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Abstract
Background Hydrocephalus is a significant contributor to morbidity following aneurysmal subarachnoid hemorrhage (aSAH). We aimed to investigate the association between primary treatment modality and the incidence of hydrocephalus requiring CSF diversion, using a target trial approach for causal inference.
Methods This cohort study used US administrative health claims data (Clinformatics Data Mart) and was conducted among aSAH patients undergoing primary treatment with either clipping or coiling, from January 1, 2004, to February 28, 2023. The primary outcome was hydrocephalus requiring CSF diversion surgery while the secondary outcome was mortality. Multivariable regression and 1:1 propensity score (PS) matching were used for confounder control. Crude and adjusted hazard ratios (HRs) with 95% CIs were calculated.
Results A total of 5816 patients (mean age 59 years; 72% women) undergoing clipping (n=1794) or coiling (n=4022) were included in the primary cohort. The 1:1 PS matched cohort had 1794 participants per arm. Clipping demonstrated higher hazards of shunt dependent hydrocephalus compared with coiling in both the multivariable Fine–Gray model (HR 1.39, 95% CI 1.19 to 1.62) and the PS matched cohorts (HR 1.39, 95% CI 1.16 to 1.66). Mortality analysis favored clipping in the crude analysis (HR 0.78, 95% CI 0.69 to 0.88) but leaned toward coiling after confounder adjustment (HR 1.13, 95% CI 1.00 to 1.29 in the multivariable model; HR 1.11, 95% CI 0.95 to 1.29 in the PS matched cohort).
Conclusion These findings suggest that coiling is associated with reduced hazards of shunt dependent hydrocephalus following aSAH compared with clipping, and provide valuable insights for shared decision making among clinicians and patients, in the context of conflicting evidence from smaller observational studies.
- Hydrocephalus
- Aneurysm
- Statistics
Data availability statement
No data are available. The data used in this study are derived from Clinformatics Data Mart Database (Optum, Eden Prairie, Minnesota, USA). Access to the data was granted under a data use agreement, and all analyses were conducted within a secure computing environment. Due to privacy and confidentiality agreements, the insurance claims data cannot be publicly shared or made directly available.
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Data availability statement
No data are available. The data used in this study are derived from Clinformatics Data Mart Database (Optum, Eden Prairie, Minnesota, USA). Access to the data was granted under a data use agreement, and all analyses were conducted within a secure computing environment. Due to privacy and confidentiality agreements, the insurance claims data cannot be publicly shared or made directly available.
Footnotes
JS and EP are joint senior authors.
X @atomar_md, @dannidiestro
Contributors ATO conceived and designed the study, collected and analyzed the data, drafted the initial manuscript, and is the guarantor for this study. JDBD provided subject matter expertise and contributed to study design. JS provided subject matter expertise, contributed to the study design, assisted in funding acquisition, and supervised the study. EP provided methodological and statistical expertise, contributed to the study design, assisted in funding acquisition, and supervised the study. All authors critically revised the manuscript, and provided final approval for publication.
Funding This study was funded by the Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.
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