Treatment of ruptured and unruptured cerebral aneurysms in the USA: A paradigm shift
ABSTRACT 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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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 · 0.47 Impact Factor
- Acta Neurochirurgica 04/2012; 154(6):1011-2; author reply 1013-4. DOI:10.1007/s00701-012-1343-z · 1.79 Impact Factor
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ABSTRACT: Although coil embolization is one of the most effective treatments for intracranial aneurysms (ICAs), the procedure is often unsuccessful. For example, an ICA may persist after coil embolization if deployed coils fail to block the flow of blood into the aneurysm. Unfortunately, the specific flow changes that are effected by embolic coiling (and other endovascular therapies) are poorly understood, which creates a barrier to the design and execution of optimal treatments in the clinic. We present an in vitro pulsatile flow study of treated basilar tip aneurysm models that elucidates relationships between controllable treatment parameters and clinically important post-treatment fluid dynamics. We also compare fluid dynamic performance across embolic coils and more recently proposed devices (e.g., the Pipeline Embolization Device) that focus on treating ICAs by diverting rather than blocking blood flow. In agreement with previous steady flow studies, coil embolization reduced velocity magnitude at the aneurysmal neck by greater percentages for a narrowneck aneurysm, and reduced flow into aneurysms by greater percentages at lower parent vessel flow rates. However, flow diversion reduced flow into a wide-neck aneurysm more so than coil embolization, regardless of flow conditions. Lastly, results also showed that for the endovascular devices we examined, treatment effects were generally less dramatic under physiologic pulsatile flow conditions as compared to steady flow conditions. The fluid dynamic performance data presented in this study represent the first direct in vitro comparison of coils and flow diverters in aneurysm models, and provide a novel, quantitative basis to aid in designing endovascular treatments toward specific fluid dynamic outcomes.IEEE Transactions on Biomedical Engineering 04/2013; 60(4). DOI:10.1109/TBME.2012.2228002 · 2.23 Impact Factor