Introduction Intracranial stent placement has been increasingly utilized as an adjunct to coil embolization during endovascular repair of cerebral aneurysms. However, some neuro-interventionalists have remained hesitant to utilize intracranial stents in patients with subarachnoid hemorrhage (SAH) due to the need for dual antiplatelet agents; moreover, high morbidity has been reported when this treatment modality was utilized in the setting of acute rupture. This is the first nationwide study to evaluate the impact of intracranial stent placement on the in-hospital outcomes after aneurysmal SAH.
Methods Data from the Nationwide Inpatient Sample (2005–2011) were extracted. Patients with a diagnosis of subarachnoid hemorrhage who underwent aneurysm repair either via a microsurgical or endovascular approach were included. Multivariate logistic regression analyzes were performed to calculate the adjusted odds of in-hospital mortality; the development of any post-procedural complication, a neurological complication, and a hematologic complication; and of a non-routine hospital discharge for patients who underwent intracranial stent placement compared to those treated without stent placement. Co-variates included in all analyzes were patient age, gender, co-morbidities, expected primary payer, ventriculostomy, mechanical ventilation, intraparenchymal hemorrhage, as well as hospital bed size and teaching status. Subgroup analysis compared those treated with an intracranial stent to those treated with endovascular embolization without stent placement.
Results 13,260 hospital admissions were examined and 0.94% of patients (n = 104) underwent placement of an intracranial stent. The frequency of stent usage varied from a nadir of 0.5% in 2006 to a zenith of 1.9% in 2010. Those who required a ventriculostomy for cerebrospinal fluid diversion were significantly less likely to undergo aneurysm repair with stent placement (P = 0.003). Although in-hospital mortality was higher for those who underwent intracranial stent placement (16.0% vs. 12.8%) this was not associated with a significant difference in multivariate analysis (OR: 1.36, 95% CI: 0.84, 2.20, P = 0.20). The odds of developing a post-operative complication (78.4% vs. 79.2%, OR: 0.98, 95% CI 0.60, 1.58, P = 0.92), a neurological complication (38.1% vs. 31.4%, OR: 1.36, 95% CI: 0.91, 2.05, P = 0.14), and a hematologic complication (25.6% vs. 20.3%, OR: 1.41, 95% CI: 0.85, 2.33, P = 0.18) were not found to be significantly greater in multivariate analyzes for those who underwent intracranial stent placement. Likewise, intracranial stent placement was not associated with a significant difference in the likelihood a nonroutine hospital discharge (61.0% vs. 55.6%, OR: 1.32, 95% CI: 0.79, 2.21, P = 0.28). However, in a subgroup analyzes exclusively examining patients treated endovascularly, there was a trend towards higher rate of hematologic complications in those who underwent adjuvant intracranial stent placement (25.6% vs. 18.5%, OR: 1.67, 95% CI: 0.99, 2.81, P = 0.05).
Conclusions In this nationwide study evaluating patients with subarachnoid hemorrhage, patients who underwent endovascular aneurysm repair with placement of an intracranial stent were not found in multivariate analyzes to have a significant difference in mortality, complications, or discharge disposition compared to those who underwent aneurysm repair without stent placement. However, there was a trend towards higher rate of hematologic complications for those treated with intracranial stent placement compared to patients treated endovascularly without adjuvant stent placement.
Disclosures H. Dasenbrock: None. Y. Subat: None. K. Frerichs: None. D. Guttieres: None. R. Du: None. M. Aziz-Sultan: 2; C; Codman, Covidien.