Brinjikji, Waleed

Background and Purpose— Flow diverters are important tools in the treatment of intracranial aneurysms. However, their impact on aneurysmal occlusion rates, morbidity, mortality, and complication rates is not fully examined. Methods— We conducted a systematic review of the literature searching multiple databases for reports on the treatment of intracranial aneurysms with flow-diverter devices. Random effects meta-analysis was used to pool outcomes of aneurysmal occlusion rates at 6 months, and procedure-related morbidity, mortality, and complications across studies. Results— A total of 29 studies were included in this analysis, including 1451 patients with 1654 aneurysms. Aneurysmal complete occlusion rate was 76% (95% confidence interval [CI], 70%–81%). Procedure-related morbidity and mortality were 5% (95% CI, 4%–7%) and 4% (95% CI, 3%–6%), respectively. The rate of postoperative subarachnoid hemorrhage was 3% (95% CI, 2%–4%). Intraparenchymal hemorrhage rate was 3% (95% CI, 2%–4%). Perforator infarction rate was 3% (95% CI, 1%–5%), with significantly lower odds of perforator infarction among patients with anterior circulation aneurysms compared with those with posterior circulation aneurysms (odds ratio, 0.01; 95% CI, 0.00–0.08; P <0.0001). Ischemic stroke rate was 6% (95% CI, 4%–9%), with significantly lower odds of perforator infarction among patients with anterior circulation aneurysms compared with those with posterior circulation aneurysms (odds ratio, 0.15; 95% CI, 0.08–0.27; P <0.0001). Conclusions— This meta-analysis suggests that treatment of intracranial aneurysms with flow-diverter devices is feasible and effective with high complete occlusion rates. However, the risk of procedure-related morbidity and mortality is not negligible. Patients with posterior circulation aneurysms are at higher risk of ischemic stroke, particularly perforator infarction. These findings should be considered when considering the best therapeutic option for intracranial aneurysms.

Background and Purpose— Minorities in the United States have less access to healthcare system resources, especially preventative treatments. We sought to determine whether racial and sex disparities existed in the treatment of unruptured intracranial aneurysms. Methods— Using the Nationwide Inpatient Sample, hospitalizations for clipping and coiling of intracranial aneurysms from 2001 to 2009 were identified by cross-matching International Classification of Diseases, 9th Revision codes for diagnosis of unruptured aneurysm and subarachnoid hemorrhage (SAH) with procedure codes for clipping or coiling of cerebral aneurysms. Demographic information analyzed included age (<50, 50–64, 65–79, and ≥80 years), race (white, black, Hispanic, Asian/Pacific Islander), sex, income quartile, primary payer (Medicare, Medicaid, private insurance, self-pay, no charge, other), and Charlson comorbidity index. Results— When compared with patients treated for SAH, those treated for unruptured intracranial aneurysm were significantly more likely to be women (75.0% versus 69.0%; P <0.0001). In all, 9.7% of patients receiving treatment for SAH were self-payers versus 3.0% of patients being treated for unruptured intracranial aneurysm ( P <0.0001). In all, 62.2% of patients receiving treatment for SAH were white compared with 76.4% of patients being treated for unruptured intracranial aneurysm ( P <0.0001). There was a higher proportion of black, Hispanic, and Asian patients in the SAH treatment group when compared with the unruptured aneurysm treatment group ( P <0.0001 for all groups). Conclusions— When compared with patients undergoing treatment for SAH, patients undergoing surgical and endovascular treatment for unruptured intracranial aneurysm are generally from higher socioeconomic strata and are more likely to be insured, women, and white. Future studies are needed to determine the underlying causes and solutions for this disparity.

Background Evaluating recombinant tissue plasminogen activator utilization rates is important, as many studies have demonstrated that administration of recombinant tissue plasminogen activator to qualified patients significantly improves prognosis. Aims We investigated recent trends in the utilization and outcomes of administration of intravenous recombinant tissue plasminogen activator in the United States using the National Inpatient Sample between 2001 and 2008. Methods We identified patients with a primary diagnosis of acute ischemic stroke who underwent treatment with intravenous recombinant tissue plasminogen activator and studied utilization rates and clinical outcomes: discharge to long-term facility (morbidity), in-hospital death (mortality), and intracranial hemorrhage. Information on demographics, hospital characteristics, and comorbidities was collected. A multivariate logistic regression analysis was performed to determine independent predictors of morbidity, mortality, and intracranial hemorrhage. Results Intravenous recombinant tissue plasminogen activator utilization increased from 1·3% in 2001 to 3·5% in 2008. On multivariate analysis, variables associated with increased morbidity after intravenous recombinant tissue plasminogen activator administration included advanced age ( P < 0·001), female gender ( P < 0·001), and comorbidities of atrial fibrillation ( P < 0·001) and hypertension ( P < 0·001). Increased mortality was associated with increased age ( P < 0·001) and comorbidities of atrial fibrillation, congestive heart failure, coronary artery disease, and diabetes ( P < 0·001 for all comorbidities). Conclusions Intravenous recombinant tissue plasminogen activator utilization rates increased between 2001 and 2008. Advanced age and atrial fibrillation were significantly associated with increased morbidity and mortality among patients treated with intravenous recombinant tissue plasminogen activator.

Background— Despite several advances in postresuscitation care over the past decade, population-based mortality rates for patients hospitalized with cardiac arrest in the United States have not been studied over this time period. The aim of this study was to determine the annual in-hospital mortality rates of patients with cardiac arrest from 2001 to 2009. Methods and Results— The US mortality rates for hospitalized patients with cardiac arrest were determined using the 2001 to 2009 US National Inpatient Sample, a national hospital discharge database. Using the International Classification of Diseases , 9 th Edition, code 427.5, we identified patients hospitalized in the United States with cardiac arrest from 2001 to 2009. The main outcome measure was in-hospital mortality. A total of 1 190 860 patients were hospitalized with a diagnosis of cardiac arrest in the United States from 2001 to 2009. The in-hospital mortality rate decreased each year from 69.6% in 2001 to 57.8% in 2009. In multivariable analysis, when controlling for age, sex, race, and comorbidities, earlier year was a strong independent predictor of in-hospital death. The mortality rate declined across all analyzed subgroups, including sex, age, race, and stratification by comorbidity. Conclusions— The in-hospital mortality rate of patients hospitalized with cardiac arrest in the United States decreased by 11.8% from 2001 to 2009.

Background and Purpose— It is important to know the costs for hospitalization for ischemic stroke patients treated with intravenous thrombolysis so that comparisons can be made with payments to hospitals. Methods— Using the National Inpatient Sample, we evaluated hospitalization costs for patients treated with intravenous thrombolysis for acute ischemic stroke in the United States from 2001 to 2008. Cost data were correlated with demographics and clinical outcome. Results— Intravenous thrombolysis for acute ischemic stroke was received by 63 472 patients; 24 094 patients were younger than age 65 years and 40 780 patients were 65 years or older. Median hospital costs in 2008 dollars were $14 102 (interquartile range, $9987–$20 819) for patients with good outcome, $18 856 (interquartile range, $13 145–$30 423) for patients with severe disability, and $19 129 (interquartile range, $11 966–$30 781) for patients with in-hospital mortality. Average 2008 Medicare payments were $10 098 for intravenous thrombolysis without complication and $13 835 for intravenous thrombolysis with major complication. Conclusions— Hospitalization costs for patients treated with intravenous thrombolysis are substantially higher than Medicare payments.

Objective A study was undertaken to estimate the fraction of intracranial aneurysms that might be amenable to treatment with the pipeline embolization device (PED), a current flow diverter device, and to determine the types of aneurysms that are probably not amenable to treatment with this device. Methods A retrospective analysis of 200 consecutive intracranial aneurysms as seen on three-dimensional rotational angiography images was conducted. Based on aneurysm and parent artery morphology, four independent observers experienced in the use of the PED judged the likelihood that a given aneurysm could theoretically be treated with one or more PED using a 5-point scale: grades 1 and 2 indicated amenability to treatment with multiple devices; grade 3 indicated amenability to treatment with one device; and grades 4 and 5 indicated the aneurysm would not be amenable to treatment with the PED. Aneurysms were analyzed on the basis of anatomical factors only. Rupture status was not considered. Interobserver agreement was determined. Results 94 of 200 aneurysms (47%) were judged to be likely to be amenable to treatment with the PED; 50 cases (25%) were judged to be amenable to the use of multiple overlapping devices while, in 44 cases (22%), coverage with a single device was preferred. There was a significant relationship between the location of the aneurysm and the grade of the aneurysm (p<0.0001). Conclusion On the basis of anatomical configuration, nearly half of the aneurysms in this study were likely to be amenable to treatment with the PED.

Background and Purpose— It is important to know the costs of hospitalization for patients undergoing endovascular embolectomy so that comparisons can be made with payments to hospitals. Methods— Using the National Inpatient Sample, we evaluated the costs of hospitalization for patients treated with endovascular embolectomy in the United States from 2006 to 2008. The primary end point examined in this study was total hospital costs, and these were correlated with clinical outcome. Results— A total of 3864 patients received endovascular embolectomy. A total of 1649 patients were <65 years old and 2205 patients were ≥65 years old. Median hospital costs in 2008 dollars were $36 999 (interquartile range, $26 662–$56 405) for patients with good outcome, $50 628 (interquartile range, $33 135–$76 063) for patients with severe disability, and $35 109 (interquartile range, $25 053–$62 621) for patients with mortality. Conclusions— Hospitalization costs for patients treated with endovascular embolectomy are rather high, probably due to the serious nature of their illness. Medicare payments have not been adequate reimbursement for these hospitalizations.

Object 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. Methods 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. Results 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. Conclusions 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.

Background and Purpose Endovascular and surgical options are both available for the treatment of unruptured cerebral aneurysms. Knowledge of the costs for hospitalization of these patients is important to understanding economic impact of these patients on hospitals. Methods Using the National Inpatient Sample, hospitalizations for clipping and coiling of unruptured cerebral aneurysms from 2001 to 2008 were identified by cross-matching ICD-9 codes for diagnosis of unruptured aneurysm with procedure codes for clipping or coiling of cerebral aneurysms, and excluding all patients with diagnosis of subarachnoid hemorrhage and intracerebral hemorrhage. Hospital costs for 2008 were correlated with age, gender, and discharge status, and compared to Medicare payments. Results Costs of both clipping and coiling have increased from 2001 to 2008. The median 2008 hospital costs were US$23 574 (IQR 18233–29941) for clipping and US$25 734 (IQR 17436–35846) for coiling without complication, which were higher than the average Medicare payment of US$12 599. The median hospital costs were US$36 188 (IQR 21831–55308) for clipping and US$40 502 (IQR 24289–50108) for coiling treatments complicated by major morbidity, and US$68 165 (IQR 32972–100211) for clipping and US$56 020 (IQR 00000–00000) for coiling treatments complicated by mortality, which were higher than the average Medicare payments for patients with major complications and comorbidities of US$22 946. In multivariate analysis, female gender was associated with higher costs for coiling (p=0.02), and poor discharge status was associated with higher costs for both clipping (p<0.001) and coiling (p<0.001). Conclusions Hospitalization costs for patients undergoing clipping and coiling of unruptured cerebral aneurysms are substantially higher than Medicare payments.