilvy
- From the Neurosurgical Service, Beth Israel Deaconess Medical Center, Brain Aneurysm Institute, Harvard Medical School, Boston, MA (M.H.C., C.J.G., L.H., A.J.T., C.S.O.); and Department of Neurosurgery, Massachusetts General Hospital, Boston (C.J.S.).
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Deshaies EM, Villwock MR, Singla A, Toshkezi G, Padalino DJ. Minimally Invasive Thumb-sized Pterional Craniotomy for Surgical Clip Ligation of Unruptured Anterior Circulation Aneurysms. J Vis Exp 2015:e51661. [PMID: 26325337 DOI: 10.3791/51661] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
Less invasive surgical approaches for intracranial aneurysm clipping may reduce length of hospital stay, surgical morbidity, treatment cost, and improve patient outcomes. We present our experience with a minimally invasive pterional approach for anterior circulation aneurysms performed in a major tertiary cerebrovascular center and compare the results with an aged matched dataset from the Nationwide Inpatient Sample (NIS). From August 2008 to December 2012, 22 elective aneurysm clippings on patients ≤55 years of age were performed by the same dual fellowship-trained cerebrovascular/endovascular neurosurgeon. One patient (4.5%) experienced transient post-operative complications. 18 of 22 patients returned for follow-up imaging and there were no recurrences through an average duration of 22 months. A search in the NIS database from 2008 to 2010, also for patients aged ≤55 years of age, yielded 1,341 hospitalizations for surgical clip ligation of unruptured cerebral aneurysms. Inpatient length of stay and hospital charges at our institution using the minimally invasive thumb-sized pterional technique were nearly half that of NIS (length of stay: 3.2 vs 5.7 days; hospital charges: $52,779 vs. $101,882). The minimally invasive thumb-sized pterional craniotomy allows good exposure of unruptured small and medium-sized supraclinoid anterior circulation aneurysms. Cerebrospinal fluid drainage from key subarachnoid cisterns and constant bimanual microsurgical techniques avoid the need for retractors which can cause contusions, localized venous infarctions, and post-operative cerebral edema at the retractor sites. Utilizing this set of techniques has afforded our patients with a shorter hospital stay at a lower cost compared to the national average.
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Affiliation(s)
- Eric M Deshaies
- Neurovascular and Stroke Center, Crouse Neuroscience Institute; Department of Biology, Syracuse University;
| | - Mark R Villwock
- Neurovascular and Stroke Center, Crouse Neuroscience Institute
| | - Amit Singla
- Department of Neurosurgery, University of Florida
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Koźba-Gosztyła M, Czapiga B, Jarmundowicz W. Aneurismal subarachnoid hemorrhage: who remains for surgical treatment in the post-ISAT era? Arch Med Sci 2015; 11:536-43. [PMID: 26170846 PMCID: PMC4495139 DOI: 10.5114/aoms.2013.37333] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2013] [Revised: 07/30/2013] [Accepted: 08/04/2013] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Although there have been a number of studies on changes and trends in the management of aneurismal subarachnoid hemorrhage (aSAH) since publication of the International Subarachnoid Aneurysm Trial (ISAT), no data exist on what category of patients still remains for surgical treatment. Our goal was to investigate the changes that occurred in the characteristics of a population of aSAH patients treated surgically in the post-ISAT period in a single neurosurgical center, with limited availability of endovascular service. MATERIAL AND METHODS The study included 402 aSAH patients treated surgically in our unit between January 2004 and December 2011. Each year, data regarding number of admissions, age, aneurysm location and size, clinical and radiological presentation, outcome and mortality rates were collected and analyzed. RESULTS The annual number of admissions more than halved in the study period (from 69 in 2004 to 32 in 2011). There were no linear trends regarding patients' mean age, clinical presentation and outcomes, but the number of patients in Fisher grade 4 increased and mortality slightly decreased. An unexpected, statistically significant increase occurred in the incidence of anterior communicating artery aneurysms (from 36.2% to 50%) and medium size aneurysms (from 34.7% to 56.2%) treated surgically, with a corresponding decrease in the incidence of middle cerebral artery aneurysms (from 40.5% to 34.3%) and large aneurysms (from 21.7% to 12.5%). CONCLUSIONS Unexpected trends in characteristics of aSAH patients treated surgically could be related to treatment decision modality. Trend patterns could be properly expressed in the constant availability of endovascular services.
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Affiliation(s)
| | - Bogdan Czapiga
- Department of Neurosurgery, Wroclaw Medical University, Wroclaw, Poland
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Thompson BG, Brown RD, Amin-Hanjani S, Broderick JP, Cockroft KM, Connolly ES, Duckwiler GR, Harris CC, Howard VJ, Johnston SCC, Meyers PM, Molyneux A, Ogilvy CS, Ringer AJ, Torner J. Guidelines for the Management of Patients With Unruptured Intracranial Aneurysms: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke 2015; 46:2368-400. [PMID: 26089327 DOI: 10.1161/str.0000000000000070] [Citation(s) in RCA: 616] [Impact Index Per Article: 68.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
PURPOSE The aim of this updated statement is to provide comprehensive and evidence-based recommendations for management of patients with unruptured intracranial aneurysms. METHODS Writing group members used systematic literature reviews from January 1977 up to June 2014. They also reviewed contemporary published evidence-based guidelines, personal files, and published expert opinion to summarize existing evidence, indicate gaps in current knowledge, and when appropriate, formulated recommendations using standard American Heart Association criteria. The guideline underwent extensive peer review, including review by the Stroke Council Leadership and Stroke Scientific Statement Oversight Committees, before consideration and approval by the American Heart Association Science Advisory and Coordinating Committee. RESULTS Evidence-based guidelines are presented for the care of patients presenting with unruptured intracranial aneurysms. The guidelines address presentation, natural history, epidemiology, risk factors, screening, diagnosis, imaging and outcomes from surgical and endovascular treatment.
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Abstract
For a variety of neurosurgical conditions, increasing surgeon and hospital volumes correlate with improved outcomes, such as mortality, complication rates, length of stay, hospital charges, and discharge disposition. Neurosurgeons can improve patient outcomes at the population level by changing practice and referral patterns to regionalize care for select conditions at high-volume specialty treatment centers. Individual practitioners should be aware of where they fall on the volume spectrum and understand the implications of their practice and referral habits on their patients.
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35
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Boogaarts HD, Conde MPD, Janssen E, van Nuenen WFM, de Vries J, Donders R, Westert GP, Grotenhuis JA, Bartels RHMA. The value of the Charlson Co-morbidity Index in aneurysmal subarachnoid haemorrhage. Acta Neurochir (Wien) 2014; 156:1663-7. [PMID: 24973200 DOI: 10.1007/s00701-014-2160-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2014] [Accepted: 06/12/2014] [Indexed: 11/30/2022]
Abstract
BACKGROUND Several studies have included different co-morbid conditions in prediction models for stroke patients. For subarachnoid haemorrhage (SAH), it is not known whether the Charlson Co-morbidity Index (CCI) is associated with outcome. We evaluated if this index was associated with outcome in patients with ruptured intracerebral aneurysms. METHODS The data of all consecutive aneurysmal SAH (aSAH) patients treated at the Radboudumc, Nijmegen, The Netherlands and entered in the database were retrospectively analysed. Clinical condition at admission was recorded using the WFNS (World Federation of Neurological Surgeons Grading System) grade was collected, as were the age and treatment modality. The burden of co-morbidity was retrospectively registered using the CCI. Outcome was dichotomised on the modified Rankin Scale (mRS; 0-2, favourable outcome; 3-6, unfavourable outcome). A binary logistic regression analysis was performed. RESULTS Between 6th May 2008 and 31st July 2013, 457 patients were admitted because of non-traumatic SAH (aSAH). Seventy-seven (16.8 %) patients had no aneurysm. Of the 380 patients with aSAH, information on co-morbid conditions was available for 371 patients. Thirty-six of those 371 had no treatment because of: bad clinical condition in 34 (9.2 %), a non-treatable dissecting aneurysm in 1 (0.3 %) and the explicit wishes of another. Co-morbidity was present in 113 (31.5 %) patients. Binary logistic regression analysis revealed no added value of using the CCI in predicting the outcome (p = 0.91). CONCLUSIONS This study reports that the CCI is not associated with the outcome classified on the mRS at 6 months in patients after aSAH. The CCI has no added value in case-mix correction.
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Affiliation(s)
- Hieronymus D Boogaarts
- Department of Neurosurgery, Radboudumc, Geert Grooteplein Zuid 10, 6500 HB, Nijmegen, The Netherlands,
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Tykocki T, Kostyra K, Czyż M, Kostkiewicz B. Four-year trends in the treatment of cerebral aneurysms in Poland in 2009-2012. Acta Neurochir (Wien) 2014; 156:861-8. [PMID: 24499992 PMCID: PMC3988525 DOI: 10.1007/s00701-014-2006-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2013] [Accepted: 01/18/2014] [Indexed: 10/28/2022]
Abstract
BACKGROUND The dilemma concerning the appropriate treatment of the intracranial aneurysms (IAs) has not yet been resolved and still remains under fierce debate. This study refers to the recent trends in the use of and outcomes related to coiling compared with clipping for unruptured and ruptured IAs in Poland over a 4-year period. METHODS The analysis refers to treatment of IAs performed in Poland between 2009-2012. Patients' records were cross-matched by ICD-9 codes for ruptured SAH (430) or unruptured cerebral aneurysm (437.3) along with codes for clipping (39.51) and coiling (39.79, 39.72, or 39.52). Multivariable logistic regression was used to compare in-hospital deaths, hospital length of stay (LOS), therapy allocation and aneurysm locations in unruptured vs. ruptured and clipped vs. coiled groups. Differences in the number of procedures between 16 administrative regions were standardized per 100,000 people. RESULTS In 2009-2012, 11,051 procedures were identified, including 5,968 ruptured and 5,083 unruptured aneurysms. Overall increase was 2.3 % in clipping and 13.1 % in coiling; a significant trend was found in endovascular procedures (p = 0.044). Ruptured aneurysms were clipped more frequently (OR = 1.66;); in unruptured IAs, endovascular procedure was preferred 3.5 times more than clipping. The annual in-hospital mortality was 7.6 % in clipping and 6.7 % in endovascular treatment. LOS was two times longer after clipping in unruptured aneurysms (OR = 2.013). After the procedures were standardized per 100,000 people, the average for Poland was established as 9.09 in 2009, 10.86 in 2010, 10.55 in 2011, and 11.49 in 2012. This index had the highest values in Mazovia (12.9, 2009; 15.4, 2010; 17.4, 2011; 18.6, 2012. CONCLUSIONS Data analysis revealed an increase in overall number of IAs treated in Poland between 2009-2012. A significant upward trend of endovascular procedures was found, whereas the number of clipped aneurysms remained relatively steady over the study period.
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Fang S, Brinjikji W, Murad MH, Kallmes DF, Cloft HJ, Lanzino G. Endovascular treatment of anterior communicating artery aneurysms: a systematic review and meta-analysis. AJNR Am J Neuroradiol 2014; 35:943-7. [PMID: 24287090 DOI: 10.3174/ajnr.a3802] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Endovascular therapy has become an acceptable alternative to traditional clipping for the management of intracranial aneurysms. However, a limited number of studies have examined outcomes and complications specific to embolization of anterior communicating artery aneurysms. MATERIALS AND METHODS A systematic review of the literature was conducted with the use of multiple data bases to identify reports on endovascular treatment of anterior communicating artery aneurysms between 1994 and 2012. Angiographic results, clinical outcomes, and complication rates were pooled across studies by using random-effects meta-analysis with subgroup analysis of outcomes by rupture status and time trend stratification. RESULTS Fourteen studies, consisting of 1552 treated anterior communicating artery aneurysms, were included in this meta-analysis. The rate of immediate and long-term complete and near-complete angiographic occlusion was 88% (95% CI = 81-93%) and 85% (95% CI = 78-90%), respectively. Intraprocedural rupture rate was 4% (95% CI = 3-6%). The re-bleeding rate was 2% (95% CI = 1-4%) and the retreatment rate was 7% (95% CI = 5-12%). Morbidity or mortality caused by perioperative stroke occurred at a 3% (95% CI = 2-6%) rate. Overall procedure-related morbidity and mortality were 6% (95% CI = 4-8%) and 3% (95% CI = 2-4%), respectively. Outcomes did not differ between ruptured and unruptured aneurysms, nor did outcomes change over time, though these latter subanalyses were relatively underpowered. CONCLUSIONS Endovascular therapy for anterior communicating artery aneurysms is associated with a high rate of complete angiographic occlusion. However, the procedure-related permanent morbidity and mortality are not negligible for aneurysms in this location.
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Affiliation(s)
- S Fang
- From Mayo Medical School (S.F.), Department of Radiology (W.B., D.F.K., H.J.C.)
| | - W Brinjikji
- From Mayo Medical School (S.F.), Department of Radiology (W.B., D.F.K., H.J.C.)
| | - M H Murad
- Division of Preventive Medicine (M.H.M.)
| | - D F Kallmes
- From Mayo Medical School (S.F.), Department of Radiology (W.B., D.F.K., H.J.C.)
| | - H J Cloft
- From Mayo Medical School (S.F.), Department of Radiology (W.B., D.F.K., H.J.C.)
| | - G Lanzino
- Department of Neurologic Surgery (G.L.), Mayo Clinic, Rochester, Minnesota.
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Brinjikji W, Kallmes DF, Lanzino G, Cloft HJ. Carotid revascularization treatment is shifting to low volume centers. J Neurointerv Surg 2014; 7:336-40. [DOI: 10.1136/neurintsurg-2014-011180] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2014] [Accepted: 03/21/2014] [Indexed: 11/03/2022]
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40
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Boogaarts HD, van Amerongen MJ, de Vries J, Westert GP, Verbeek ALM, Grotenhuis JA, Bartels RHMA. Caseload as a factor for outcome in aneurysmal subarachnoid hemorrhage: a systematic review and meta-analysis. J Neurosurg 2014; 120:605-11. [DOI: 10.3171/2013.9.jns13640] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Increasing evidence exists that treatment of complex medical conditions in high-volume centers is found to improve outcome. Patients with subarachnoid hemorrhage (SAH), a complex disease, probably also benefit from treatment at a high-volume center. The authors aimed to determine, based on published literature, whether a higher hospital caseload is associated with improved outcomes of patients undergoing treatment after aneurysmal subarachnoid hemorrhage.
Methods
The authors identified studies from MEDLINE, Embase, and the Cochrane Library up to September 28, 2012, that evaluated outcome in high-volume versus low-volume centers in patients with SAH who were treated by either clipping or endovascular coiling. No language restrictions were set. The compared outcome measure was in-hospital mortality. Mortality in studies was pooled in a random effects meta-analysis. Study quality was reported according to the GRADE (Grading of Recommendations Assessment, Development and Evaluation) criteria.
Results
Four articles were included in this analysis, representing 36,600 patients. The quality of studies was graded low in 3 and very low in 1. Meta-analysis using a random effects model showed a decrease in hospital mortality (OR 0.77 [95% CI 0.60–0.97]; p = 0.00; I2 = 91%) in high-volume hospitals treating SAH patients. Sensitivity analysis revealed the relative weight of the 1 low-quality study. Removal of the study with very low quality increased the effect size of the meta-analysis to an OR of 0.68 (95% CI 0.56–0.84; p = 0.00; I2 = 86%). The definition of hospital volume differed among studies. Cutoffs and dichotomizations were used as well as division in quartiles. In 1 study, low volume was defined as 9 or fewer patients yearly, whereas in another it was defined as fewer than 30 patients yearly. Similarly, 1 study defined high volume as more than 20 patients annually, and another defined it as more than 50 patients a year. For comparability between studies, recalculation was done with dichotomized data if available. Cross et al., 2003 (low volume ≤ 18, high volume ≥ 19) and Johnston, 2000 (low volume ≤ 31, high volume ≥ 32) provided core data for recalculation. The overall results of this analysis revealed an OR of 0.85 (95% CI 0.72–0.99; p = 0.00; I2 = 87%).
Conclusions
Despite the shortcomings of this study, the mortality rate was lower in hospitals with a larger caseload. Limitations of the meta-analysis are the not uniform cutoff values and uncertainty about case mix.
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Affiliation(s)
| | | | | | - Gert P. Westert
- 2Scientific Institute for Quality of Healthcare (IQ Healthcare), and Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
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41
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Walendy V, Strauss C, Rachinger J, Stang A. Treatment of aneurysmal subarachnoid haemorrhage in Germany: a nationwide analysis of the years 2005-2009. Neuroepidemiology 2013; 42:90-7. [PMID: 24334973 DOI: 10.1159/000355843] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2013] [Accepted: 09/04/2013] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The aim of this study was to provide population-based nationwide rates of the different treatment modalities of aneurysmal subarachnoid haemorrhage (aSAH). METHODS German Diagnosis-Related Group data of the years 2005-2009 were used to calculate hospitalisation rates for intracranial aneurysm with aSAH. This study includes over 83 million hospitalisations. RESULTS We identified 15,768 hospitalisations with a diagnosis of aSAH. Throughout the observation period, the age-standardised rate for both sexes increased by 69% (95% confidence interval, CI 54-84) for coiling and 13% (95% CI 4-23) for clipping. The estimated annual percent change in the overall hospitalisation rate was 7.4% (95% CI 5.2-9.6). Age-standardised hospitalisation rates varied considerably by region. The estimated hospitalisation rate ratio of overall hospitalisation rates (East/West) was 0.86 (95% CI 0.80-0.91) for males and 0.81 (95% CI 0.77-0.85) for females. After adjustment for age and co-morbidity, the hazard ratio (HR) for in-hospital mortality was higher for coiling than clipping (HR = 1.12, 95% CI 1.01-1.23). Patients who received coiling or clipping had ventricular shunt placement in 5.0 (n = 819) and 6.1% (n = 998), respectively. The estimated length of stay was 3.3 days (95% CI 2.56-4.05) shorter for coiling than clipping. CONCLUSIONS We provide for the first time nationwide, representative hospitalisation rates for the treatment of aSAH. Our results indicate a change in the practice pattern for Germany during the observation period. We observed a gradual increase in overall hospitalisation rates for aSAH.
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Affiliation(s)
- Victor Walendy
- Institut für Klinische Epidemiologie, Medizinische Fakultät, Halle, Germany
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42
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McDonald JS, McDonald RJ, Fan J, Kallmes DF, Lanzino G, Cloft HJ. Comparative effectiveness of ruptured cerebral aneurysm therapies: propensity score analysis of clipping versus coiling. AJNR Am J Neuroradiol 2013; 35:164-9. [PMID: 23868158 DOI: 10.3174/ajnr.a3642] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE The relative merits of treating ruptured aneurysms with clipping versus coiling continue to be a topic of debate. We evaluated a national, multihospital patient data base to examine recent trends in ruptured aneurysm therapies and to compare peri-procedural outcomes between clipping and coiling treatments. MATERIALS AND METHODS The Premier Perspective data base was used to identify patients hospitalized between 2006-2011 for ruptured aneurysm who underwent clipping or coiling therapy. A propensity score model, representing the probability of receiving clipping, was generated for each patient by use of relevant patient and hospital variables. After Greedy-type matching of the propensity score, the risk of in-hospital mortality and morbidity was compared between clipping and coiling cohorts. RESULTS A total of 5229 patients with ruptured aneurysm (1228 clipping, 4001 coiling) treated at 125 hospitals were identified. Clipping therapy frequency decreased from 27% in 2006 to 21% in 2011. After propensity score adjustment, in-hospital mortality risk was similar between groups (OR = 0.94 [95% CI, 0.73-1.21]; P = .62). However, unfavorable outcomes were more common after clipping compared with coiling, including discharge to long-term care (OR = 1.32 [95% CI, 1.12-1.56]; P = .0006), ischemic complications (OR = 1.51 [95% CI, 1.24-1.83]; P = .0009), neurologic complications (OR = 1.64 [95% CI, 1.18-2.27]; P = .0018), and other surgical complications (OR = 1.55 [95% CI, 1.05-2.33]; P = .0240). CONCLUSIONS This study of a data base of multiple hospitals in the United States demonstrates that clipping of ruptured cerebral aneurysms resulted in greater adjusted morbidity compared with coiling.
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Brinjikji W, Lanzino G, Kallmes DF, Cloft HJ. Cerebral aneurysm treatment is beginning to shift to low volume centers. J Neurointerv Surg 2013; 6:349-52. [DOI: 10.1136/neurintsurg-2013-010811] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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44
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Nuño M, Patil CG, Lyden P, Drazin D. The effect of transfer and hospital volume in subarachnoid hemorrhage patients. Neurocrit Care 2013; 17:312-23. [PMID: 22843190 DOI: 10.1007/s12028-012-9740-y] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Prompt management of aneurysmal subarachnoid hemorrhage (SAH) is critical. Literature is inconclusive regarding outcomes for patients directly admitted to specialized centers versus transferred from lower-volume hospitals. Providers are often unclear about the safety of transferring critical patients. This study evaluated the "transfer effect" in a large sample of aneurysmal SAH patients undergoing treatment. METHODS Using Nationwide Inpatient Sample 2002-2007 data, we analyzed outcomes of SAH patients treated with coil or clip procedures. Analyses studied the effect of direct-admit versus transfer admission on mortality, discharge disposition, complications, length of stay (LOS), and total charges. RESULTS Of 47,114 patients, 31,711 (67.3 %) were direct-admits and 15,403 (32.7 %) were transfers. More transfer patients were coiled than direct-admits (45.3 vs. 33.7 %, p < 0.0001) and fewer underwent ventriculostomy (26.6 vs. 31.5 %, p = 0.003). Older age (OR 1.2, p < 0.0001), higher disease severity (OR 1.4, p < 0.0001), lower volume (OR 1.5, p < 0.0001), and ventriculostomy (OR 2.1, p < 0.0001) increased mortality and predicted non-routine discharge, complications, LOS, and charges. Transfer patients had similar mortality (OR 0.9, p = 0.13) and complications (OR 0.9, p = 0.22) as direct-admits, but incurred higher non-routine discharge (OR 1.3, p = 0.002). Analysis of grade V patients demonstrated similar outcomes between direct-admits and transfers; however, charges for treating transfer patients were notably higher ($401,386 vs. $242,774, p = 0.03). CONCLUSION Patients treated in the lowest volume hospitals were 1.6 times more likely to die than those treated at the highest quintile hospitals. Among the critically ill grade V patients, transfer to higher-volume specialized centers did not increase the likelihood of a poor prognosis.
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Affiliation(s)
- Miriam Nuño
- Department of Neurosurgery, Cedars-Sinai Medical Center, Center for Neurosurgical Outcomes Research, Maxine Dunitz Neurosurgical Institute, 8631 W. Third Street, Suite 800E, Los Angeles, CA 90048, USA
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45
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Lad SP, Babu R, Rhee MS, Franklin RL, Ugiliweneza B, Hodes J, Nimjee SM, Zomorodi AR, Smith TP, Friedman AH, Patil CG, Boakye M. Long-term Economic Impact of Coiling vs Clipping for Unruptured Intracranial Aneurysms. Neurosurgery 2013; 72:1000-11; discussion 1011-3. [DOI: 10.1227/01.neu.0000429284.91142.56] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND:
Treatment of unruptured intracranial aneurysms (UIAs) involves endovascular coiling or aneurysm clipping. While many studies have compared these treatment modalities with respect to various clinical outcomes, few studies have investigated the economic costs associated with each procedure.
OBJECTIVE:
To determine the reoperation rate, postoperative complications, and inpatient and outpatient costs associated with surgical or endovascular treatment of patients with UIAs in the United States.
METHODS:
We utilized the MarketScan database to examine patients who underwent surgical clipping or endovascular coiling procedures for UIAs from 2000 to 2009, comparing reoperation rates, complications, and angiogram and healthcare resource use. Propensity score matching techniques were used to match patients.
RESULTS:
We identified 4,504 patients with surgically treated UIAs, with propensity score matching of 3,436 patients. Reoperation rates were significantly lower in the clipping group compared to the coiling group at 1- (P < .001), 2- (P < .001), and 5 years (P < .001) following the procedure. However, postoperative complications (immediate, 30 and 90 days) were significantly higher in those undergoing surgical clipping. Although hospital length of stay and costs were higher in the clipping group for the index procedure, the number of postoperative angiograms and outpatient services used at 1, 2, and 5 years were significantly higher in the coiling group.
CONCLUSION:
Though surgical clipping resulted in lower reoperation rates, it was associated with higher complication rates and initial costs. However, overall costs at 2 and 5 years were similar to endovascular coiling due to the significantly higher number of follow-up angiograms and outpatient costs in these patients.
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Affiliation(s)
| | - Ranjith Babu
- Department of Surgery, Division of Neurosurgery, and
| | - Michael S. Rhee
- Department of Neurosurgery, University of Louisville, Louisville, Kentucky
| | - Robbi L. Franklin
- Department of Neurosurgery, University of Louisville, Louisville, Kentucky
| | | | - Jonathan Hodes
- Department of Neurosurgery, University of Louisville, Louisville, Kentucky
| | | | | | - Tony P. Smith
- Department of Radiology, Division of Vascular and Interventional Radiology Duke University Medical Center, Durham, North Carolina
| | | | - Chirag G. Patil
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Maxwell Boakye
- Roblex Rex VA Medical Center, 800 Zorn Avenue, Louisville, Kentucky
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McDonald JS, McDonald RJ, Fan J, Kallmes DF, Lanzino G, Cloft HJ. Comparative Effectiveness of Unruptured Cerebral Aneurysm Therapies. Stroke 2013; 44:988-94. [DOI: 10.1161/strokeaha.111.000196] [Citation(s) in RCA: 80] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Endovascular therapy has increasingly become the most common treatment for unruptured cerebral aneurysms in the United States. We evaluated a national, multi-hospital database to examine recent utilization trends and compare periprocedural outcomes between clipping and coiling treatments of unruptured aneurysms.
Methods—
The Premier Perspective database was used to identify patients hospitalized between 2006 to 2011 for unruptured cerebral aneurysm who underwent clipping or coiling therapy. A logistic propensity score was generated for each patient using relevant patient, procedure, and hospital variables, representing the probability of receiving clipping. Covariate balance was assessed using conditional logistic regression. Following propensity score adjustment using 1:1 matching methods, the risk of in-hospital mortality and morbidity was compared between clipping and coiling cohorts.
Results—
A total of 4899 unruptured aneurysm patients (1388 clipping, 3551 coiling) treated at 120 hospitals were identified. Following propensity score adjustment, clipping patients had a similar likelihood of in-hospital mortality (odds ratio [OR], 1.43; 95% confidence interval [CI], 0.49–4.44;
P
=0.47) but a significantly higher likelihood of unfavorable outcomes, including discharge to long-term care (OR, 4.78; 95% CI, 3.51–6.58;
P
<0.0001), ischemic complications (OR, 3.42; 95% CI, 2.39–4.99;
P
<0.0001), hemorrhagic complications (OR, 2.16; 95% CI, 1.33–3.57;
P
<0.0001), postoperative neurological complications (OR, 3.39; 95% CI, 2.25–5.22;
P
<0.0001), and ventriculostomy (OR, 2.10; 95% CI, 1.01–4.61;
P
=0.0320) compared with coiling patients.
Conclusions—
Among patients treated for unruptured intracranial aneurysms in a large sample of hospitals in the United States, clipping was associated with similar mortality risk but significantly higher periprocedural morbidity risk compared with coiling.
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Affiliation(s)
- Jennifer S. McDonald
- From the Departments of Radiology (J.S.M., R.J.M., D.F.K., G.L., H.J.C.), Health Sciences Research (J.F.), and Neurosurgery (D.F.K., G.L., H.J.C.), Mayo Clinic, Rochester, MN
| | - Robert J. McDonald
- From the Departments of Radiology (J.S.M., R.J.M., D.F.K., G.L., H.J.C.), Health Sciences Research (J.F.), and Neurosurgery (D.F.K., G.L., H.J.C.), Mayo Clinic, Rochester, MN
| | - Jiaquan Fan
- From the Departments of Radiology (J.S.M., R.J.M., D.F.K., G.L., H.J.C.), Health Sciences Research (J.F.), and Neurosurgery (D.F.K., G.L., H.J.C.), Mayo Clinic, Rochester, MN
| | - David F. Kallmes
- From the Departments of Radiology (J.S.M., R.J.M., D.F.K., G.L., H.J.C.), Health Sciences Research (J.F.), and Neurosurgery (D.F.K., G.L., H.J.C.), Mayo Clinic, Rochester, MN
| | - Giuseppe Lanzino
- From the Departments of Radiology (J.S.M., R.J.M., D.F.K., G.L., H.J.C.), Health Sciences Research (J.F.), and Neurosurgery (D.F.K., G.L., H.J.C.), Mayo Clinic, Rochester, MN
| | - Harry J. Cloft
- From the Departments of Radiology (J.S.M., R.J.M., D.F.K., G.L., H.J.C.), Health Sciences Research (J.F.), and Neurosurgery (D.F.K., G.L., H.J.C.), Mayo Clinic, Rochester, MN
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Chandra SP, Kumar A. Clipping of a re-grown basilar bifurcation aneurysm following coiling: an extreme surgical challenge. Neurol India 2013; 60:676-7. [PMID: 23287351 DOI: 10.4103/0028-3886.105223] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Wong JM, Ziewacz JE, Panchmatia JR, Bader AM, Pandey AS, Thompson BG, Frerichs K, Gawande AA. Patterns in neurosurgical adverse events: endovascular neurosurgery. Neurosurg Focus 2012; 33:E14. [DOI: 10.3171/2012.7.focus12180] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
As part of a project to devise evidence-based safety interventions for specialty surgery, the authors sought to review current evidence in endovascular neurosurgery concerning the frequency of adverse events in practice, their patterns, and current methods of reducing the occurrence of these events. This review represents part of a series of papers written to consolidate information about these events and preventive measures as part of an ongoing effort to ascertain the utility of devising system-wide policies and safety tools to improve neurosurgical practice.
Based on a review of the literature, thromboembolic events appeared to be the most common adverse events in endovascular neurosurgery, with a reported incidence ranging from 2% to 61% depending on aneurysm rupture status and mode of detection of the event. Intraprocedural and periprocedural prevention and rescue regimens are advocated to minimize this risk; however, evidence on the optimal use of anticoagulant and antithrombotic agents is limited. Furthermore, it is unknown what proportion of eligible patients receive any prophylactic treatment.
Groin-site hematoma is the most common access-related complication. Data from the cardiac literature indicate an overall incidence of 9% to 32%, but data specific to neuroendovascular therapy are scant. Manual compression, compression adjuncts, and closure devices are used with varying rates of success, but no standardized protocols have been tested on a broad scale. Contrast-induced nephropathy is one of the more common causes of hospital-acquired renal insufficiency, with an incidence of 30% in high-risk patients after contrast administration. Evidence from medical fields supports the use of various preventive strategies.
Intraprocedural vessel rupture is infrequent, with the reported incidence ranging from 1% to 9%, but it is potentially devastating. Improvements in device technology combined with proper endovascular technique play an important role in reducing this risk.
Occasionally, anatomical or technical difficulties preclude treatment of the lesion of interest. Reports of such occurrences are scant, but existing series suggest an incidence of 4% to 6%. Management strategies for radiation-induced effects are also discussed. The incidence rates are unknown, but protective techniques have been demonstrated.
Many of these complications have strategies that appear effective in reducing their risk of occurrence, but development and evaluation of systematic guidelines and protocols have been widely lacking. Furthermore, there has been little monitoring of levels of adherence to potentially effective practices. Protocols and monitoring programs to support integrated implementation may be broadly effective.
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Affiliation(s)
- Judith M. Wong
- 1Department of Health Policy and Management, Harvard School of Public Health
- 2Center for Surgery and Public Health and
- 3Departments of Neurosurgery,
| | - John E. Ziewacz
- 4Department of Neurosurgery, University of Michigan Health Systems, Ann Arbor, Michigan; and
| | - Jaykar R. Panchmatia
- 5Department of Orthopaedics and Trauma, Heatherwood and Wexham Park Hospitals, London, United Kingdom
| | - Angela M. Bader
- 1Department of Health Policy and Management, Harvard School of Public Health
- 2Center for Surgery and Public Health and
- 6Anesthesiology, Perioperative and Pain Medicine, and
| | - Aditya S. Pandey
- 4Department of Neurosurgery, University of Michigan Health Systems, Ann Arbor, Michigan; and
| | - B. Gregory Thompson
- 4Department of Neurosurgery, University of Michigan Health Systems, Ann Arbor, Michigan; and
| | | | - Atul A. Gawande
- 1Department of Health Policy and Management, Harvard School of Public Health
- 2Center for Surgery and Public Health and
- 7Surgery, Brigham and Women's Hospital, Boston, Massachusetts
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Andaluz N, Zuccarello M. Treatment strategies for complex intracranial aneurysms: review of a 12-year experience at the university of cincinnati. Skull Base 2012; 21:233-42. [PMID: 22470266 DOI: 10.1055/s-0031-1280685] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Complex intracranial aneurysms (CIAs) include those classified as giant, those located in brain regions of technically difficult access, or that involve arterial trunks/branches, and/or have complicated wall structure. We reviewed retrospectively our management of such lesions in a 12-year period. From 1997 to 2009, 192 patients were admitted with CIAs (133 females, 59 males; average age 55 years); 128 presented with subarachnoid hemorrhage (SAH) and 64 with unruptured, symptomatic CIAs. The SAH group had 73 anterior- and 55 posterior-circulation aneurysms. Most frequent location was middle cerebral artery. Treatment strategies included clipping (65.6%), coiling/stenting (28.1%), bypass (3.1%), no treatment (3.1%). Coiling/stenting was exclusively used for posterior-circulation aneurysms. Outcomes were good (modified Rankin Scale [mRS] 0 to 2) in 54 patients (42.2%), fair (mRS = 3 to 4) in 38 (29.7%), and poor (mRS = 5 to 6) in 36 (28.1%). Among unruptured CIAs, there were 47 anterior- and 17 posterior-circulation aneurysms. Most frequent location was ophthalmic. Thirty (46.9%) were clipped, 19 (29.7%) coiled, 6 (9.4%) by-passed, 2 (3.1%) wrapped, and 7 (10.9%) had no treatment. Outcomes were good in 57 patients (89%) and fair in 7 (11%). Good outcomes were obtained in unruptured CIAs using a multidisciplinary approach. Ruptured CIAs carry a significantly worse prognosis than overall SAH patients.
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Trends in the incidence of subarachnoid hemorrhage in South Korea from 2006-2009: an ecological study. World Neurosurg 2012; 79:499-503. [PMID: 22902357 DOI: 10.1016/j.wneu.2012.07.032] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2011] [Revised: 07/05/2012] [Accepted: 07/20/2012] [Indexed: 01/24/2023]
Abstract
OBJECTIVE The purpose of this study is to investigate trends in the incidence of subarachnoid hemorrhage (SAH) in South Korea from 2006-2009. METHODS We used the national health claim database managed by Health Insurance Review and Assessment Service, which contains all hospital records of every Korean citizen. Patients with SAH were defined as International Classification of Diseases-10 codes with a hospitalization period of ≥ 14 days or death within 14 days of hospitalization. We evaluated trends in the incidence of SAH during a 4-year period using the Cochran-Armitage trend test. RESULTS We identified 35,263 patients with SAH among adult patients (≥ 18 years old) from 2005-2009. Age-adjusted SAH incidence rates decreased from 13.4 in 2006 to 12.4 in 2009/100,000 men (P = 0.0025) and women also showed a decrease from 19.4-17.3/100,000 (P < 0.0001). However, this decreasing pattern was not shown in patients less than 50 years of age. SAH incidence showed gender differences dependent on age; men who were 40 years old or less had a higher incidence than women. CONCLUSIONS The age-adjusted incidence rates of SAH were slightly decreased in South Korea. Further research should be conducted to identify the clinical risk factors to reduce SAH incidence rates even more, especially in younger people.
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