Treatment of ruptured and unruptured cerebral aneurysms in the USA: A paradigm shift

Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts 02215, USA.
Journal of Neurointerventional Surgery (Impact Factor: 2.77). 06/2011; 4(3):182-9. DOI: 10.1136/jnis.2011.004978
Source: PubMed


Integration of data from clinical trials and advancements in technology predict a change in selection for treatment of patients with cerebral aneurysm.
To describe patterns of use and in-hospital mortality associated with surgical and endovascular treatments of cerebral aneurysms over the past decade.
The 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.
From 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.
The 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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    • "Thus, the hegemony of surgical clipping was broken by aneurysm coiling causing shifting treatment paradigms. The number of endovascular procedures has grown steadily since 1990s [6, 10, 11, 14]. At the same time, the number of clipped IAs had a downward trend with a significant decrease in the group of unruptured aneurysms [1, 4, 6, 10]. "
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    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.
    Acta Neurochirurgica 02/2014; 108649946(18). DOI:10.1007/s00701-014-2006-z · 1.77 Impact Factor
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    • "As a matter of fact, in many centers worldwide endovascular techniques majorly replaced surgery for aneurysms; however, it is not possible to lay down definitive rules for the lack of consensus studies. On the other hand, single institutions experiences have been recently published [3–6]. In a recent single-center series, it was found that 87.5% of aneurysmal subarachnoid hemorrhage patients were treated with endovascular techniques, while 12.5% with craniotomy and clip ligation, thus demonstrating the amount of shifting toward the endovascular therapy [7]. "
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    ABSTRACT: Introduction: The purpose of the present contribution is to perform a detailed anatomic and virtual reality three-dimensional stereoscopic study in order to test the effectiveness of the extended endoscopic endonasal approaches for selected anterior and posterior circulation aneurysms. Methods: The study was divided in two main steps: (1) simulation step, using a dedicated Virtual Reality System (Dextroscope, Volume Interactions); (2) dissection step, in which the feasibility to reach specific vascular territory via the nose was verified in the anatomical laboratory. Results: Good visualization and proximal and distal vascular control of the main midline anterior and posterior circulation territory were achieved during the simulation step as well as in the dissection step (anterior communicating complex, internal carotid, ophthalmic, superior hypophyseal, posterior cerebral and posterior communicating, basilar, superior cerebellar, anterior inferior cerebellar, vertebral, and posterior inferior cerebellar arteries). Conclusion: The present contribution is intended as strictly anatomic study in which we highlighted some specific anterior and posterior circulation aneurysms that can be reached via the nose. For clinical applications of these approaches, some relevant complications, mainly related to the endonasal route, such as proximal and distal vascular control, major arterial bleeding, postoperative cerebrospinal fluid leak, and olfactory disturbances must be considered.
    01/2014; 2014:703792. DOI:10.1155/2014/703792
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    ABSTRACT: After the decision is made to treat an intracranial aneurysm, clinicians must choose between two competing treatment options; open surgery or endovascular therapy. The rationale underlying the choice of treatment modality is usually unclear, as there is little good quality evidence available. We discuss the patient and aneurysm-related factors cited in the neurovascular literature that are considered to influence aneurysm treatment choices. The relevance and direction of influence of rupture status, age, type of presentation, and general medical condition, as well as aneurysm size, location, morphology, and multiplicity are discussed. The validity of these factors in influencing treatment decisions remains unclear, with frequently opposing views on the same factor by clinicians practicing opposing techniques. Perceived differences in efficacy and safety of the two different treatment approaches are commonly used in an attempt to justify treatment choices. Difficulties with treatment selection and case-by-case reasoning are reviewed. Properly designed and conducted randomized trials are necessary in order to settle the controversy and to determine the optimal treatment modality for intracranial aneurysms. In the absence of reliable knowledge on which to base treatment decisions, the ethically appropriate choice for any clinician, from surgical or endovascular backgrounds, is to participate in randomized trials.
    Neurochirurgie 04/2012; 58(2-3):61-75. DOI:10.1016/j.neuchi.2012.02.023 · 0.41 Impact Factor
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