Increasing treatment of ruptured cerebral aneurysms at high-volume centers in the United States: Clinical article

Mayo Medical School, Rochester, Minnesota 55905, USA.
Journal of Neurosurgery (Impact Factor: 3.74). 08/2011; 115(6):1179-83. DOI: 10.3171/2011.7.JNS11590
Source: PubMed


Evidence of better outcomes in patients with aneurysmal subarachnoid hemorrhage treated at higher-volume centers might be expected to result in more of these patients being referred to such centers. The authors evaluated the US National Inpatient Sample for the years 2001 to 2008 for trends in patient admissions for the treatment of ruptured aneurysms at high- and low-volume centers.
The authors determined the number of ruptured aneurysms treated with clipping or coiling annually at low-volume (≤ 20 patients/year) and high-volume (> 20 patients/year) centers and also counted the number of high- and low-volume centers performing each treatment. Hospitalizations for clipping or coiling ruptured aneurysms were identified by cross-matching International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes for the diagnosis of a ruptured aneurysm (ICD-9-CM 430) with procedure codes for clipping (ICD-9-CM 39.51) or coiling (ICD-9-CM 39.52, 39.79, or 39.72) cerebral aneurysms.
In 2001, 31% (435 of 1392) of the patients who underwent clipping and 0% (0 of 122 patients) of those who underwent coiling did so at high-volume centers, whereas in 2008 these numbers increased to 62% (627 of 1016) and 68% (917 of 1351) of patients, respectively. For clipping procedures, the number of low-volume centers significantly declined from 177 in 2001 to 85 in 2008, whereas the number of high-volume centers remained constant at 13-15. For coiling procedures, the number of low-volume centers decreased from 62 in 2001 to 54 in 2008, whereas the number of high-volume centers substantially increased from 0 in 2001 to 16 in 2005 and remained constant thereafter.
The treatment of ruptured cerebral aneurysms increasingly occurs at high-volume centers in the US. This trend is favorable given that better outcomes are associated with the treatment of these lesions at high-volume centers.

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Available from: Waleed Brinjikji, Aug 10, 2015
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    • "Numerous studies have shown the relationships between hospital volume and outcome in cerebral aneurysm clipping [19, 20]. Leake et al. evaluated the US National Inpatient Sample for the period 2001–2008 for outcomes and trends in patient admissions for treating subarachnoid hemorrhage at high- and low-volume centers [19], concluding that the treatment of ruptured cerebral aneurysms increasingly occurs at high-volume centers in the United States. They observed enhanced outcomes associated with treating these lesions at high-volume centers [19]. "
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    ABSTRACT: Background Adjunctive stenting has increasingly become an acceptable option for the endovascular treatment of unruptured aneurysms. The Nationwide Inpatient Sample (NIS) was used to compare US in-hospital outcomes related to coiling with and without adjunctive stenting for unruptured aneurysms. Methods Hospitalizations for coiling of unruptured cerebral aneurysms from 2004 to 2008 were identified in the NIS by extracting ICD-9-CM codes for the diagnosis of unruptured aneurysm (437.3) and intracranial stenting (00.65) with coiling (39.52, 39.79 or 39.72) of cerebral aneurysms. All patients with a diagnosis of subarachnoid hemorrhage (430) and/or intracerebral hemorrhage (431) were excluded. Mortality and discharge to a long-term facility were compared between stent and non-stent patient groups using multivariate regression analysis. Results Patients treated with stent-assisted coiling had an in-hospital mortality rate of 0.08–0.8% compared with a death rate of 0.5% (95% CI 0.3% to 0.7%) for patients who did not receive a stent during coiling (p=0.36). Patients in the stent group had a 3% rate of discharge to a care facility (95% CI 1.5% to 5.8%) compared with 5% (95% CI 4.5% to 5.6%) for those in the non-stent group (p=0.14). Patients treated with a stent had a similar likelihood of in-hospital mortality (adjusted OR, 2.12 (95% CI 0.32 to 7.11), p=0.34) and a lower likelihood of discharge to a long-term care facility (adjusted OR 0.59 (95% CI 0.24 to 1.16), p=0.16) compared with the non-stent group. Conclusions Adjunctive stenting adds little in-hospital risk to the endovascular treatment of cerebral aneurysms. However, the need for dual antiplatelet therapy may predispose to delayed hemorrhagic complications and discontinuation of dual antiplatelet therapy may lead to delayed thromboembolic complications.
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    ABSTRACT: BACKGROUND:: Microsurgical clip obliteration remains a time-honored and viable option for the treatment of select aneurysms with very low rates of recurrence. OBJECTIVE:: We studied previously clipped aneurysms that were found to have recurrences to better understand the patterns and configuration of these rare entities. METHODS:: A retrospective review was performed of two prospectively maintained databases of aneurysm treatments from two institutions spanning 14 years to identify patients with recurrent previously clipped intracranial aneurysms. RESULTS:: Twenty-six aneurysm recurrences were identified. Three types of recurrence were identified: Type I: proximal to the clip tines, Type II: distal, and Type III: lateral. The most common type of recurrence was that arising distal to the clip tines (46.1%), and the least frequently encountered was that arising proximal to the tines (19.2%). Laterally located recurrences were found in 34.6% of cases. CONCLUSION:: We have described three different patterns of aneurysm recurrence with respect to the clip application: those occurring proximal, distal, or lateral to the clip tines.
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