scholarly journals Unruptured Intracranial Aneurysm Initial Treatment and Follow-up Cost Analysis: Pipeline Flow Diverters vs Coiling

Neurosurgery ◽  
2019 ◽  
Vol 66 (Supplement_1) ◽  
Author(s):  
Herschel Wilde ◽  
Spencer Twitchell ◽  
Michael Karsy ◽  
Philipp Taussky ◽  
Ramesh Grandhi
Keyword(s):  
Intracranial Aneurysms ◽  
Endovascular Techniques ◽  
Analysis Pipeline ◽  
Unruptured Intracranial Aneurysm ◽  
Discharge Disposition ◽  
Aneurysm Treatment ◽  
American Society ◽  
American Society Of Anesthesiologists ◽  
Flow Diverters

Abstract INTRODUCTION Intracranial aneurysms represent a relatively common epidemiological problem, with a prevalence of 3% to 5% in the U.S. Surveillance and treatment remain costly enterprises especially with the advent of safer endovascular techniques, including coiling and pipeline embolization devices (PEDs). While a number of studies have evaluated aneurysm treatment cost, inclusion of follow-up costs had been limited. We sought to examine how follow-up costs after treatment could impact overall cost for different endovascular techniques. METHODS The value driven outcomes (VDO) database was used to evaluate the upfront and follow-up costs of electively treated patients who underwent coiling or PED for intracranial aneurysms from July 2011 to December 2017. RESULTS A total of 114 patients (n = 37 coiled, n = 77 PED) were included with no difference in age (61.3 ± 12.8 vs 57.0 ± 14.5 yr, P = .2), gender (males: 32.4% vs 22.1%, P = .2), American Society of Anesthesiologists (ASA) grade (P = .5), discharge disposition (P = .1), length of stay (3.1 ± 5.5 vs 2.4 ± 2.6 d, P = .2) or follow-up (22.7 ± 18.5 vs 18.6 ± 14.9 mo, P = .2). No differences in admission treatment (P = .5) or follow-up (P = .3) costs were seen for coiling or PED treatments. Initial costs were predominantly supplies/implants (56.1% vs 63.7%) for both coiling and PED. Follow-up costs were mostly facility costs (68.2% vs 67.5%) without differences in supplies/implants (10.5% vs 9.4%) or imaging (17.0% vs 17.8%) costs between coiling and PED. No differences in subgroup (eg, facility, supplies/implants, pharmacy, imaging, laboratory) costs were also observed. CONCLUSION These results suggested that coiling or PED could be used for aneurysm treatment in a cost-conscious manner when factoring both upfront and follow-up costs.

Use of flow-diverting stents as salvage treatment following failed stent-assisted embolization of intracranial aneurysms

2015 ◽  
Vol 8 (7) ◽  
pp. 692-695 ◽  
Author(s):  
Daniel M Heiferman ◽  
Joshua T Billingsley ◽  
Manish K Kasliwal ◽  
Andrew K Johnson ◽  
Kiffon M Keigher ◽  
...  
Keyword(s):  
Blood Flow ◽  
Intracranial Aneurysms ◽  
Cerebral Aneurysms ◽  
Flow Diverter ◽  
Salvage Treatment ◽  
Endovascular Techniques ◽  
Pipeline Embolization Device ◽  
Wall Apposition ◽  
Flow Diverters

Flow-diverting stents, including the Pipeline embolization device (PED) and Silk, have been beneficial in the treatment of aneurysms previously unable to be approached via endovascular techniques. Recurrent aneurysms for which stent-assisted embolization has failed are a therapeutic challenge, given the existing intraluminal construct with continued blood flow into the aneurysm. We report our experience using flow-diverting stents in the repair of 25 aneurysms for which stent-assisted embolization had failed. Nineteen (76%) of these aneurysms at the 12-month follow-up showed improved Raymond class occlusion, with 38% being completely occluded, and all aneurysms demonstrated decreased filling. One patient developed a moderate permanent neurologic deficit. Appropriate stent sizing, proximal and distal construct coverage, and preventing flow diverter deployment between the previously deployed stent struts are important considerations to ensure wall apposition and prevention of endoleak. Flow diverters are shown to be a reasonable option for treating previously stented recurrent cerebral aneurysms.

Management of Unruptured Intracranial Aneurysm in Japan

1998 ◽  
Vol 18 (4) ◽  
pp. 357-364 ◽  
Author(s):  
Noriaki Aoki ◽  
Takao Kitahara ◽  
Tsuguya Fukui ◽  
J. Robert Beck ◽  
Kazui Soma ◽  
...  
Keyword(s):  
Clinical Trial ◽  
Sensitivity Analysis ◽  
Glasgow Outcome Scale ◽  
Intracranial Aneurysms ◽  
University Hospital ◽  
Health Providers ◽  
Unruptured Intracranial Aneurysm ◽  
Unruptured Intracranial Aneurysms ◽  
Quality Adjusted Life

The purpose of this study was to analyze the management of individual patients with unruptured intracranial aneurysms (UN-ANs) using a decision-analytic approach. Tran sition probabilities among Glasgow Outcome Scale (GOS) categories were estimated from the published literature and data from patients who had been treated at Kitasato University Hospital. Utilities were obtained from 140 health providers based principally on the GOS. Baseline analysis for a healthy 40-year-old man with an anterior UN-AN less than 10 mm in diameter showed that the quality-adjusted life expectancies for preventive operation and follow-up were 15.34 and 14.66 years, respectively. For a follow-up strategy to be preferred, the annual rupture rate had to be as low as 0.9%. These results were sustained through extensive sensitivity analysis. The results sup port preventive operation for UN-ANs, and identify problems that can be clarified with a well-designed stratified clinical trial. Key words: decision analysis; Markov model; unruptured intracranial aneurysms; Glasgow Outcome Scale; utility; preventive oper ations. (Med Decis Making 1998;18:357-364)

Are Guidelines Important? Results of a Prospective Quality Improvement Lumbar Fusion Project

Neurosurgery ◽  
2021 ◽  
Author(s):  
James Harrop ◽  
Alexandra Emes ◽  
Ameet Chitale ◽  
Chengyuan Wu ◽  
Fadi Al Saiegh ◽  
...  
Keyword(s):  
Patient Outcomes ◽  
Odds Ratio ◽  
Lumbar Fusion ◽  
Evidence Based ◽  
Multiple Logistic Regression ◽  
Surgical Indications ◽  
American Society ◽  
American Society Of Anesthesiologists ◽  
Based Medicine

Abstract BACKGROUND United States (U.S.) healthcare is a volume-based inefficient delivery system. Value requires the consideration of quality, which is lacking in most healthcare disciplines. OBJECTIVE To assess whether patients who met specific evidence-based medicine (EBM)-based criteria preoperatively for lumbar fusion would achieve higher rates of achieving the minimal clinical important difference (MCID) than those who did not meet the EBM indications. METHODS All elective lumbar fusion cases, March 2018 to August 2019, were prospectively evaluated and categorized based on EBM guidelines for surgical indications. The MCID was defined as a reduction of ≥5 points in Oswestry Disability Index (ODI). Multiple logistic regression identified multivariable-adjusted odds ratio of EBM concordance. RESULTS A total of 325 lumbar fusion patients were entered with 6-mo follow-up data available for 309 patients (95%). The median preoperative ODI score was 24.4 with median 6-mo improvement of 7.0 points (P < .0001). Based on ODI scores, 79.6% (246/309) improved, 3.8% (12/309) had no change, and 16% (51/309) worsened. A total of 191 patients had ODI improvement reaching the MCID. 93.2% (288/309) cases were EBM concordant, while 6.7% (21/309) were not. In multivariate analysis, EBM concordance (P = .0338), lower preoperative ODI (P < .001), lower ASA (American Society of Anesthesiologists) (P = .0056), and primary surgeries (P = .0004) were significantly associated with improved functional outcome. EBM concordance conferred a 3.04 (95% CI 1.10-8.40) times greater odds of achieving MCID in ODI at 6 mo (P = .0322), adjusting for other factors. CONCLUSION This analysis provides validation of EBM guideline criteria to establish optimal patient outcomes. The EBM concordant patients had a greater than 3 times improved outcome compared to those not meeting EBM fusion criteria.

scholarly journals Sexual Dysfunction: Prevalence and Prognosis in Patients Operated for Degenerative Lumbar Spondylolisthesis

Neurosurgery ◽  
2019 ◽  
Vol 66 (Supplement_1) ◽  
Author(s):  
Andrew Kai-Hong Chan ◽  
Erica F Bisson ◽  
Kai-Ming G Fu ◽  
Paul Park ◽  
Leslie Robinson ◽  
...  
Keyword(s):  
Sexual Function ◽  
Sexual Life ◽  
Quality Outcomes ◽  
Degenerative Lumbar Spondylolisthesis ◽  
Negative Effect ◽  
American Society ◽  
Lumbar Spondylolisthesis ◽  
American Society Of Anesthesiologists ◽  
The Impact

Abstract INTRODUCTION There is a paucity of investigation on the impact of spondylolisthesis surgery on back-pain related sexual inactivity. To this end, we utilized the prospective Quality Outcomes Database (QOD) registry to investigate factors predictive of improved sex life following surgery. METHODS This was an analysis of a prospective registry of 608 patients who underwent surgery for grade 1 degenerative lumbar spondylolisthesis at 12 high-enrolling sites. Of these, 218 patients were included who were sexually active and had both baseline and 24-mo sexual function follow-up. Baseline variables were collected. Outcomes were collected at 24 mo. Sexual function was assessed by the associated question in the Oswestry Disability Index, “With regards to pain, how would you say your sex life is?” Outcomes were dichotomized into patients who had improved sexual function and those who had same or worse sexual function. RESULTS Mean age was 58.0 ± 11.0 yr and 108 (49.5%) patients were women. At baseline, 178 patients (81.7%) had an impaired sex life. At final follow-up, 130 patients (73.0% of the 178 impaired) had an improved sex life. In univariate comparisons, those with improved sexual life had lower body mass index (BMI) (29.6 ± 5.5 vs 34.4 ± 6.0; P < .001) and a lower proportion of American Society of Anesthesiologists' grades 3 or 4 (33.1%% vs 54.2%; P = .01). Following surgery, those with improved sex lives noted higher satisfaction following surgery (84.5% vs 64.6% would undergo surgery again, P = .002). In adjusted analyses, lower BMI was associated with an improved sex life at 24 mo (OR = 1.14; 95% CI [1.05-1.20]; P < .001). CONCLUSION Over 80% of patients who present for surgery for degenerative lumbar spondylolisthesis report a negative effect of the disease on sex life. However, most patients (73%) report an improvement in sex life postoperatively. Improvement in sex life was associated with significantly greater satisfaction with surgery. Lower BMI was predictive of improved sex life postoperatively.

scholarly journals The Paisley Pattern Breast Reduction

2019 ◽  
Vol 27 (2) ◽  
pp. 189-194
Author(s):  
Devra B. Becker
Keyword(s):  
Chart Review ◽  
Operative Time ◽  
Breast Reduction ◽  
Proof Of Concept ◽  
Flap Necrosis ◽  
Institutional Review ◽  
American Society ◽  
American Society Of Anesthesiologists ◽  
Wise Pattern

Background: Skin resection patterns inform the shape and scars after breast reduction. The 2 most commonly performed skin resection patterns, the Wise pattern and vertical pattern, each have limitations. The most common challenge is addressing excess lateral skin while avoiding medial scars. The Paisley Pattern breast reduction addresses this by incorporating lateral dogear excision in the skin resection design. Methods: Thirty consecutive patients received a Paisley Pattern breast reduction. After institutional review board approval, a chart review was performed to evaluate resection weight, operative time, American Society of Anesthesiologists class, flap necrosis, and seroma. Results: Operative times were comparable to published times for the Wise and vertical pattern techniques. No patients had lateral flap necrosis, and no patients required a return to the operating room during the follow-up period. One patient developed a unilateral seroma that was drained by interventional radiology. Conclusions: This report of a novel skin resection design demonstrates a proof of concept that the skin resection pattern can be performed safely in a wide variety of patients. Although there is a learning curve to the technique to prevent over-resection laterally, it provides efficient and aesthetically acceptable alternative to the Wise and vertical skin resection patterns for both large and small reductions.

scholarly journals Endovascular Treatment of Intracranial Aneurysms in the Flow Diverter Era: Frequency of Use and Results in a Consecutive Series of 550 Treatments in a Single Centre

2014 ◽  
Vol 20 (4) ◽  
pp. 428-435 ◽  
Author(s):  
Willem Jan van Rooij ◽  
Ratna S Bechan ◽  
Jo P. Peluso ◽  
Menno Sluzewski
Keyword(s):  
Intracranial Aneurysms ◽  
Flow Diverter ◽  
Flow Diversion ◽  
Consecutive Series ◽  
Complication Rates ◽  
Parent Vessel ◽  
Vessel Occlusion ◽  
Permanent Neurological Deficit ◽  
Flow Diverters

Flow diverter devices became available in our department in 2009. We considered treatment with flow diverters only in patients with aneurysms not suitable for surgery or conventional endovascular techniques. This paper presents our preliminary experience with flow diverters in a consecutive series of 550 endovascular aneurysm treatments. Between January 2009 and July 2013, 550 endovascular treatments for intracranial aneurysms were performed. Of these, 490 were first-time aneurysm treatments in 464 patients and 61 were additional treatments of previously coiled aneurysms in 51 patients. Endovascular treatments consisted of selective coiling in 445 (80.8%), stent-assisted coiling in 68 (12.4%), balloon-assisted coiling in 13 (2.4%), parent vessel occlusion in 12 (2.2%) and flow diverter treatment in 12 (2.2%). Eleven patients with 12 aneurysms were treated with flow diverters. Two patients had ruptured dissecting aneurysms. One patient with a basilar trunk aneurysm died of acute in stent thrombosis and another patient died of brain stem ischaemia at 32 months follow-up. One patient had ischaemia with permanent neurological deficit. Two aneurysms are still open at up to 30 months follow-up. Flow diversion was used in 2% of all endovascular treatments. Both our own poor results and the high complication rates reported in the literature have converted our initial enthusiasm to apprehension and hesitancy. The safety and efficacy profile of flow diversion should discourage the use of these devices in aneurysms that can be treated with other techniques.

Aneurysms with persistent patency after treatment with the Pipeline Embolization Device

2016 ◽  
Vol 126 (6) ◽  
pp. 1894-1898 ◽  
Author(s):  
Peter Kan ◽  
Visish M. Srinivasan ◽  
Nnenna Mbabuike ◽  
Rabih G. Tawk ◽  
Vin Shen Ban ◽  
...  
Keyword(s):  
Intracranial Aneurysms ◽  
Cerebral Aneurysms ◽  
Artery Aneurysm ◽  
Superior Cerebellar Artery ◽  
Anterior Inferior Cerebellar Artery ◽  
Pipeline Embolization Device ◽  
Cerebellar Artery ◽  
Middle Cerebral Artery Aneurysms ◽  
Flow Diverters

The Pipeline Embolization Device (PED) was approved for the treatment of intracranial aneurysms from the petrous to the superior hypophyseal segment of the internal carotid artery. However, since its approval, its use for treatment of intracranial aneurysms in other locations and non-sidewall aneurysms has grown tremendously. The authors report on a cohort of 15 patients with 16 cerebral aneurysms that incorporated an end vessel with no significant distal collaterals, which were treated with the PED. The cohort includes 7 posterior communicating artery aneurysms, 5 ophthalmic artery aneurysms, 1 superior cerebellar artery aneurysm, 1 anterior inferior cerebellar artery aneurysm, and 2 middle cerebral artery aneurysms. None of the aneurysms achieved significant occlusion at the last follow-up evaluation (mean 24 months). Based on these observations, the authors do not recommend the use of flow diverters for the treatment of this subset of cerebral aneurysms.

Selective endovascular treatment of 71 intracranial aneurysms with platinum coils

1993 ◽  
Vol 79 (1) ◽  
pp. 3-10 ◽  
Author(s):  
Alfredo E. Casasco ◽  
Armand Aymard ◽  
Y. Pierre Gobin ◽  
Emmanuel Houdart ◽  
André Rogopoulos ◽  
...  
Keyword(s):  
Intracranial Aneurysms ◽  
Mortality Rates ◽  
Posterior Circulation ◽  
Endovascular Techniques ◽  
Anterior Circulation ◽  
Content Type ◽  
Grade Ii ◽  
Platinum Coils ◽  
Type Of Surgery

✓ Seventy-one intracranial aneurysms were treated by endovascular techniques, with the placement of minicoils inside the aneurysmal sac. Most aneurysms were manifest by hemorrhage (67 cases), and 43 of these were treated within the first 3 days after presentation. At the 1-year follow-up examination, the outcome was scored as good in 84.5% of cases, but the morbidity and mortality rates were 4.2% and 11.3%, respectively. Twenty-nine aneurysms in the anterior circulation and 42 in the posterior circulation were treated. In this series, 23 patients were classified as Hunt and Hess neurological Grade I, 27 as Grade II, 12 as Grade III, nine as Grade IV, and none as Grade V. Thirty-three aneurysms were less than 10 mm in diameter, 28 were 10 to 25 mm, and 10 were larger than 25 mm. The preliminary results from this study appear to justify the emergency treatment of aneurysms by this approach. Aneurysms in the posterior circulation are particularly well suited for this type of surgery.

scholarly journals Comprehensive review of imaging of intracranial aneurysms and angiographically negative subarachnoid hemorrhage

2019 ◽  
Vol 47 (6) ◽  
pp. E20 ◽  
Author(s):  
Brian M. Howard ◽  
Ranliang Hu ◽  
Jack W. Barrow ◽  
Daniel L. Barrow
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Best Practices ◽  
Intracranial Aneurysms ◽  
Vascular Lesion ◽  
Reference Standard ◽  
Unruptured Intracranial Aneurysm ◽  
Imaging Protocols ◽  
Ruptured Intracranial Aneurysms

Intracranial aneurysms confer the risk of subarachnoid hemorrhage (SAH), a potentially devastating condition, though most aneurysms will remain asymptomatic for the lifetime of the patient. Imaging is critical to all stages of patient care for those who harbor an unruptured intracranial aneurysm (UIA), including to establish the diagnosis, to determine therapeutic options, to undertake surveillance in patients who elect not to undergo treatment or whose aneurysm(s) portends such a low risk that treatment is not indicated, and to perform follow-up after treatment. Neuroimaging is equally as important in patients who suffer an SAH. DSA remains the reference standard for imaging of intracranial aneurysms due to its high spatial and temporal resolution. As noninvasive imaging technology, such as CTA and MRA, improves, the diagnostic accuracy of such tests continues to increasingly approximate that of DSA. In cases of angiographically negative SAH, imaging protocols are necessary not only for diagnosis but also to search for an initially occult vascular lesion, such as a thrombosed, ruptured aneurysm that might be detected in a delayed fashion. Given the crucial role of neuroimaging in all aspects of care for patients with UIAs and SAH, it is incumbent on those who care for these patients, including cerebrovascular neurosurgeons, interventional neurologists and neuroradiologists, and diagnostic radiologists and neurointensivists, to understand the role of imaging in this disease and how individual members of the multispecialty team use imaging to ensure best practices to deliver cutting-edge care to these often complex cases. This review expounds on the role of imaging in the management of UIAs and ruptured intracranial aneurysms and in the workup of angiographically negative subarachnoid hemorrhage.

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