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Original research
Treatment and diagnosis of cerebral aneurysms in the post-International Subarachnoid Aneurysm Trial (ISAT) era: trends and outcomes
  1. Evan Luther1,
  2. David J McCarthy1,2,
  3. Marie-Christine Brunet1,
  4. Samir Sur1,
  5. Stephanie H Chen1,
  6. Dallas Sheinberg1,
  7. David Hasan3,
  8. Pascal Jabbour4,
  9. Dileep R Yavagal5,
  10. Eric C Peterson1,
  11. Robert M Starke1
  1. 1Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
  2. 2Neurosurgery, University of Miami School of Medicine, Miami, Florida, USA
  3. 3Neurological Surgery, University of Iowa, Iowa City, Iowa, USA
  4. 4Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
  5. 5Neurology, University of Miami Miller School of Medicine, Miami, Florida, USA
  1. Correspondence to David J McCarthy, Neurosurgery, University of Miami School of Medicine, Miami, FL 33136, USA; dmdavo99{at}gmail.com

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.

  • aneurysm
  • coil
  • hemorrhage
  • history
  • technology
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Footnotes

  • Twitter @PascalJabbourMD, @Starke_neurosurgery

  • EL and DJM contributed equally.

  • Contributors EL: conception of the work, acquisition, analysis, or interpretation of data, drafting the work. DMcC: conception of the work, acquisition, analysis, or interpretation of data, drafting the work, final approval. M-CB: drafting the work, interpretation of data, final approval. SS: drafting the work, interpretation of data, final approval. SC: drafting the work, interpretation of data, final approval. DS: drafting the work, interpretation of data, final approval. DH: drafting the work, interpretation of data, final approval. PJ: drafting the work, interpretation of data, final approval. DY: drafting the work, interpretation of data, final approval. EP: drafting the work, interpretation of data, final approval. RS: conception of the work, interpretation of data, drafting the work, final approval.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available upon reasonable request and moreso on the HCUP website.

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