Abstract WP94: Clinical Outcomes of Unruptured Cerebral Aneurysms Treated With Clipping or Coiling in Japan: The J-aspect Study

Background: Evaluation of the overall clinical outcomes of stroke care is important for improving institutional quality of care. We performed a nationwide survey in Japan to analyze cases of unruptured cerebral aneurysms using the diagnostic procedure combination (DPC). Methods and Results: Certified neurosurgical training institutions in Japan provided data from the DPC database on patients hospitalized with neurosurgical diseases between April 1, 2012 and March 31, 2013. Patients hospitalized owing to unruptured cerebral aneurysms were identified from the DPC database based on the International Classification of Diseases (ICD)-10 diagnosis code (I671). We excluded patients with emergency admissions. We compared the mortality rates, modified Rankin Scale (mRS) scores, postoperative complications of patients who underwent clipping and coiling. With respect to postoperative complications, we evaluated the ratio of an event of complication (brain infarction, brain hemorrhage and cardiac infarction) and the number of complications (scored using patient safety indicators: PSIs and hospital-acquired conditions: HACs). We used hierarchical logistic regression models to estimate the odds ratios (ORs) for in-hospital mortality and complications. We identified 6329 patients with unruptured cerebral aneurysms (3710 clipping, 2619 coiling). Patient characteristics, mortality rates, and mRS were similar between groups. Patients who underwent coiling had a significantly lower number of complications than patients who underwent clipping (PSIs: OR = 0.40; P < 0.001, HACs: OR = 0.47; P = 0.001). Adversely, there was an increased likelihood of ischemic stroke in coiling patients compared with clipping patients (coiling: 7.2%; clipping: 4.7%; OR = 1.37; P = 0.011). 83.2% of coiling patients underwent MRI after the operation, compared with 37.3% of clipping patients. Conclusions: Our data demonstrated that coiling patients had lower number of post-operative complications and higher number of ischemic stroke than clipping patients. But the cause that higher number of coiling patients had ischemic stroke than clipping patients because higher number of coiling patients were underwent MRI after operation compared with clipping patients.

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Abstract TP19: Clinical Outcomes In Patients With Acute Ischemic Stroke Due To Large Vessel Occlusion In The Modern Era: 2010-2011 Experience With 423 Patients.

Stroke ◽

10.1161/str.44.suppl_1.atp19 ◽

2013 ◽

Vol 44 (suppl_1) ◽

Author(s):

Maxim Mokin ◽

Tareq Kass-Hout ◽

Omar Kass-Hout ◽

Erol Veznedaroglu ◽

Fadi Nahab ◽

...

Keyword(s):

Ischemic Stroke ◽

Endovascular Treatment ◽

Acute Ischemic Stroke ◽

Clinical Outcomes ◽

Medical Management ◽

Mortality Rates ◽

Artery Occlusion ◽

Large Vessel ◽

Large Vessel Occlusion ◽

Vessel Occlusion

Background and Purpose: Acute ischemic stroke due to large vessel occlusion is associated with a poor prognosis. With no consensus about the best treatment option, various treatment modalities including conservative management, intravenous tissue plasminogen activator, and endovascular approach are currently being used. Methods: Retrospective data including demographic information, baseline NIHSS score, site of occlusion (based on CTA, MRA or angiogram), type of treatment and clinical outcomes were collected from 4 centers in the United States during the period of 2010-2011. Results: A total of 423 were included in final analysis: 175 patients received conservative medical management, 54 patients received intravenous (IV) thrombolysis alone, and 194 patients had endovascular treatment (with or without prior IV tPA). Younger patients were more likely to receive endovascular treatment (p<0.001). There was no statistically significant difference among the sex and co-morbid conditions among the three groups. Proximal middle cerebral artery was the most commonly involved vessel. Strokes due to basilar artery occlusion or internal carotid artery occlusion were associated with worst outcomes in all three groups. Conservative medical management had the lowest rates of symptomatic intracerebral hemorrhage but also the highest mortality rates at 3 months. Patients who received endovascular treatment within the first 3 hrs had better outcome and lower mortality rates as compared to patients with intervention during 3-8 hours or beyond 8 hrs. Conclusions: Our study represents real world experience on the management and outcomes of acute ischemic strokes due to large vessel occlusion. Our results help understand natural history of strokes with large vessel occlusion, as well as modern trends in managing these patients with intravenous and intraarterial treatment approaches.

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Abstract 2779: The Safety of Intravenous Thrombolysis for Ischemic Stroke in Patients With Pre-Existing Cerebral Aneurysms: A Retrospective, Hospital-Based Study

Stroke ◽

10.1161/str.43.suppl_1.a2779 ◽

2012 ◽

Vol 43 (suppl_1) ◽

Author(s):

Nancy Edwards ◽

Hooman Kamel ◽

S. Andrew Josephson

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Cerebral Aneurysms ◽

Intravenous Thrombolysis ◽

Aneurysm Rupture ◽

Exact Test ◽

Intravenous Tissue Plasminogen Activator ◽

Unruptured Cerebral Aneurysms ◽

Risk Of Hemorrhage ◽

Iv Tpa

Background and Purpose: Unruptured cerebral aneurysms are currently considered a contraindication to intravenous tissue plasminogen activator (IV tPA) for acute ischemic stroke. This is due to a theoretical increase in the risk of hemorrhage from aneurysm rupture, although it is unknown whether this risk is significant. We sought to determine the safety of IV tPA administration in a cohort of patients with pre-existing aneurysms. Methods: We reviewed the medical records of patients treated for acute ischemic stroke with IV tPA during an 11-year period at two academic medical centers. We identified a subset of patients with unruptured cerebral aneurysms present on pre-thrombolysis vascular imaging. Our outcomes of interest were any intracranial hemorrhage (ICH), symptomatic ICH, and subarachnoid hemorrhage (SAH). Fisher’s exact test was used to compare the rates of hemorrhage among patients with and without aneurysms. Results: We identified 236 eligible patients, of whom 22 had unruptured cerebral aneurysms. The rate of ICH among patients with aneurysms (14%, 95% CI 3-35%) did not significantly differ from the rate among patients without aneurysms (19%, 95% CI 14-25%). None of the patients with aneurysms developed symptomatic ICH (0%, 95% CI 0-15%), compared with 10 of 214 patients without aneurysms (5%, 95% CI 2-8%). Similar proportions of patients developed SAH (5%, 95% CI 0-23% versus 6%, 95% CI 3-10%). Conclusion: Our findings suggest that IV tPA for acute ischemic stroke is safe to administer in patients with pre-existing cerebral aneurysms as the risk of aneurysm rupture and symptomatic ICH is low.

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Detection and Significance of Incidental Unruptured Cerebral Aneurysms in Patients Undergoing Intravenous Thrombolysis for Acute Ischemic Stroke

Journal of Neuroimaging ◽

10.1111/j.1552-6569.2010.00560.x ◽

2010 ◽

Vol 22 (2) ◽

pp. 197-200 ◽

Cited By ~ 18

Author(s):

Joon-Tae Kim ◽

Man-Seok Park ◽

Woong Yoon ◽

Ki-Hyun Cho

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Cerebral Aneurysms ◽

Intravenous Thrombolysis ◽

Unruptured Cerebral Aneurysms

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Tissue plasminogen activator for acute ischemic stroke in patients with unruptured cerebral aneurysms

Journal of Stroke and Cerebrovascular Diseases ◽

10.1053/jscd.2000.7213 ◽

2000 ◽

Vol 9 (4) ◽

pp. 181-184 ◽

Cited By ~ 8

Author(s):

Luis D'Olhaberriague ◽

Nishit Joshi ◽

Seement Chaturvedi ◽

Panayiotis Mitsias ◽

William Coplin ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Plasminogen Activator ◽

Tissue Plasminogen Activator ◽

Cerebral Aneurysms ◽

Tissue Plasminogen ◽

Unruptured Cerebral Aneurysms

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Prevalence and Characteristics of Unruptured Cerebral Aneurysms in Ischemic Stroke Patients

Journal of Stroke ◽

10.5853/jos.2016.00164 ◽

2016 ◽

Vol 18 (3) ◽

pp. 321-327 ◽

Cited By ~ 3

Author(s):

Ji Hwa Kim ◽

Sang Hyun Suh ◽

Joonho Chung ◽

Yeo-Jin Oh ◽

Sung Jun Ahn ◽

...

Keyword(s):

Ischemic Stroke ◽

Cerebral Aneurysms ◽

Stroke Patients ◽

Unruptured Cerebral Aneurysms

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Prevalence of patient safety indicators and hospital-acquired conditions in those treated for unruptured cerebral aneurysms: establishing standard performance measures using the Nationwide Inpatient Sample database

Journal of Neurosurgery ◽

10.3171/2013.5.jns122378 ◽

2013 ◽

Vol 119 (4) ◽

pp. 966-973 ◽

Cited By ~ 29

Author(s):

Kyle M. Fargen ◽

Maryam Rahman ◽

Dan Neal ◽

Brian L. Hoh

Keyword(s):

Health Care ◽

Adverse Event ◽

Patient Safety ◽

Nationwide Inpatient Sample ◽

Cerebral Aneurysms ◽

Patient Safety Indicators ◽

Hospital Acquired Conditions ◽

Unruptured Cerebral Aneurysms ◽

Hospital Acquired

Object The Agency for Healthcare Research and Quality (AHRQ) patient safety indicators (PSIs) and the Centers for Medicare and Medicaid Services hospital-acquired conditions (HACs) are metrics used to gauge the quality of health care provided by health care institutions. The PSIs and HACs are publicly reported metrics and are directly linked to reimbursement for services. To better understand the prevalence of these adverse events in hospitalized patients treated for unruptured cerebral aneurysms, the authors determined the incidence rates of PSIs and HACs among patients with a diagnosis of unruptured aneurysm in the Nationwide Inpatient Sample (NIS) database. Methods The NIS, part of the AHRQ's Healthcare Cost and Utilization Project, was queried for all hospitalizations between 2002 and 2010 involving coiling or clipping of unruptured cerebral aneurysms. The incidence rate for each PSI and HAC was determined by searching the hospital records for ICD-9 codes. The SAS statistical software package was used to calculate incidences and perform multivariate analyses to determine the effects of patient variables on the probability of each indicator developing. Results There were 54,589 hospitalizations involving unruptured cerebral aneurysms in the NIS database for the years 2002–2010; 8314 patients (15.2%) underwent surgical clipping and 9916 (18.2%) were treated with endovascular coiling. One thousand four hundred ninety-two PSI and HAC events occurred among the 8314 patients treated with clipping; at least 1 PSI or HAC occurred in 14.6% of these patients. There were 1353 PSI and HAC events among the 9916 patients treated with coiling; at least 1 PSI or HAC occurred in 10.9% of these patients. Age, sex, and comorbidities had statistically significant associations with an adverse event. Compared with the patients having no adverse event, those having at least 1 PSI during their hospitalizations had significantly longer hospital stays (p < 0.0001), higher hospital costs (p < 0.0001), and higher mortality rates (p < 0.0001). Conclusions These results estimate baseline national rates of PSIs and HACs in patients with unruptured cerebral aneurysms. These data may be used to gauge individual institutional quality of care and patient safety metrics in comparison with national data.

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Flow Reduction in Jailed Arteries After Stenting of Cerebral Aneurysms

ASME 2009 Summer Bioengineering Conference, Parts A and B ◽

10.1115/sbc2009-206144 ◽

2009 ◽

Author(s):

Juan R. Cebral ◽

Fernando Mut ◽

Sunil Appanaboyina ◽

Rainald Löhner ◽

Esteban Scrivano ◽

...

Keyword(s):

Blood Flow ◽

Ischemic Stroke ◽

Flow Rate ◽

Cerebral Aneurysms ◽

Flow Reduction ◽

Perforating Artery ◽

Unruptured Cerebral Aneurysms ◽

Endovascular Devices ◽

Arterial Branch

Recently, there has been increased interest in the use of flow divertion endovascular devices such as stents [1–3] to treat unruptured cerebral aneurysms. The goal of these devices is to deviate the blood flow away from the aneurysm and promote its thrombosis and exclusion from the circulation. However, one of the major concerns with these devices is the possibility of occluding a small arterial branch or perforating artery that may be jailed by the stent mesh. This could result in an ischemic stroke. The goal of this study was to assess the reduction in the flow rate in jailed side branches after stenting of cerebral aneurysms.

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Relationship between patient safety indicator events and comprehensive stroke center volume status in the treatment of unruptured cerebral aneurysms

Journal of Neurosurgery ◽

10.3171/2017.5.jns162778 ◽

2018 ◽

Vol 129 (2) ◽

pp. 471-479 ◽

Cited By ~ 1

Author(s):

Chad W. Washington ◽

L. Ian Taylor ◽

Robert J. Dambrino ◽

Paul R. Clark ◽

Gregory J. Zipfel

Keyword(s):

Patient Safety ◽

Cerebral Aneurysm ◽

Cerebral Aneurysms ◽

Volume Status ◽

Patient Safety Indicators ◽

Poor Outcome ◽

Unruptured Cerebral Aneurysm ◽

Unruptured Cerebral Aneurysms ◽

Comprehensive Stroke Center ◽

Stroke Center

OBJECTIVEThe Agency of Healthcare Research and Quality (AHRQ) has defined Patient Safety Indicators (PSIs) for assessments in quality of inpatient care. The hypothesis of this study is that, in the treatment of unruptured cerebral aneurysms (UCAs), PSI events are less likely to occur in hospitals meeting the volume thresholds defined by The Joint Commission for Comprehensive Stroke Center (CSC) certification.METHODSUsing the 2002–2011 National (Nationwide) Inpatient Sample, patients treated electively for a nonruptured cerebral aneurysm were selected. Patients were evaluated for PSI events (e.g., pressure ulcers, retained surgical item, perioperative hemorrhage, pulmonary embolism, sepsis) defined by AHRQ-specified ICD-9 codes. Hospitals were categorized by treatment volume into CSC or non-CSC volume status based on The Joint Commission’s annual volume thresholds of at least 20 patients with subarachnoid hemorrhage and performance of 15 or more endovascular coiling or surgical clipping procedures for aneurysms.RESULTSA total of 65,824 patients underwent treatment for an unruptured cerebral aneurysm. There were 4818 patients (7.3%) in whom at least 1 PSI event occurred. The overall inpatient mortality rate was 0.7%. In patients with a PSI event, this rate increased to 7% compared with 0.2% in patients without a PSI event (p < 0.0001). The overall rate of poor outcome was 3.8%. In patients with a PSI event, this rate increased to 23.3% compared with 2.3% in patients without a PSI event (p < 0.0001). There were significant differences in PSI event, poor outcome, and mortality rates between non-CSC and CSC volume-status hospitals (PSI event, 8.4% vs 7.2%; poor outcome, 5.1% vs 3.6%; and mortality, 1% vs 0.6%). In multivariate analysis, all patients treated at a non-CSC volume-status hospital were more likely to suffer a PSI event with an OR of 1.2 (1.1–1.3). In patients who underwent surgery, this relationship was more substantial, with an OR of 1.4 (1.2–1.6). The relationship was not significant in the endovascularly treated patients.CONCLUSIONSIn the treatment of unruptured cerebral aneurysms, PSI events occur relatively frequently and are associated with significant increases in morbidity and mortality. In patients treated at institutions achieving the volume thresholds for CSC certification, the likelihood of having a PSI event, and therefore the likelihood of poor outcome and mortality, was significantly decreased. These improvements are being driven by the improved outcomes in surgical patients, whereas outcomes and mortality in patients treated endovascularly were not sensitive to the CSC volume status of the hospital and showed no significant relationship with treatment volumes.

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